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

A systematic review of simulated-patient methods used in community pharmacy to assess the... Abstract 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. community pharmacy, counselling behaviour, non-prescription medicines, simulated patient Introduction Community pharmacists are the most accessible healthcare professionals to the public.[1,2] Playing a key role in ensuring the quality use of medicines, pharmacists and their staff can provide patients with advice on safe, appropriate and effective use of medicines, identify potential drug-related problems and intervene when necessary.[1,3,4] The prevention and management of inappropriate use of non-prescription medicines is especially crucial in current pharmacy practice, where non-prescription medicines can cause harm when not used appropriately.[5] Administering the correct dose of a medicine is an important consideration for all people; however it is most critical in children, who are more vulnerable to overdose and underdose because most of their doses are individually calculated based on the weight or age of the child.[6] It is therefore imperative that adequate information about medicines is given, for appropriate management of common childhood ailments. The recognition of the important public health contribution of community pharmacists has generated considerable efforts to enhance pharmacists' ability to reinforce appropriate and manage inappropriate medicine-taking behaviour.[7] Improvements in health outcomes largely depend on how effectively community pharmacists and their staff can influence patients to make appropriate decisions about medicine taking.[8] In the last decade, simulated-patient methods have been used around the globe, as an assessment and educational tool, to identify issues in current pharmacy practice and inform interventions to shape practice behaviour of pharmacists and their staff.[3,8–18] A simulated patient (also known as pseudo patron, pseudo patient, standardised patient, simulated patient, pseudo customer, covert participant, shopper patient, disguised shopper, surrogate shopper or mystery shopper) is an individual who is trained to go to a pharmacy and enact predetermined scenarios, while being indistinguishable from genuine patients, to assess aspects of customer care provided by pharmacy staff.[3,8,13,19–23] Community pharmacy is an ideal setting for this type of real-time observation and research, as pharmacists and their staff can be accessed without appointment, unlike other healthcare professionals.[24] The simulated-patient method is an unobtrusive means of observing actual staff responses in a natural environment, under conditions uninfluenced by awareness that behaviour is being monitored.[25–27] It is thus an effective method of deriving valid, true-to-life outcomes, which are otherwise challenging to achieve by any other method.[23] Although an effective assessment tool, using simulated-patient methods solely for assessment purposes has served as a basis for negative criticism of pharmacy staff skills and performance, and thus has attracted negative attitudes from those who have been subject to this approach.[8,18] However, when used for educational purposes, simulated-patient methods are an effective training tool, rather than simply an observation.[18] A recent trend in simulated-patient methods has seen a shift of emphasis from merely assessing behaviour of pharmacists and their staff, to using the outcomes of these visits as formative feedback to enhance continuous professional development.[8,16] In well-designed studies, when simulated patients are used for educational purposes in the pharmacy setting, educators have entered the pharmacy immediately after the simulated-patient visit, to discuss the observations with pharmacists and/or their staff.[8,26] These methods not only provide an accurate assessment of practice behaviour, but also use performance feedback as a basis for further skills acquisition.[8] The simulated-patient method is negotiated with pharmacists and their staff beforehand, being fully integrated into an educational programme. This is otherwise known as ‘in principle’ consent, when participants give prior consent without knowing the exact timing of the simulated-patient visit.[16] Research has shown that the awareness of an impending simulated-patient visit serves as a powerful motivator to continue applying acquired skills, as participants cannot predict when another assessment will take place.[8] By using the simulated-patient method to evaluate the strengths and weaknesses of pharmacy staff, educators can develop appropriate interventions to address specific needs of participants.[1,8,28] This formative role of simulated-patient methods seeks to improve quality of advice regarding non-prescription medicines.[16] Performance feedback provided to pharmacists and their staff after a simulated-patient visit appears to be an important aspect of the simulated-patient method, as it allows for gradual and ongoing fine-tuning of practice behaviour over time.[8,18] However, little is known on how feedback has been delivered to pharmacists and their staff post simulated-patient visits. Although simulated-patient methods as an educational tool have been used in the pharmacy setting for over a decade, systematic reviews of simulated-patient studies have not investigated feedback provision.[19,23] Furthermore, the review by Mesquita et al. highlighted that no studies found in their review had focused on children's medicines, which often require unique counselling information.[19] Therefore there is a need for further knowledge on how feedback is being provided in the pharmacy setting and on how pharmacists and their staff perceive these methods in pharmacy education, as well as exploring how simulated patients can be used to improve the quality use of medicines in children. The aim of this bibliographic review was to explore the use of the simulated-patient method in the community pharmacy setting involving non-prescription medicines. Previous reviews have mainly focussed on simulated-patient scenarios employed to assess communication skills of pharmacists and their staff and outcome measures. This review, however, focuses on the purpose of the simulated-patient method, the types of scenarios employed to assess practice behaviour (with particular interest in whether scenarios have involved children's medicines), as well as whether and how performance feedback was delivered to pharmacists and their staff, and how these simulated-patient methods were perceived by participants. This review will inform the design of a simulated patient intervention to improve the management of common childhood ailments in community pharmacy. Method Search strategy The databases IPA (International Pharmaceutical Abstracts), EMBASE and MEDLINE were searched using the following key words and search strategy: (‘pseudo patient’ OR ‘pseudo customer’ OR ‘standardised patient’ OR ‘standardized patient’ OR ‘shopper patient’ OR ‘mystery shopper’ OR ‘simulated patient’ OR ‘pseudo patron’ OR ‘covert participant’ OR ‘surrogate shopper’ OR ‘disguised shopper’) AND ((‘community’ AND ‘pharmacy’) OR ‘community pharmacy’) in all three databases The search strategy and review protocol were jointly developed by TX and RM. Data collection and extraction was carried out by TX. The search was limited to articles published in the English language, from 1990 to 2010 (Table 1,Tables 2–3). Titles and abstracts generated by this search strategy were manually screened independently by all three authors for relevance and eligibility for full text retrieval. The reference lists of the retrieved articles and previous review articles were manually searched for additional relevant references. Table 1 Search results from International Pharmaceutical Abstracts database No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 Open in new tab Table 1 Search results from International Pharmaceutical Abstracts database No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 Open in new tab Table 2 Search results from the EMBASE database No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 Open in new tab Table 2 Search results from the EMBASE database No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 Open in new tab Table 3 Search results from MEDLINE No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 Open in new tab Table 3 Search results from MEDLINE No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 Open in new tab Ethical approval was not applicable as no human subjects were involved. Inclusion and exclusion criteria Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines,[29] studies were included in this systematic review if they were original research articles (with the conventional research study structure of introduction, methods, results, discussion and conclusions), which adopted simulated-patient methods for non-prescription medicines in the community pharmacy setting and had been published between 1990 and 2010. Systematic reviews, letters to the editor, abstracts, meeting reports and opinion pieces were excluded from the review, as were duplicate articles and those not published in English. The review was not restricted to any country. Data extraction and analysis The following information from relevant studies was then extracted and reviewed by TX: (1) country in which the study was performed; (2) study design; (3) purpose of the study (assessment or educational); (4) whether participants were aware of the impending simulated-patient visits or not (covert or consented); (5) scenarios and medication requests adopted by the study method (with a particular focus on whether scenarios involved requests for treating children); (6) data-collection methods; (7) employment of performance feedback; (8) methods of feedback delivery; and (9) participant opinions of the simulated patient methodology. A data extraction form to record this information was completed for all studies and subsequently tabulated (Table 4). The data were then reviewed independently by the remaining two authors and discussions were held between all three authors in the event of any discrepancies. Table 4 Summary of simulated-patient studies in pharmacy practice involving non-prescription medicines Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush CS, cross-sectional; ECP, emergency contraceptive pill; N/A, not applicable; NRT, nicotine replacement therapy; PP, pre–post; RCT, randomised controlled trial; STI, sexually transmitted infection. Open in new tab Table 4 Summary of simulated-patient studies in pharmacy practice involving non-prescription medicines Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush CS, cross-sectional; ECP, emergency contraceptive pill; N/A, not applicable; NRT, nicotine replacement therapy; PP, pre–post; RCT, randomised controlled trial; STI, sexually transmitted infection. Open in new tab Results Number of studies The search strategy generated 177 results in IPA, 148 in EMBASE and 34 in MEDLINE. Of these, 31, 30 and 22 respectively were eligible for full text retrieval (Tables 1–3). Further refinement using the inclusion and exclusion criteria, addition of relevant references from retrieved articles and previous reviews, and duplicate exclusion (Figures 1 and 2) resulted in a total of 30 studies from 31 articles being identified and reviewed according to the criteria described in the method (Table 4). Figure 1 Open in new tabDownload slide Distribution of articles by database. Figure 2 Open in new tabDownload slide Search strategy and flow of articles.[29] Study designs and purposes Sixteen of the 30 reviewed studies were cross-sectional (CS) studies, designed to solely assess counselling behaviour of pharmacists and their staff when presented with various scenarios involving non-prescription medicines.[1,4,15,16,22,25,30–40] Two studies were pre–post studies (PP), one assessing performance progress during a national 4-year programme[41] and the other to assess a change in counselling after product rescheduling.[21] The remaining 12 studies incorporated an educational aspect into the simulated patient method,[3,9–14,17,20,42–44] of which eight were randomised controlled trials (RCTs), to test the feasibility and effectiveness of educational strategies being implemented into practice.[11–13,17,20,42–44] The other four studies involving an educational component were of a CS design.[3,9,10,14] Types of scenarios and participant awareness of impending visits A variety of symptom and direct product requests were used in the studies, with 12 studies exclusively focusing on direct product requests,[4,9–12,14–17,21,30,37] 11 on symptom-based requests[1,22,32–36,38,39,42,43] and seven involved a rotation of both.[3,13,20,25,31,40,41,44] A wide range of medical conditions were involved in the studies, with only three out of the 30 involving requests for children.[33–35] With regard to awareness of impending visits, in 11 studies, participants were not notified of the impending simulated-patient visits (covert),[1,4,21,25,30,32–34,36,38,42] whereas ‘in principle’ consent was sought in 19 studies (consented),[3,9–17,20,22,31,35,37,39–41,43,44] although only nine used the immediate feedback and coaching techniques. Data collection methods Twenty-nine studies specified the use of data collection sheets, completed soon after the simulated-patient visits.[1,3,4,9–13,15–17,20–22,25,30–44] Nine of the 30 studies used audio recordings during the simulated-patient interaction, in order to accurately recall what occurred during the interaction.[9,12–15,17,33,41,44] One study only used audio recording for the researcher to recount thoughts about the interaction, rather than to aid in feedback delivery.[40] Performance feedback and participant perceptions Thirteen studies incorporated performance feedback,[1,3,9–17,25,35] nine of which delivered feedback immediately after the simulated-patient visits, either by the researcher, simulated patient or a trained pharmacy educator.[3,9–15,17] Three studies involved delayed feedback in the form of a letter to individual participants[16,25,35] and one study incorporated indirect performance feedback, in the form of a letter addressed to the country's national pharmaceutical society, to disseminate the information to community pharmacists.[1] Seven studies gathered feedback from participants regarding the use of simulated patients in pharmacy practice research.[3,9,10,12,13,20,35] All opinions gathered were positive. Discussion Main findings This review systematically explored the use of the simulated-patient method in 30 studies involving non-prescription medicines in the community pharmacy setting. The simulated-patient method has been used to assess and improve the counselling skills of pharmacists and their staff, employing a wide variety of scenarios. Few simulated-patient studies have incorporated performance feedback to encourage behavioural change and improve counselling skills, and even fewer involve the provision of children's medicines. Limitations Although the strength of this review is its systematic design, there are some limitations. This review covered all eligible studies as generated by the search strategy, however because of the many synonyms for the term ‘simulated patient’, some may have been missed during the keyword search. This review was also limited to studies published in English, therefore relevant studies published in languages other than English could have been overlooked. Furthermore, the quality and robustness of study designs were not assessed in this review as the main focus was to extract data regarding study methods and the inclusion or exclusion of performance feedback. Future studies, therefore, may wish to include assessment of study design quality. Purpose and benefits of simulated-patient visits Eleven studies used the simulated-patient method in a purely covert manner, as a tool for assessing practice behaviour of pharmacists and their staff, although a further 10 did not provide immediate feedback, hence also using the study mainly for performance assessment. This finding is in accordance with a recent systematic review by Mesquita et al., whereby the results showed that the focus of simulated-patient methods was primarily on assessment, rather than as an educational focus for enhancing practice skills of pharmacists and their staff.[19] This also highlights that although simulated patients have been used in pharmacy practice, little published information and regard has focused on the role of performance feedback and training in pharmacy education, in shaping the behaviour of pharmacists and their staff.[19,45] The literature has revealed that this method may be a valuable tool to shape practice behaviour and, in the few studies that monitored acceptance of this as an educational tool, participants rated the experience positively. Therefore, because of its face validity, reliability and acceptance, it could be more widely used as a tool to assess current training needs in community pharmacy, identify potential barriers to change, and to compare different practice change strategies.[12,15,20] Of course to be used for educational purposes, i.e. to improve performance through immediate feedback, the simulated-patient visits need to be conducted with prior consent from participants to involve the Hawthorne effect, whereby performance improves with the knowledge of impending assessment.[1,11] The Hawthorne effect is desirable, as it enables pharmacists and their staff to maintain a high level of performance, which then becomes routine practice. Therefore, simulated patients used in a consented, educational and reflective framework, as part of continuing professional development, aims to improve future performance.[36] Importance of accurate performance documentation Written notes or checklists, documented as soon as possible after simulated-patient visits, were the most common method of data collection. This was also found by a systematic review by Watson et al.[19] In fact, the use of self-completed questionnaires are the most common method of data collection in pharmacy practice research in general.[28] However, problems can arise as a result of time separation between observation and data recording, with regards to the fallibility of recall and memory.[24] Cognitive psychologists suggest that factors that may affect the reliability and validity of data collected from simulated-patient visits relate to the process of memory, namely encoding, storage and retrieval of data.[46] This concern can be addressed with the use of audio recording, to minimise selectivity and inferences associated with research observation and recording, and to give a better understanding of detailed content of the simulated-patient visits, rather than relying exclusively on the simulated patient or researcher.[17,41] Despite the fact that audio recording validates and enhances data integrity, giving more detailed information about the content of simulated-patient interaction, only nine out of the 30 reviewed studies audio recorded the simulated-patient visits.[9,12–15,17,33,41,44] One researcher argued that audio recording was not used because the data collected were few and easy to memorise.[22] Another study design endeavoured to include audio recording, but claimed it was not always possible, for reasons unclear.[15] Other studies saw the lack of audio recording as a study limitation[1,43] and interestingly, ethics approval was sought for audio recording simulated-patient interactions for one particular study but was refused.[4] The results of this review concur with the finding by Watson et al., which outlined that audio recording is sometimes only used to record researcher comments and perceptions on completion of simulated-patient visits, rather than to aid in data collection and feedback delivery.[23] It is thus recommended that the use of standardised data collection tools accompanied with audio recording (following ethics approval) is the ideal method of data collection, in order to ensure validation of recorded data.[23,47] Audio recording can also assure the reliability and accuracy of feedback, if provided.[1,7,14,41,48] Importance of providing immediate performance feedback Performance feedback was delivered in less than half of the reviewed studies. It is critical for a person to receive information about the closeness of his/her actual performance to predetermined desired behaviour, in order to evaluate possibilities for improvement.[18] This is particularly true in assessing standards of practice relating to customer care and advice.[10] The provision of performance feedback enhances training in addressing areas of improvement, and serves as an effective means of helping to further refine practice skills.[12,17,18,44,49] In studies that did incorporate performance feedback, the feedback delivered was not always immediate.[1,16,25,35] Performance feedback is most effective when it is provided immediately after behaviour, in order for the subject to have a clear recollection of their performance.[3,8,12,18] This finding highlights that there is limited research exploring the use of simulated patients with immediate performance feedback as a means of reinforcing appropriate practice and providing support to improve counselling.[13] Important considerations and theoretical frameworks in providing performance feedback The majority of studies incorporated performance feedback in the simulated-patient method did not explicitly detail the theoretical framework or methods employed to ensure that the feedback delivered was accurate, nor did they evaluate the quality of the feedback delivery. Psychological research has shown that an individual's response to performance feedback is mediated by their perceived accuracy of the feedback. In other words, perception of feedback accuracy, involving concepts of justice and fairness, is core to the motivational effects of feedback.[50] Research suggests that perceptions of inaccurate feedback are likely to provoke behavioural responses contrary to those desired by the feedback provider.[51,52] An important implication for the simulated patient method is that some pharmacists and their staff may be unlikely to accept feedback they perceive to be inaccurate or ‘unfair’, if they perceive the appraisal system to be invalid.[51,52] Therefore, there is a need to conceptualise ‘fairness’ in the context of feedback provision in simulated-patient methods. Pharmacy educators need to convey awareness and understanding of factors that may be influencing performance, such as manpower, patient expectations and lack of external support or assistance, for feedback to be perceived as being truly accurate, including the concept of fairness, so participants change their behaviour as desired.[50] The concept of Motivational Interviewing for behavioural change As well as delivering accurate feedback to participants, it is also important for pharmacy educators to be able to affect behaviour change when delivering performance feedback to pharmacists post simulated-patient visits. The Agenda-led Outcome-based Analysis (ALOBA) model[53] has been used in the past for this purpose, however Motivational Interviewing (MI)[54] is an alternative conceptual framework for shaping practice behaviour when delivering such feedback. Motivational Interviewing is a counselling approach based on the well-established principle of social psychology, ‘I learn what I believe as I hear myself talk’.[55] According to MI, one of the most effective attitude-change methods is to have the individual verbalise him/herself the need and willingness to change. Indeed, research shows that counselling approaches based on MI promote behaviour change in a wide range of healthcare settings.[54] Therefore, an approach to feedback provision based on MI principles in which the pharmacy educator prompts the pharmacist to verbalise the positive aspect of his/her performance, as well as how to improve it, potentially makes behaviour change more likely to occur.[56] Indeed, studies have supported the notion that if feedback is delivered in a non-confrontational way, with emphasis on positive aspects of behaviour, as well as providing corrective information (also known as coaching), it can empower and increase the confidence of the feedback recipient in his or her own skills, thus improving performance.[3,8,11] In addition, this form of feedback provision would be particularly useful in addressing communication anxiety in pharmacy, a phenomenon that is presented by 30% of pharmacists, whereby they do not lack communication skills, but rather evaluate their own performance poorly. That is, the positive feedback provided by the pharmacy educator serves to increase pharmacists' confidence in their own counselling skills, thus reducing communication anxiety.[19] A similar approach to feedback provision has been described by de Almeida Neto (2003),[5] however it has not been tested empirically. Future studies should consider introducing principles of MI to feedback provision. Positive participant perceptions of performance feedback The simulated-patient method with performance feedback was very well received by participants in the reviewed studies,[3,9,10,12,13,20,35] confirming its feasibility and acceptance in assessing the competence of pharmacists and their staff, as well as being part of an educational strategy in the community pharmacy setting.[3,20] The most frequent reason for volunteering in these projects was to find out how their pharmacy was performing, to learn new practice skills, and to improve their counselling services.[18,35] When conducted in a professional and sensitive manner, feedback serves as a sound and effective method of learning, to improve counselling quality, thus being acceptable for future education and training.[13] Owing to the feedback given, the simulated patient method was ‘motivating and educational’, in encouraging change in practice and in helping improve counselling standards in the long term.[35] Future focus on children's medicines Finally, although simulated patients can be used to assess and educate on a wide variety of scenarios, only three of the 30 reviewed studies used scenarios involving children's medicines.[33–35] This finding concurs with the systematic review by Mesquita et al., however they reported no studies employing scenarios involving children.[19] This area of pharmacy requires focus, as these studies showed poor management of many childhood ailments.[33–35] Furthermore, two of these three studies[33,34] did not include any element of feedback and training, which may be an effective tool in improving the management of common childhood ailments, and one had delayed feedback.[35] Finally, the scenarios used in the studies reviewed included the treatment of diarrhoea,[33,34] head lice and rash.[35] Whilst these are commonly presenting symptoms in childhood, it is interesting to note that no studies have had a specific focus on cough and cold or paracetamol (acetaminophen)-based preparations, which are widely used in children and often require weight-based dose calculations.[57–59] Research has shown that parents and caregivers gain much children's medicines information and advice from pharmacists, yet lack of knowledge or inadequate advice about such medicines can lead to undesirable consequences, such as inappropriate use and dosing.[60,61] More work on improving the way parents manage common childhood ailments through appropriate advice from a pharmacy is warranted. Conclusions This review found that few simulated-patient studies have incorporated performance feedback to encourage behavioural change or improvement in pharmacy practice skills, and studies that have incorporated feedback did not provide sufficient detail on their methods. The consented methodology must be utilised to take advantage of the Hawthorne effect and performance feedback needs to be immediate so the interaction is easily recalled by the pharmacy staff member. At present, few studies have assessed the acceptability of simulated-patient methods in community pharmacy and none have involved children's cough, cold and fever management. There is therefore a need for further studies using techniques adopted in motivational interviewing to explore the use of the simulated-patient method with immediate performance feedback as a means of reinforcing appropriate practice and providing support to improve counselling in the area of children's cough, cold and fever management. Declarations Conflict of interest The Authors declare that they have no conflicts of interest to disclose. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1 Chua SS et al. Response of community pharmacists to the presentation of back pain: a simulated patient study . Int J Pharm Pract 2006 ; 14 : 171 – 178 . Google Scholar Crossref Search ADS WorldCat 2 Whitehead P et al. Patient drug information and consumer choice of pharmacy . Int J Pharm Pract 1999 ; 7 : 71 – 79 . Google Scholar Crossref Search ADS WorldCat 3 Berger K et al. Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany . J Clin Pharm Ther 2005 ; 30 : 45 – 57 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Schneider CR et al. Measuring the assessment and counseling provided with the supply of nonprescription asthma reliever medication: a simulated patient study . 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Google Scholar Crossref Search ADS PubMed WorldCat 61 Taylor DM et al. Therapeutic errors among children in the community setting: nature, causes and outcomes . J Paediatr Child Health 2009 ; 45 : 304 – 309 . Google Scholar Crossref Search ADS PubMed WorldCat © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Pharmacy Practice Oxford University Press

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

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Publisher
Oxford University Press
Copyright
Copyright © 2022 Royal Pharmaceutical Society
ISSN
0961-7671
eISSN
2042-7174
DOI
10.1111/j.2042-7174.2012.00201.x
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Abstract

Abstract 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. community pharmacy, counselling behaviour, non-prescription medicines, simulated patient Introduction Community pharmacists are the most accessible healthcare professionals to the public.[1,2] Playing a key role in ensuring the quality use of medicines, pharmacists and their staff can provide patients with advice on safe, appropriate and effective use of medicines, identify potential drug-related problems and intervene when necessary.[1,3,4] The prevention and management of inappropriate use of non-prescription medicines is especially crucial in current pharmacy practice, where non-prescription medicines can cause harm when not used appropriately.[5] Administering the correct dose of a medicine is an important consideration for all people; however it is most critical in children, who are more vulnerable to overdose and underdose because most of their doses are individually calculated based on the weight or age of the child.[6] It is therefore imperative that adequate information about medicines is given, for appropriate management of common childhood ailments. The recognition of the important public health contribution of community pharmacists has generated considerable efforts to enhance pharmacists' ability to reinforce appropriate and manage inappropriate medicine-taking behaviour.[7] Improvements in health outcomes largely depend on how effectively community pharmacists and their staff can influence patients to make appropriate decisions about medicine taking.[8] In the last decade, simulated-patient methods have been used around the globe, as an assessment and educational tool, to identify issues in current pharmacy practice and inform interventions to shape practice behaviour of pharmacists and their staff.[3,8–18] A simulated patient (also known as pseudo patron, pseudo patient, standardised patient, simulated patient, pseudo customer, covert participant, shopper patient, disguised shopper, surrogate shopper or mystery shopper) is an individual who is trained to go to a pharmacy and enact predetermined scenarios, while being indistinguishable from genuine patients, to assess aspects of customer care provided by pharmacy staff.[3,8,13,19–23] Community pharmacy is an ideal setting for this type of real-time observation and research, as pharmacists and their staff can be accessed without appointment, unlike other healthcare professionals.[24] The simulated-patient method is an unobtrusive means of observing actual staff responses in a natural environment, under conditions uninfluenced by awareness that behaviour is being monitored.[25–27] It is thus an effective method of deriving valid, true-to-life outcomes, which are otherwise challenging to achieve by any other method.[23] Although an effective assessment tool, using simulated-patient methods solely for assessment purposes has served as a basis for negative criticism of pharmacy staff skills and performance, and thus has attracted negative attitudes from those who have been subject to this approach.[8,18] However, when used for educational purposes, simulated-patient methods are an effective training tool, rather than simply an observation.[18] A recent trend in simulated-patient methods has seen a shift of emphasis from merely assessing behaviour of pharmacists and their staff, to using the outcomes of these visits as formative feedback to enhance continuous professional development.[8,16] In well-designed studies, when simulated patients are used for educational purposes in the pharmacy setting, educators have entered the pharmacy immediately after the simulated-patient visit, to discuss the observations with pharmacists and/or their staff.[8,26] These methods not only provide an accurate assessment of practice behaviour, but also use performance feedback as a basis for further skills acquisition.[8] The simulated-patient method is negotiated with pharmacists and their staff beforehand, being fully integrated into an educational programme. This is otherwise known as ‘in principle’ consent, when participants give prior consent without knowing the exact timing of the simulated-patient visit.[16] Research has shown that the awareness of an impending simulated-patient visit serves as a powerful motivator to continue applying acquired skills, as participants cannot predict when another assessment will take place.[8] By using the simulated-patient method to evaluate the strengths and weaknesses of pharmacy staff, educators can develop appropriate interventions to address specific needs of participants.[1,8,28] This formative role of simulated-patient methods seeks to improve quality of advice regarding non-prescription medicines.[16] Performance feedback provided to pharmacists and their staff after a simulated-patient visit appears to be an important aspect of the simulated-patient method, as it allows for gradual and ongoing fine-tuning of practice behaviour over time.[8,18] However, little is known on how feedback has been delivered to pharmacists and their staff post simulated-patient visits. Although simulated-patient methods as an educational tool have been used in the pharmacy setting for over a decade, systematic reviews of simulated-patient studies have not investigated feedback provision.[19,23] Furthermore, the review by Mesquita et al. highlighted that no studies found in their review had focused on children's medicines, which often require unique counselling information.[19] Therefore there is a need for further knowledge on how feedback is being provided in the pharmacy setting and on how pharmacists and their staff perceive these methods in pharmacy education, as well as exploring how simulated patients can be used to improve the quality use of medicines in children. The aim of this bibliographic review was to explore the use of the simulated-patient method in the community pharmacy setting involving non-prescription medicines. Previous reviews have mainly focussed on simulated-patient scenarios employed to assess communication skills of pharmacists and their staff and outcome measures. This review, however, focuses on the purpose of the simulated-patient method, the types of scenarios employed to assess practice behaviour (with particular interest in whether scenarios have involved children's medicines), as well as whether and how performance feedback was delivered to pharmacists and their staff, and how these simulated-patient methods were perceived by participants. This review will inform the design of a simulated patient intervention to improve the management of common childhood ailments in community pharmacy. Method Search strategy The databases IPA (International Pharmaceutical Abstracts), EMBASE and MEDLINE were searched using the following key words and search strategy: (‘pseudo patient’ OR ‘pseudo customer’ OR ‘standardised patient’ OR ‘standardized patient’ OR ‘shopper patient’ OR ‘mystery shopper’ OR ‘simulated patient’ OR ‘pseudo patron’ OR ‘covert participant’ OR ‘surrogate shopper’ OR ‘disguised shopper’) AND ((‘community’ AND ‘pharmacy’) OR ‘community pharmacy’) in all three databases The search strategy and review protocol were jointly developed by TX and RM. Data collection and extraction was carried out by TX. The search was limited to articles published in the English language, from 1990 to 2010 (Table 1,Tables 2–3). Titles and abstracts generated by this search strategy were manually screened independently by all three authors for relevance and eligibility for full text retrieval. The reference lists of the retrieved articles and previous review articles were manually searched for additional relevant references. Table 1 Search results from International Pharmaceutical Abstracts database No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 Open in new tab Table 1 Search results from International Pharmaceutical Abstracts database No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 No. . Searches . Results . 1 Pseudo patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 3 2 Pseudo customer$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 3 Standardised patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 4 Standardized patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 102 5 Shopper patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 6 Mystery shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 7 7 Simulated patient$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 90 8 Pseudo patron$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 5 9 Covert participant$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 2 10 Surrogate shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 11 Disguised shopper$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 1 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 212 13 Pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 161 808 14 Community.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 20 593 15 13 and 14 17 320 16 Community pharmac$.mp. [mp = title, subject heading word, registry word, abstract, trade name/generic name] 8 570 17 15 or 16 165 081 18 12 and 17 191 19 Limit 18 to (english language and yr = ‘1990 -Current’) 177 20 From 19 keep 2, 4, 6, 11, 18, 35–38 . . . 31 Open in new tab Table 2 Search results from the EMBASE database No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 Open in new tab Table 2 Search results from the EMBASE database No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 No. . Query . Results . 1 Pseudo AND patient$ 3 128 2 Pseudo AND customer$ 15 3 Standardised AND patient$ 4 145 4 Standardized AND patient$ 22 948 5 Shopper AND patient$ 37 6 Mystery AND shopper$ 23 7 Simulated AND patient$ 5 466 8 Pseudo AND patron$ 12 9 Covert AND participant$ 25 10 Surrogate AND shopper$ 1 11 Disguised AND shopper$ 2 12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 35 383 13 ‘community’/exp OR community AND (‘pharmacy’/exp OR pharmacy) AND [1990–2010]/py 8 607 14 #12 AND #13 157 15 #12 AND #13 AND [english]/lim AND [1990–2010]/py 148 16 From #15 keep 4, 7, 9, 15, 18, 24, 30, 45, 55–56 . . . 30 Open in new tab Table 3 Search results from MEDLINE No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 Open in new tab Table 3 Search results from MEDLINE No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 No. . Searches . Results . 1 Pseudo patient$.mp. 26 2 Pseudo customer$.mp. 4 3 Standardised patient$.mp. 119 4 Standardized patient$.mp. 1 147 5 Shopper patient$.mp. 0 6 Mystery shopper$.mp. 29 7 Simulated patient$.mp. 827 8 Pseudo patron$.mp. 5 9 Covert participant$.mp. 4 10 Surrogate shopper$.mp. 1 11 Disguised shopper$.mp. 2 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 2 100 13 Pharmac$.mp. 464 671 14 Community.mp. 249 245 15 13 and 14 8 237 16 Community pharmac$.mp. 2 894 17 15 or 16 8 237 18 12 and 17 35 19 Limit 18 to (english language and yr = ‘1990 -Current’) 34 20 From 19 keep 1–2, 4–7, 10–13, 15–18, 20, 22 . . . 22 Open in new tab Ethical approval was not applicable as no human subjects were involved. Inclusion and exclusion criteria Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines,[29] studies were included in this systematic review if they were original research articles (with the conventional research study structure of introduction, methods, results, discussion and conclusions), which adopted simulated-patient methods for non-prescription medicines in the community pharmacy setting and had been published between 1990 and 2010. Systematic reviews, letters to the editor, abstracts, meeting reports and opinion pieces were excluded from the review, as were duplicate articles and those not published in English. The review was not restricted to any country. Data extraction and analysis The following information from relevant studies was then extracted and reviewed by TX: (1) country in which the study was performed; (2) study design; (3) purpose of the study (assessment or educational); (4) whether participants were aware of the impending simulated-patient visits or not (covert or consented); (5) scenarios and medication requests adopted by the study method (with a particular focus on whether scenarios involved requests for treating children); (6) data-collection methods; (7) employment of performance feedback; (8) methods of feedback delivery; and (9) participant opinions of the simulated patient methodology. A data extraction form to record this information was completed for all studies and subsequently tabulated (Table 4). The data were then reviewed independently by the remaining two authors and discussions were held between all three authors in the event of any discrepancies. Table 4 Summary of simulated-patient studies in pharmacy practice involving non-prescription medicines Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush CS, cross-sectional; ECP, emergency contraceptive pill; N/A, not applicable; NRT, nicotine replacement therapy; PP, pre–post; RCT, randomised controlled trial; STI, sexually transmitted infection. Open in new tab Table 4 Summary of simulated-patient studies in pharmacy practice involving non-prescription medicines Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush Researchers . Study location . Study design . Purpose . Covert/consented . Scenarios . Data collection . Performance feedback? . Feedback delivery . Opinions . Chiang and Chapman[25] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: Nicobloc Sheet only Yes (delayed) Letters to pharmacies N/A Symptom: best way to quit smoking Schneider et al.[4] Australia CS To assess the counselling behaviour of pharmacists and their staff Covert Product: salbutamol Sheet only No N/A N/A Benrimoj et al.[14] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: over the counter medicines in general Audio (no sheet specified) Yes (immediate) From trained coordinator N/A Benrimoj et al.[9] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet with audio Yes (immediate) From educator Positive Benrimoj et al.[10] Australia CS To assess adherence to counselling standards, with an educational component Consented Products: non-prescription medicines in general Sheet only Yes (immediate) From educator, followed up with letter Positive Kelly et al.[15] Australia CS To assess the counselling behaviour of pharmacists and their staff Consented Products: ibuprofen, cold & flu medicine, paracetamol + codeine + doxylamine Sheet with audio Yes (immediate) From pharmacy educator N/A de Almeida Neto et al.[11] Australia RCT To evaluate the effectiveness of educational strategies Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet (no audio) Yes (immediate) From researcher N/A de Almeida Neto et al.[12] Australia RCT (Follow up of previous study) Consented Inappropriate analgesic use (paracetamol + codeine + doxylamine) Sheet with audio Yes (immediate) From researcher Positive Anderson and Alexander[38] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: primary dysmenorrhea Sheet only No N/A N/A Rutter et al.[36] UK CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: headache, abdomen pain Sheet only No N/A N/A Weiss et al.[16] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only Yes (delayed) Individual letters to those who requested feedback N/A Krska et al.[35] UK CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: constipation with haemorrhoids, child with rash, toothache, cystitis in female, child with head lice Sheet only Yes (delayed) After all data tabulated; individual and group feedback Positive Watson et al.[20] UK RCT To test the feasibility of education strategies Consented Products and symptoms: antifungals for vaginal candidiasis Sheet only No N/A Positive Watson et al.[44] UK RCT To test the feasibility of education strategies Consented Non-prescription communication skills Sheet with audio No N/A N/A Watson et al.[13] UK RCT To test and compare the feasibility of simulated patient feedback versus pharmacy educator feedback Consented Products: ibuprofen, omeprazole Sheet with audio Yes (immediate) From simulated patient or pharmacy educator Positive Symptom: indigestion French and Kaunitz[30] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Product: ECP Sheet only No N/A N/A Lamsam and Kropff[34] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: leg cramps and fatigue, cough, allergic rhinitis, childhood diarrhoea Sheet only No N/A N/A Wertheimer et al.[32] USA CS To assess the counselling behaviour of pharmacists and their staff Covert Symptoms: genital herpes versus back pain Sheet only No N/A N/A Cohen et al.[37] Canada CS To assess the counselling behaviour of pharmacists and their staff Consented Product: ECP Sheet only No N/A N/A Dolovich et al.[43] Canada RCT To assess the implementation of workshop skills into practice Consented Symptom: asthma-related problems Sheet only No N/A N/A Alte et al.[22] Germany CS To assess the counselling behaviour of pharmacists and their staff Consented Symptom: headache Sheet only No N/A N/A Products: sleeping pill + sedating antihistamine Berger et al.[3] Germany CS To assess the counselling behaviour of pharmacists and their staff, with an educational component Consented Product: antacid Symptom: headache Sheet only Yes (immediate) From simulated patient, with written summary Positive Norris[31,40] New Zealand CS To assess the counselling behaviour of pharmacists and their staff Consented Product: diclofenac Sheet only No N/A N/A Symptom: thrush Driesen and Vandenplas[33] Belgium CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: baby with diarrhoea Sheet with audio No N/A N/A Chua et al.[1] Malaysia CS To assess the counselling behaviour of pharmacists and their staff Covert Symptom: back pain Sheet only Yes (delayed and indirect) Results to country's pharmaceutical society N/A Kwena et al.[39] Kenya CS To assess the counselling behaviour of pharmacists and their staff Consented Symptoms: gonorrhoea, genital ulcer Sheet only No N/A N/A Garcia et al.[42] Peru RCT To assess the effects of training on counselling behaviour of pharmacists and their staff Covert Symptom: STI Sheet only No N/A N/A Sigrist et al.[17] Switzerland RCT To assess the effectiveness of a training workshop Consented Products: non-prescription analgesics Sheet with audio Yes (immediate) From simulated patient N/A Granas et al.[21] Norway PP To assess a change counselling behaviour of pharmacists and their staff Covert Product: NRT Sheet only No N/A N/A Puumalainen et al.[41] Finland PP To assess progress during a national 4-year programme Consented Products: nasal spray, ketoprofen with ranitidine, salbutamol inhaler Sheet with audio No N/A N/A Symptoms: thrush CS, cross-sectional; ECP, emergency contraceptive pill; N/A, not applicable; NRT, nicotine replacement therapy; PP, pre–post; RCT, randomised controlled trial; STI, sexually transmitted infection. Open in new tab Results Number of studies The search strategy generated 177 results in IPA, 148 in EMBASE and 34 in MEDLINE. Of these, 31, 30 and 22 respectively were eligible for full text retrieval (Tables 1–3). Further refinement using the inclusion and exclusion criteria, addition of relevant references from retrieved articles and previous reviews, and duplicate exclusion (Figures 1 and 2) resulted in a total of 30 studies from 31 articles being identified and reviewed according to the criteria described in the method (Table 4). Figure 1 Open in new tabDownload slide Distribution of articles by database. Figure 2 Open in new tabDownload slide Search strategy and flow of articles.[29] Study designs and purposes Sixteen of the 30 reviewed studies were cross-sectional (CS) studies, designed to solely assess counselling behaviour of pharmacists and their staff when presented with various scenarios involving non-prescription medicines.[1,4,15,16,22,25,30–40] Two studies were pre–post studies (PP), one assessing performance progress during a national 4-year programme[41] and the other to assess a change in counselling after product rescheduling.[21] The remaining 12 studies incorporated an educational aspect into the simulated patient method,[3,9–14,17,20,42–44] of which eight were randomised controlled trials (RCTs), to test the feasibility and effectiveness of educational strategies being implemented into practice.[11–13,17,20,42–44] The other four studies involving an educational component were of a CS design.[3,9,10,14] Types of scenarios and participant awareness of impending visits A variety of symptom and direct product requests were used in the studies, with 12 studies exclusively focusing on direct product requests,[4,9–12,14–17,21,30,37] 11 on symptom-based requests[1,22,32–36,38,39,42,43] and seven involved a rotation of both.[3,13,20,25,31,40,41,44] A wide range of medical conditions were involved in the studies, with only three out of the 30 involving requests for children.[33–35] With regard to awareness of impending visits, in 11 studies, participants were not notified of the impending simulated-patient visits (covert),[1,4,21,25,30,32–34,36,38,42] whereas ‘in principle’ consent was sought in 19 studies (consented),[3,9–17,20,22,31,35,37,39–41,43,44] although only nine used the immediate feedback and coaching techniques. Data collection methods Twenty-nine studies specified the use of data collection sheets, completed soon after the simulated-patient visits.[1,3,4,9–13,15–17,20–22,25,30–44] Nine of the 30 studies used audio recordings during the simulated-patient interaction, in order to accurately recall what occurred during the interaction.[9,12–15,17,33,41,44] One study only used audio recording for the researcher to recount thoughts about the interaction, rather than to aid in feedback delivery.[40] Performance feedback and participant perceptions Thirteen studies incorporated performance feedback,[1,3,9–17,25,35] nine of which delivered feedback immediately after the simulated-patient visits, either by the researcher, simulated patient or a trained pharmacy educator.[3,9–15,17] Three studies involved delayed feedback in the form of a letter to individual participants[16,25,35] and one study incorporated indirect performance feedback, in the form of a letter addressed to the country's national pharmaceutical society, to disseminate the information to community pharmacists.[1] Seven studies gathered feedback from participants regarding the use of simulated patients in pharmacy practice research.[3,9,10,12,13,20,35] All opinions gathered were positive. Discussion Main findings This review systematically explored the use of the simulated-patient method in 30 studies involving non-prescription medicines in the community pharmacy setting. The simulated-patient method has been used to assess and improve the counselling skills of pharmacists and their staff, employing a wide variety of scenarios. Few simulated-patient studies have incorporated performance feedback to encourage behavioural change and improve counselling skills, and even fewer involve the provision of children's medicines. Limitations Although the strength of this review is its systematic design, there are some limitations. This review covered all eligible studies as generated by the search strategy, however because of the many synonyms for the term ‘simulated patient’, some may have been missed during the keyword search. This review was also limited to studies published in English, therefore relevant studies published in languages other than English could have been overlooked. Furthermore, the quality and robustness of study designs were not assessed in this review as the main focus was to extract data regarding study methods and the inclusion or exclusion of performance feedback. Future studies, therefore, may wish to include assessment of study design quality. Purpose and benefits of simulated-patient visits Eleven studies used the simulated-patient method in a purely covert manner, as a tool for assessing practice behaviour of pharmacists and their staff, although a further 10 did not provide immediate feedback, hence also using the study mainly for performance assessment. This finding is in accordance with a recent systematic review by Mesquita et al., whereby the results showed that the focus of simulated-patient methods was primarily on assessment, rather than as an educational focus for enhancing practice skills of pharmacists and their staff.[19] This also highlights that although simulated patients have been used in pharmacy practice, little published information and regard has focused on the role of performance feedback and training in pharmacy education, in shaping the behaviour of pharmacists and their staff.[19,45] The literature has revealed that this method may be a valuable tool to shape practice behaviour and, in the few studies that monitored acceptance of this as an educational tool, participants rated the experience positively. Therefore, because of its face validity, reliability and acceptance, it could be more widely used as a tool to assess current training needs in community pharmacy, identify potential barriers to change, and to compare different practice change strategies.[12,15,20] Of course to be used for educational purposes, i.e. to improve performance through immediate feedback, the simulated-patient visits need to be conducted with prior consent from participants to involve the Hawthorne effect, whereby performance improves with the knowledge of impending assessment.[1,11] The Hawthorne effect is desirable, as it enables pharmacists and their staff to maintain a high level of performance, which then becomes routine practice. Therefore, simulated patients used in a consented, educational and reflective framework, as part of continuing professional development, aims to improve future performance.[36] Importance of accurate performance documentation Written notes or checklists, documented as soon as possible after simulated-patient visits, were the most common method of data collection. This was also found by a systematic review by Watson et al.[19] In fact, the use of self-completed questionnaires are the most common method of data collection in pharmacy practice research in general.[28] However, problems can arise as a result of time separation between observation and data recording, with regards to the fallibility of recall and memory.[24] Cognitive psychologists suggest that factors that may affect the reliability and validity of data collected from simulated-patient visits relate to the process of memory, namely encoding, storage and retrieval of data.[46] This concern can be addressed with the use of audio recording, to minimise selectivity and inferences associated with research observation and recording, and to give a better understanding of detailed content of the simulated-patient visits, rather than relying exclusively on the simulated patient or researcher.[17,41] Despite the fact that audio recording validates and enhances data integrity, giving more detailed information about the content of simulated-patient interaction, only nine out of the 30 reviewed studies audio recorded the simulated-patient visits.[9,12–15,17,33,41,44] One researcher argued that audio recording was not used because the data collected were few and easy to memorise.[22] Another study design endeavoured to include audio recording, but claimed it was not always possible, for reasons unclear.[15] Other studies saw the lack of audio recording as a study limitation[1,43] and interestingly, ethics approval was sought for audio recording simulated-patient interactions for one particular study but was refused.[4] The results of this review concur with the finding by Watson et al., which outlined that audio recording is sometimes only used to record researcher comments and perceptions on completion of simulated-patient visits, rather than to aid in data collection and feedback delivery.[23] It is thus recommended that the use of standardised data collection tools accompanied with audio recording (following ethics approval) is the ideal method of data collection, in order to ensure validation of recorded data.[23,47] Audio recording can also assure the reliability and accuracy of feedback, if provided.[1,7,14,41,48] Importance of providing immediate performance feedback Performance feedback was delivered in less than half of the reviewed studies. It is critical for a person to receive information about the closeness of his/her actual performance to predetermined desired behaviour, in order to evaluate possibilities for improvement.[18] This is particularly true in assessing standards of practice relating to customer care and advice.[10] The provision of performance feedback enhances training in addressing areas of improvement, and serves as an effective means of helping to further refine practice skills.[12,17,18,44,49] In studies that did incorporate performance feedback, the feedback delivered was not always immediate.[1,16,25,35] Performance feedback is most effective when it is provided immediately after behaviour, in order for the subject to have a clear recollection of their performance.[3,8,12,18] This finding highlights that there is limited research exploring the use of simulated patients with immediate performance feedback as a means of reinforcing appropriate practice and providing support to improve counselling.[13] Important considerations and theoretical frameworks in providing performance feedback The majority of studies incorporated performance feedback in the simulated-patient method did not explicitly detail the theoretical framework or methods employed to ensure that the feedback delivered was accurate, nor did they evaluate the quality of the feedback delivery. Psychological research has shown that an individual's response to performance feedback is mediated by their perceived accuracy of the feedback. In other words, perception of feedback accuracy, involving concepts of justice and fairness, is core to the motivational effects of feedback.[50] Research suggests that perceptions of inaccurate feedback are likely to provoke behavioural responses contrary to those desired by the feedback provider.[51,52] An important implication for the simulated patient method is that some pharmacists and their staff may be unlikely to accept feedback they perceive to be inaccurate or ‘unfair’, if they perceive the appraisal system to be invalid.[51,52] Therefore, there is a need to conceptualise ‘fairness’ in the context of feedback provision in simulated-patient methods. Pharmacy educators need to convey awareness and understanding of factors that may be influencing performance, such as manpower, patient expectations and lack of external support or assistance, for feedback to be perceived as being truly accurate, including the concept of fairness, so participants change their behaviour as desired.[50] The concept of Motivational Interviewing for behavioural change As well as delivering accurate feedback to participants, it is also important for pharmacy educators to be able to affect behaviour change when delivering performance feedback to pharmacists post simulated-patient visits. The Agenda-led Outcome-based Analysis (ALOBA) model[53] has been used in the past for this purpose, however Motivational Interviewing (MI)[54] is an alternative conceptual framework for shaping practice behaviour when delivering such feedback. Motivational Interviewing is a counselling approach based on the well-established principle of social psychology, ‘I learn what I believe as I hear myself talk’.[55] According to MI, one of the most effective attitude-change methods is to have the individual verbalise him/herself the need and willingness to change. Indeed, research shows that counselling approaches based on MI promote behaviour change in a wide range of healthcare settings.[54] Therefore, an approach to feedback provision based on MI principles in which the pharmacy educator prompts the pharmacist to verbalise the positive aspect of his/her performance, as well as how to improve it, potentially makes behaviour change more likely to occur.[56] Indeed, studies have supported the notion that if feedback is delivered in a non-confrontational way, with emphasis on positive aspects of behaviour, as well as providing corrective information (also known as coaching), it can empower and increase the confidence of the feedback recipient in his or her own skills, thus improving performance.[3,8,11] In addition, this form of feedback provision would be particularly useful in addressing communication anxiety in pharmacy, a phenomenon that is presented by 30% of pharmacists, whereby they do not lack communication skills, but rather evaluate their own performance poorly. That is, the positive feedback provided by the pharmacy educator serves to increase pharmacists' confidence in their own counselling skills, thus reducing communication anxiety.[19] A similar approach to feedback provision has been described by de Almeida Neto (2003),[5] however it has not been tested empirically. Future studies should consider introducing principles of MI to feedback provision. Positive participant perceptions of performance feedback The simulated-patient method with performance feedback was very well received by participants in the reviewed studies,[3,9,10,12,13,20,35] confirming its feasibility and acceptance in assessing the competence of pharmacists and their staff, as well as being part of an educational strategy in the community pharmacy setting.[3,20] The most frequent reason for volunteering in these projects was to find out how their pharmacy was performing, to learn new practice skills, and to improve their counselling services.[18,35] When conducted in a professional and sensitive manner, feedback serves as a sound and effective method of learning, to improve counselling quality, thus being acceptable for future education and training.[13] Owing to the feedback given, the simulated patient method was ‘motivating and educational’, in encouraging change in practice and in helping improve counselling standards in the long term.[35] Future focus on children's medicines Finally, although simulated patients can be used to assess and educate on a wide variety of scenarios, only three of the 30 reviewed studies used scenarios involving children's medicines.[33–35] This finding concurs with the systematic review by Mesquita et al., however they reported no studies employing scenarios involving children.[19] This area of pharmacy requires focus, as these studies showed poor management of many childhood ailments.[33–35] Furthermore, two of these three studies[33,34] did not include any element of feedback and training, which may be an effective tool in improving the management of common childhood ailments, and one had delayed feedback.[35] Finally, the scenarios used in the studies reviewed included the treatment of diarrhoea,[33,34] head lice and rash.[35] Whilst these are commonly presenting symptoms in childhood, it is interesting to note that no studies have had a specific focus on cough and cold or paracetamol (acetaminophen)-based preparations, which are widely used in children and often require weight-based dose calculations.[57–59] Research has shown that parents and caregivers gain much children's medicines information and advice from pharmacists, yet lack of knowledge or inadequate advice about such medicines can lead to undesirable consequences, such as inappropriate use and dosing.[60,61] More work on improving the way parents manage common childhood ailments through appropriate advice from a pharmacy is warranted. Conclusions This review found that few simulated-patient studies have incorporated performance feedback to encourage behavioural change or improvement in pharmacy practice skills, and studies that have incorporated feedback did not provide sufficient detail on their methods. The consented methodology must be utilised to take advantage of the Hawthorne effect and performance feedback needs to be immediate so the interaction is easily recalled by the pharmacy staff member. At present, few studies have assessed the acceptability of simulated-patient methods in community pharmacy and none have involved children's cough, cold and fever management. There is therefore a need for further studies using techniques adopted in motivational interviewing to explore the use of the simulated-patient method with immediate performance feedback as a means of reinforcing appropriate practice and providing support to improve counselling in the area of children's cough, cold and fever management. 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Journal

International Journal of Pharmacy PracticeOxford University Press

Published: Sep 6, 2012

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