對社區藥局藥師進行持續教育成效及經營現況之互動探討
Evaluation of a Continuing Education Program and Current Practice for Community Pharmacists
中文摘要
美國近年來強調藥事照顧在許多慢性病病患之照顧計劃上的角色，經過社區藥局 藥師提供慢性病病患之藥事照顧，其優異的臨床貢獻已獲得證實。在台灣，有關 這方面之研究目前尚未十分充足，社區藥局藥事照顧尚有長足進步的空間，藥事 人員持續教育與訓練即為當務之急。
研究目的
主要研究目的為評估在台北市，對社區藥局藥師(生)進行持續教育課程，是否能 有效改變藥師(生)有關之執業態度、增進 GDP 知識及改善執業之現況，並調查 社區藥局經營現況。
研究方法
本研究評估項目為社區藥局藥師(生)之 GDP 知識、執業態度及執業現況、社區 藥局經營現況及社區藥局訪查員評估。本研究分為二部份進行。第一部份：是一 個社區藥局藥師(生)自我比較性的研究，對有興趣報名參加的社區藥局藥師(生) 於台北市藥師公會大禮堂進行為期一個月，共四次的持續教育課程(社區藥局藥 事執業研討會)，利用藥師自填執業問卷二次，來評估比較持續教育前後之結果 及資料。第二部份：訪查員至各社區藥局面訪，對社區藥局藥師(生)進行經營現 況之調查及分析。
研究結果
自在九十年十一月十日到九十年十二月一日止共有五十四位社區藥局藥師(生) 完成本研究，問卷的完成率為 98.2%。持續教育前 GDP 知識及執業態度得分，
均偏正向高於中位分數，但執業現況得分則是偏負向，低於中位分數。在持續教 育後，執業態度得分由中位數為 81 分(73.5-94.25)進步至 84 分(74-96)(P 值
=0.320)；而 GDP 知識得分中位數仍為 7 分(7-8)(P 值=0.831)與執業現況得分中位 數仍為 27 分(23.75-31.25)(P 值=0.922)，持續教育前後無變化。整體執業態度與 整體執業現況呈現相關。在各項目上，執業態度與執業現況在項目一呈現相關 (r=0.368，P=0.006)；執業態度與執業現況在項目二亦呈現相關(r=0.352，
P=0.009)；執業 GDP 知識與執業態度呈現不相關(r=0.000，P=1.000)；執業 GDP 知識與執業現況呈現負相關(r=-0.363，P=0.007)。大部份藥師(生)對本研究之持 續教育方式有很高之接受度及滿意度。有 98.1%藥師(生)表示需要再參加類似特 別為社區藥局設計的課程;77.8%藥師(生)表示願意成為合格糖尿病衛教人員 (CDE)。未來持續教育，依序以鼻竇炎與過敏性鼻炎、高血壓、皮膚感染、女性 荷爾蒙補充療法、感冒與氣管炎為前五個藥師(生)期望參加的課程內容。
本研究藥師(生)藥局之經營型態是以複合式、未加入連鎖單店自營、加入健保特
約，提供少項專業的服務為主流。七成藥局每月營業額在 30-60 萬以下，八成以 上平均每日處方量低於 10 張；有藥歷管理的藥局仍不盡理想(70.3%)；藥局現有 設施項目，最缺乏隱密的談話空間；五成藥局之預防保健之衛教單張以 2-3 種居 多；七成以上藥局，提供五種以下的衛教單張。目前藥局藥師(生)提供的臨床服 務項目及次數偏低，藥局評估總分平均值為 5.46±4.56 分。
自全民健保及醫藥分業後，有五成的社區藥局藥師(生)認為來客數有減少的現 象；表示近兩年的營運成長狀況不佳，目前處於衰退狀態的藥局有六成；本研究 之藥師(生)近四成認為社區藥局經營最大的阻力是「健保實施後病人往大醫院 跑」，各二成認為「法規繁雜」及「景氣不好」；藥師(生)對第二階段醫藥分業成 功的預測，有五成持中立意見；藥師(生)調劑處方藥明顯的減少。七成以上的藥 師(生)認為民眾的諮詢時間延長、六成以上的藥師(生)認為民眾的諮詢內容複雜 化。近八成藥師(生)之營業利潤滿意度為中間偏負向，對藥局經營發展的看法，
較悲觀者所佔比例比較樂觀者多，約為四比三；對目前職業環境的看法，滿意約 佔四成、不滿意約佔三成多。
研究結論
結果顯示，經由持續教育的介入後，藥師(生)對藥事執業的正向認知與態度，並 未影響其藥事執業現況，反應於藥局之經營之中，表現「態度很正向，行為很負 向」充滿矛盾、知行不合一的現象。醫藥分業對社區藥局造成篩選作用，經營型 態、地點選擇及藥局外觀環境都是影響營運狀況的重要因子。民眾對社區藥局提 供藥物資訊的需求也隨醫藥分業之推行升高。需要整合性的政策與介入社區藥局 執業環境的改善，才能克服藥局經營之困難。
本研究為社區藥局藥師建立一個藥事執業模式，可擴展社區藥局現有之服務範 圍，並建立一系列病患用藥指導單張、衛教單張及持續教育課程，為本土化社區 藥局學習藥事照顧之初探性研究，具有價值。若將此模式擴展為完整之藥事照 顧，相信會有更佳之成效。
英文摘要
Separating of pharmacy practice from medicine profession was implemented since 1997 in Taiwan. However, most patients did not seek community pharmacists for prescription dispensing and medication consultation. The present study implanted a community pharmacy education program at the infancy phase of pharmaceutical care in Taiwan. It also investigated the knowledge, attitude and practice in community pharmacy and assessed the difficulties of current practice in Taiwan.
The primary objectives of this study were to evaluate the effectiveness of a continuing education program for community pharmacists in Taiwan. The secondary objectives were to survey current practice, including prescriptional dispensing, OTC medication sales, performance of pharmaceutical care, in community pharmacy practice.
In part I, a 15-hour continuing education program was held by Taipei Pharmacists’
Association (TPA) during November to December 2001. A self-administered survey with 14 attitude questions in 7-point scale and 11 practice questions in 5-point scale was constructed based on the 4 dimensions of current Good Pharmacy Practice (GPP) draft. Another 10 dichotomous knowledge questions were based on the 2nd version of Good Dispensing Practice (GDP) in Taiwan.
In part II, interviewer’s visited the community pharmacists individually and an interviewer’s questionnaire, 14-ranked items with a perfect score of 22 was administerd by interviewer . Additionally, a self-administered survey with 25 questions in 5-point scale was constructed. The pharmacist in-charged was asked to fill the questionnaire to elaborate current situation of management.
Total number of pharmacists surveyed was 54 with a complete rate of 98.2%. Before the program, median scores of knowledge and attitude exceeded the neutral points, but not that of practice. After intervention, the median of attitude scores slightly increased from 81 (interquartile range 73.5-94.25) to 84 (74-96) (p=0.320), and that of knowledge and practice kept no significant changes. Spearman’s rho coefficient indicated a mild correlation between attitude and practice in dimension one (r=0.368, p=0.006) and dimension two (r=0.352, p=0.009). A negative correlation between knowledge and practice, while no correlation between knowledge and attitude.
Pharmacists admitted high level of satisfaction to this education program and ninty-eight (98.1%) pharmacists expressed willingness to enroll similar continuing education program later. Seventy-eight (77.8%) pharmacists were interested to be a certified diabetes educator (CDE). Mean score graded by interviewers was 5.46±4.56 and mean of profit satisfaction was 4.17±2.14. Seventy percent of pharmacies
provided less than 5 of medication counseling sheets. Forty-four percent of the pharmacist predicted future toward negative direction, and 29.6% toward positive direction.
The results indicated that the positive knowledge and attitude did not result in a positive involvement in pharmacy practice. This pilot study also demonstrated that the continuing education program was valuable to the attendants. A better effectiveness could be achieved by expanding the range of practice enhancement education
program to implant pharmaceutical care. Specific integrated strategy and intervention to encourage and fortify the improvement in the equipment of environment is needed to overcome the impediment of community pharmacy practice in Taiwan.
