The caring behaviours of Danish pharmaconomists: insight for pharmacy technician practice around the world

Abstract

Objectives

Pharmacy workforce support personnel are being accorded greater scopes of practice, especially Danish pharmaconomists [pharmacy technician, experts in pharmaceuticals with a 3-year degree]. The aims of this study were to assess pharmaconomists’ caring behaviours and identify factors related to those behaviours.

Methods

A self-administered survey was distributed to a random sample of pharmaconomists in Denmark. The survey assessed caring behaviours using the Caring Behaviours Assessment and acquired data to ascertain their employers’ culture, respondent’s need for achievement, personality traits, commitment and work-related characteristics. Descriptive statistics provided insight into pharmacomomists’ predispositions, and bivariate analyses were used to identify associations of pharmaconomists’ caring with other variables under study.

Key findings

Over 300 pharmaconomists responded (52.2% response rate). Pharmaconomists reported generally high levels (well above the median on the 5-point scale) of caring behaviours. They reported higher levels (upper range of 5-point scale) of empathic behaviours, such as treating patients with respect and seeing things from the patient’s point of view but somewhat lower levels of encouraging the patient to talk about how they feel and praising the patient’s efforts, which could otherwise help patients cope with and improve their self-efficacy for disease management. Pharmaconomist caring was associated with practice setting, organisational culture and commitment to their employer.

Conclusions

Pharmaconomists reported performing behaviours that were empathic, but less frequently those associated with facilitating greater patient autonomy. Caring behaviours were associated with a number of variables related to practice setting. The findings can help to inform educational pedagogy and pharmacy personnel management.

caring behaviour, organizational culture, pharmaconomist, pharmacy technician, work environment

Introduction

It has been argued that the most critical component of pharmaceutical care, and that which is often said to be missing, is the actual ‘care’ component.^[1,2] Caring and empathy are among the most important factors in improving patients’ medication adherence.^[3] Empathy is also critical in serving various subpopulations of patients, such as those who are critically ill,^[4] older,^[5] disabled^[6] and those whose condition carries stigma that the patient carries some ‘blame’ for their own condition (e.g. lung cancer).^[7]

Caring behaviour has been defined conceptually in pharmacy as ‘acts or behaviours which are a response to the values and needs of the individual… intended to improve a person’s health’.^[8] Fjortoft and Zgarrick assessed pharmacists’ caring ability based on Mayerhoff’s theory of caring characterised by tolerance, knowing, and courage.^[9,10] They found that those reporting higher caring predispositions are more likely to be involved in providing asthma and diabetes education. While unable to discern causality, they inferred that caring predispositions supersede time pressures that pharmacists might experience. Fjortoft later found that the caring pharmacist was one not only expressing empathy but also engaged in advocacy.^[11]

Researchers have examined pharmacists’ caring, but have done so usually within the context of specific conditions, rather than in wide swaths of patients. For example, Mangione and Patel found that empathy and caring attitudes were important in the level of care pharmacists provide to patients with Celiac disease.^[12] They argued that pharmacists may not have the same level of empathy for patients with diseases unassociated with substantial comorbidities. Similarly, health professionals might lack empathy for diseases like hepatitis C, wherein the patient might be presumably ‘responsible’ for its onset.^[13,14] Desselle and Skomo found that pharmacist caring dispositions were among the more highly predictive in quality of counseling accorded to migraineurs when examining other potential factors such as pharmacists’ beliefs about medicines, level of experience, job setting and even knowledge of migraines.^[15] A study on care-taking and pharmacist-patient relationships affirmed that knowing the patient is associated with empathic relationships.^[16] Such empathy can be facilitative in the delivery of better care.^[17,18]

As pharmacists assume more clinical roles, support personnel are increasingly involved in direct care and checking their own work.^[19–24] In the community setting, pharmacy technicians have been reported to be the ‘face’ of pharmacy, taking primary responsibility for relationships with clientele.^[25,26] These trends underscore shifts in practice to promote greater autonomy for workforce cadres to promote patient-centric practice, while gaining efficiency in operations,^[27,28] and having been occurring in a number of countries and regions, including but not limited to the United Kingdom, New Zealand, Australia and the United States.

In Denmark, technicians are referred to as ‘pharmaconomists’.^[29] These pharmaconomists are all educated at the Danish College of Pharmacy Practice, a program of three full-year equivalents, or 180 European Credit Transfer System points. Pharmaconomists enjoy significant breadth of practice and autonomy, and are able to perform many of the same functions as pharmacists. In fact, their constitutional/legal inability to own a pharmacy is among the few things that distinguish between pharmaconomists and pharmacists in job scope.^[30] Given their important roles, the trend towards wider scopes of practice for support cadres, and the importance of caring behaviours in general, an examination of caring behaviours among pharmaconomists would appear to be warranted.

Caring predispositions could be associated with any of a number of factors. Personal characteristics such as gender, age, personality traits and abilities, in addition to employment-related characteristics such as when employers have strong cultures (employer favourability) that promote caring attitudes.^[31–35] To that end, the aims of this study were to assess Danish pharmaconomists’ caring behaviours and identify factors related to those caring behaviours.

Methods

Design and sample

Institutional Review Board exemption for study procedures were granted by the investigators’ universities. The study employed use of a survey to a random sample of pharmaconomists. The survey was developed in English and not translated in Danish. The investigators were unable to secure the resources for Danish translation. However, an officer with the Danish Association of Pharmaconomists, who also disseminated the survey, offered slight word changes, mostly in colloquialisms and terms more apt for the Danish context, and provided assurance that survey recipients would understand the questionnaire survey very well. The Association placed a cap of 600 surveys to be disseminated. This represents 17% of the 3531 pharmaconomists employed at the time. Study subjects were randomly selected from a registry maintained by the Association. This included pharmaconomists from potentially every setting of practice in Denmark; however, the Association maintains that there are extraordinarily few pharmaconomists uninvolved in patient care, with most practicing in community and hospital settings. The survey was implemented using Qualtrics.^[36] The procedures for survey conduct were in accordance to recommendations by Dillman et al.^[37] to maximise rate of return. Sampled subjects received a pre-notification email prior to launch of the survey, an email with a cover letter and survey link, then two reminders, each approximately 7 days apart, with the survey being closed on 3/1/17.

Study variables

Caring behaviour was measured using an instrument adapted from the Caring Behaviour Assessment (CBA) well-cited in the nursing literature.^[38] It emphasises values, beliefs and perceptions about personhood, life, health, and healing, emphasising care that manifests from predispositions as opposed to a task orientation. The CBA is comprised of 63 items across seven domains: humanism, helping/trust, teaching/learning, supportive/protective, human need, positive/negative and existential/phenomenological domains. Given the accumulating response burden from having multiple variables and resultant questions on the survey, the investigators sought to reduce the number of items used to measure caring behaviour in this study. From a factor analysis of items undertaken,^[38] investigators in the current study selected four items from each of the first five domains listed, particularly those items with the highest loading onto their respective factors. The investigators did not select items from the positive/negative or existential/phenomenological domains, as they were deemed less relevant for the current study. Response choices were measured on a Likert-type scale of frequency, from 1 (rarely, if ever), to 2 (some of the time), 3 (much of the time) and 4 (always, or nearly all the time), as recommended by Cronin and Harrison.^[38]

Need for achievement (NA) was assessed using an eight-item measure from Elliott and Dweck scored on a yes/no basis,^[39] with their work suggesting NA to be related to motivation and performance in health care. Personality was measured using the 10-Item Personality Inventory traits measure^[40] derived from the Big Five Inventory, whose basis has been associated with pharmacists’ provision of advanced services.^[41] Employer favourability was framed around the context of organisational culture, wherein organisations can exhibit cultures that permeate through to its constituent employees’ actions.^[42] Employer favourabilty was measured using one item to measure each of the six dimensions of the Organisational Culture Profile (competitiveness, sensitivity towards the community, innovation, fairness to employees, stability and achievement orientation)^[43] and an additional three items used by Clark and Mount to describe pharmacy organisations (patient care orientation, quality operations, professional versus technical).^[44]

The survey collected data on employment status, setting, job rank, gender, age, experience and measures of employer and profession commitment previously used for U.S. technicians, which propose ordinal continuums of scenarios depicting situations in which the respondent would likely leave or stay.^[45]

Data analysis

Data were analysed using SPSS, Version 21.0.^[46] Frequency distributions were tabulated. The caring behaviours scale, along with NA, employer favourability and personality scales were subjected to a principal components analysis with Promax rotation, and item analysis to evidence construct validity and appropriateness of each item prior to their use in inferential statistics. Correlation analysis (Pearson’s r), independent sample t tests and one-way analyses of variance (ANOVAs, with post-hoc Tukey’s B tests), as appropriate, were conducted to discern relationships between variables. This was followed by a backward-elimination multiple regression analysis of variables over caring behaviour.

Results

Participant characteristics

Of 600 surveys distributed, responses were obtained from 313 participants (52.2% response rate); however, in the absence of forced choice, some questions were unanswered by some respondents. Respondent employment status and other characteristics are provided in Table 1. Just over 1/2 of the respondents were working full-time. Just over 1/3 of respondents reported working at an entry-level versus nearly 2/3 at an ‘advanced’ level, as per self-report, which according to the Association is a designation conferred by many employers throughout the nation. Only 16.5% of respondents indicated little or no employer commitment, while over 40% reported being completely committed in their career.

Table 1

Descriptive characteristics of study respondents

Characteristic	n (%) or meana
Employment status
Currently working as a pharmaconomist	308 (98.4%)
Employed in some capacity other than a pharmaconomist	5 (1.6%)
Work hours
Full-time	150 (51.7%)
Part-time	140 (44.7%)
Position
Entry-level work as a pharmaconomist	103 (35.5%)
Advanced level work as a pharmaconomist	187 (64.5%)
Gender
Female	123 (100.0%)
Male	0 (00.0%)
Work setting
Ambulatory or retail (community)	141 (48.6%)
Hospital or other inpatient facility	73 (25.2%)
Other	76 (26.2%)
Employer commitment
I would have left or am looking to leave at the first opportunity	4 (2.4%)
I do not feel much commitment, and keep my options open	24 (14.1%)
I feel modest commitment and do no plan significant changes unless something unexpected happens	84 (49.4%)
I feel strong commitment to the organization and am planning my career/work future with them for the long haul	58 (34.1%)
Profession commitment
I am looking or plan to leave this career, altogether	8 (4.7%)
I do not have other plans currently,but it might not take much For me to change careers	36 (21.1%)
In spite of challenges or shortcomings,I feel good about this line of work and hope to make a career of it for quite some time	52 (30.6%)
I feel completely committed and am definitely in this career for my entire work life	74 (43.5%)
Participant age	44.57 ± 11.42
Number of years worked as a pharmaconomist	18.04 ± 13.31
Number of years worked for current employer	9.28 ± 9.20

a

Any total <308 indicates missing data; i.e. respondents were not forced to make a selection and opted not to.

Construct validity

The principal components analysis revealed caring behaviours to load onto four domains, similar to those proffered by Cronin and Harrison,^[38] with their proposed teaching/learning items being dispersed with items in other domains, here. One item was deleted for use in subsequent analyses due to poor psychometric performance. The resultant Cronbach’s α was 0.93. NA was unidimensional, with a Cronbach’s α of 0.79. Employer favourability was unidimensional with a Cronbach’s α of 0.81. The 10-item measure of personality provided a four domain factor structure not easily interpreted and with a suspect Cronbach’s α (0.53). As such, correlations of the total care score were run with each of the 10 personality traits separately, as they are unique from one another.

Caring behaviours

The caring behaviours of responding pharmaconomists are reported in Table 2. Pharmaconomists reported highest (most frequent) involvement in: treat the patient with respect, be gentle with the patient, answer the patient’s questions clearly, ask the patient questions to ensure understanding, treat the patient as an individual, and try to see things from the patients’ point of view. Behaviours with the lowest frequency means were: encourage the patient to talk about how they feel, help the patient understand their feelings, check on the patient’s condition closely, encourage the patient to believe in themselves, and not get upset when the patient is angry. On a scale ranging in possible scores from 19 to 78, the mean overall care behaviour score was 56.72 ± 13.03.

Table 2

Caring behaviours reported by respondents^a

Caring behaviour	Mean ± SDa
Treat my patient as an individual	3.39 ± 0.99
Try to see things from my patient’s point of view	3.39 ± 0.88
Reassure the patient	3.11 ± 0.95
Encourage the patient to believe in himself/herself	2.70 ± 1.02
Praise the patient’s efforts	2.27 ± 0.91
Understand the patient	3.19 ± 0.87
Ask the patient how he/she likes things done	2.78 ± 1.08
Treat the patient with respect	3.59 ± 0.83
Encourage the patient to talk about how he/she feels	2.35 ± 0.90
Help the patient understand his/her feelings	2.46 ± 0.98
Don’t become upset when the patient is angry	2.70 ± 1.03
Don’t give up on the patient when he/she is difficult to get along with	2.82 ± 0.93
Encourage the patient to ask questions about his/her illness and treatment	2.91 ± 1.02
Answer the patient’s questions clearly	3.38 ± 0.82
Ask the patient questions to be sure he/she understands	3.36 ± 0.86
Be gentle with the patient	3.45 ± 0.83
Check on the patient’s condition very closely	2.49 ± 0.95
Seem to know how the patient feels	2.80 ± 0.88
Help the patient feels good about himself/herself	2.86 ± 1.01

a

Each item scaled as 1 = rarely, if ever; 2 = some of the time; 3 = much of the time; 4 = Always or nearly all the time. Mean response to overall (total) scale = 56.72 ± 13.03. Number of responses (N) ranged from 268–302 for each item (from a total number of 308 respondents to the survey). Total number of completed responses for use in inferential statistics was 186.

Other attitudes

On a possible range of scores from 1 to 8, the mean need achievement response was 6.12 ± 1.87. Respondents indicated a high preference to receive feedback and to have clear and definable goals, but were less likely to indicate a preference for competing against others or for tasks that involve accepting personal responsibility for the outcome (Table 3). Employer favourability was modestly high, with an overall summary mean of 30.65 ± 9.44 on a scale ranging from 8 to 40 (Table 4). Employer characteristics rated most highly were their demonstrating responsibility and sensitivity towards the community they serve and being oriented towards patient care. They were rated least favourably on fairness in allocating organisational rewards and on being geared towards maximum performance. Respondents reported on a broad range of personality characteristics, with them seeing themselves as dutiful, active and compliant. They saw themselves less so as anxious/tense, and also somewhat less excitable and impulsive, even though these were still above the scale midpoint of 2.5 (Table 5).

Table 3

Pharmaconomists’ need for achievement (NA)

Item	Meana
If offered a choice of tasks, would you pick one that is moderately difficulty rather than one that is either very difficult or very easy?	0.75
Do you enjoy tasks more if you compete against others?	0.54
Do you prefer tasks that have clear definable goals and measurable outcomes?	0.86
Do you like receiving feedback about how well you are doing when you are working on a project?	0.90
Would you rather receive criticism from a harsh but competent evaluation than from one who is friendlier but less competent?	0.82
Do you prefer task where you are personally responsible for the outcome?	0.70
When working on a difficult task, do you persist even when you encounter roadblocks?	0.80
Do you typically receive high performance evaluations?	0.76

a

Where a ‘no’ response = 0, and a ‘yes’ response = 1; there is not a standard deviation for individual items. Number of responses (N) ranged from 211–284 for each item (from a total number of 308 respondents to the survey). Total number of completed responses for use in inferential statistics was 174.

Table 4

Pharmaconomists’ ratings of their employer’s ‘favourability’ (organisational culture)

Characteristic	Mean ± SD
Is competitive with other organisations	3.62 ± 1.00
Demonstrates responsibility and sensitivity towards the community it serves	4.21 ± 0.91
Is supportive of its employees	4.03 ± 0.89
Shows innovation to improve operations and facilitate effective care
Is fair in allocating organisational rewards to people at all levels of the organisation	3.36 ± 1.07
Is geared for maximum performance	3.50 ± 0.95
Is oriented towards patient care	4.19 ± 0.97
Concerns itself with quality rather than quantity	3.88 ± 0.95
Employee work is more professional than technical	4.01 ± 1.02

On a scale ranging from 1 = strongly disagree, to 5 = strongly agree. Number of responses (N) ranged from 244–281 for each item (from a total number of 308 respondents to the survey). Total number of completed responses for use in inferential statistics was 169.

Table 5

Pharmaconsists’ self-evaluation of their own personality traits

Trait	Mean ± SD
Sociable	3.66 ± 0.88
Active	4.44 ± 0.65
Forgiving	4.02 ± 0.77
Compliant	4.33 ± 0.73
Dutiful	4.71 ± 0.59
Deliberate	3.89 ± 0.97
Anxious/tense	2.40 ± 0.99
Impulsive	3.31 ± 1.04
Curious	3.79 ± 0.85
Excitable	3.22 ± 1.16

On a scale ranging from 1 = strongly disagree, to 5 = strongly agree. Number of responses (N) ranged from 226–283 for each item (from a total number of 308 respondents to the survey). Total number of completed responses for use in inferential statistics was 161.

Relationships between caring and other variables

Pharmaconomists working in the community setting reported a significantly higher level of caring than did those working in a hospital/inpatient setting (mean difference = 15.67, independent sample t = 5.09, df = 188, P < 0.01). There were higher levels of caring behaviour reported by part-time versus full-time employees (mean difference = 8.14, independent sample t = 2.73, df = 195, P < 0.01). This should be considered in the light of the fact that many more part-time workers practice in the community sector where caring was higher. There was a difference in caring by the respondents’ level of employer commitment (one-way ANOVA F statistic = 2.41, df = 3, P < 0.05), with post-hoc Tukey tests indicating significantly less caring by those with the lowest level of employer commitment versus those in the other three categories/levels of commitment. However, there was no significant relationship between profession commitment and caring behaviours.

Caring behaviour was unrelated to respondent age or number of years worked, as per correlation analysis. The positive correlation between years with current employer and caring behaviour approached significance (r = 0.18, P = 0.06). The relationship between employer favourability (i.e. the strength of the culture of their organisation) and caring behaviour was highly significant (r = 0.33, P < 0.01). Regarding need for achievement, there was a significant correlation between caring and a positive response to the statement ‘Would you rather receive criticism from a harsh but competent evaluator than from one who is friendlier but less competent?’ (r = 0.26, P < 0.01). The correlation between caring and other scale items was positive, but not statistically significant. Regarding personality, there was a statistically significant correlation between caring and being ‘forgiving’ (r = 0.20, r < 0.05). Most other correlations were positive (e.g. compliant, dutiful, social, active and impulsive) but did not achieve statistical significance. There was a negative albeit non-significant correlation between caring behaviour and being ‘excitable’.

To discern the independent contribution of each variable in explaining caring behaviour, the backward-elimination regression analysis revealed perceptions of organisational culture, full-time (versus part-time) employment and community pharmacy employment (versus hospital pharmacy employment) to be significant.

Discussion

This study revealed many of the pharmaconomists carrying out most of the caring behaviours much or nearly all of the time. As explained below, they carried out some of the caring behaviours more frequently than others, particularly those related to expressing empathy and less so those related to assisting patients with their own self-efficacy for treatment. Greater levels of caring were associated with full-time employment, working in the community setting and working in an organisation perceived to have a stronger organisational culture. Some modest relationships were observed between caring and certain personality traits and with aspects of need for achievement and commitment.

The study results should be considered in the light of several limitations. While the response rate was favourable, the possibility of non-response bias cannot be disregarded. Additionally, in request (by the Association) that the investigators not employ forced responses, some respondents elected not to answer certain questions. This could have been the result of them not completely understanding the question, pointing to a broader limitation that the survey was developed in and administered in English. While officers with the Danish Pharmaconomists Association assisted with translation of colloquialisms, and Danes generally have very solid command of English, the possibility of some questions being misinterpreted cannot be ruled out. The investigators relied on information from the Association that was not necessarily fully documented in any type of census or other study of pharmaconomists.

The prospect of respondents providing socially desirable responses cannot be precluded. In an effort to mitigate response burden, this study employed adaptations of scales previously reported, with these adaptations resulting in much fewer items. Only 20 of the original 63 items from the CBA were utilised, and no items were used from two of its original domains. The responses came from pharmaconomists in one country who have more standardised training and whose scope of practice is at least somewhat unique from technicians and other pharmacy support cadres around the world. The respondents were all women and had been working for their employers for a fairly long time on average, which might not reflect the practice environments of technicians in other countries. In Denmark, the overwhelming proportion of pharmaconomists is women and works in the community setting. In avoiding a forced-choice option, many of the demographic questions were left unanswered, including gender. It is not known why so many of the respondents decided to omit answering these questions.

Among the caring behaviours reported most frequently were being gentle, treating the patient as an individual, and seeing the patient’s point of view. These suggest high levels of empathy. Empathy is recognised as an increasingly important disposition and behaviour among pharmacists.^[47] This has been codified very strongly in accreditation standards for pharmacist education^[48] and long since recognised in the training of nurses.^[49]

Respondents reported less frequently praising the patient’s efforts, encouraging the patient to talk, not to become upset when the patient is angry, helping the patient to understand his/her feelings, and checking on the patient’s condition very closely. These behaviours can be seen as assisting the patient with their own self-efficacy for treatment and helping them cope with their condition and their medication-taking. There is much evidence to support the need to promote patient self-efficacy, which can result in improved treatment outcomes. Self-efficacy may be especially important for patients with multiple comorbidities and severe diseases.^[50,51] While empathy is helpful, there are other patient attitudes by providers that can help to promote optimal communication.^[52] Patient-centred communication does in fact necessitate that providers help patients cope and facilitate their self-management of diseases.^[53] To that end, pharmaconomist education programming might include bolstering certain aspects of the communication curriculum and heighten awareness for the importance of patient self-efficacy. This could be carried out with any number of potential educational interventions at the Danish College of Pharmacy Practice such as through role play, coupled with inculcation of patient motivation theories, like self-efficacy, in addition to motivational interviewing techniques, as has been suggested for technicians in the U.K.^[54]

The association between caring behaviours and organisational culture was strong and merits further attention.^[33] Caring behaviours have been reportedly associated with quality of worklife of those providing the care.^[34] It has been demonstrated that even physician empathy can be affected by their site (organisation) of practice.^[35] Caring behaviours of health professionals could be the result of a reciprocal exchange where those professionals feel valued by their employers.^[31]

This research also found a relationship between caring behaviours and respondents’ employer commitment. This is not the first study to find similar relationships among other health professionals. Commitment and satisfaction with co-workers facilitate organisational citizenship and caring among nurses.^[55] Nurses also are more inclined towards higher patient care if they perceive their employer’s climate as ethical.^[56] Pharmacy technicians in the U.S. reported greater propensity to perform new roles when more committed to their employer.^[57] Educators might consider deeper instruction on organisational behaviour into their curriculums, and policymakers should consider work environments when considering rules, regulations and/or scope of practice.

Few relationships were found between caring behaviours and other variables under study, such as personality. Past studies of associations between caring and personality have been equivocal. One study found a relationship between empathy and conscientiousness and agreeableness, the latter of which is comprised of ‘forgiving’ and other traits.^[58] Another found pharmacists’ attitudes towards practice change to be associated with certain personality characteristics, such as ‘openness’,^[59] Need for achievement did not explain much of caring. While the results of this study provide a good baseline of understanding pharmaconomist caring behaviours, future studies could help determine additional factors associated with higher caring abilities and determine the extent to which different types of professional and educational interventions could positively affect caring behaviours. Studies also could examine the affect of managerial or organisational policies that reward caring behaviour.

Conclusion

This initial exploration into the caring behaviours of Danish pharmaconomists provided salient results for various stakeholders in pharmacy. Pharmaconomists reported high levels of certain caring behaviours, particularly those emblematic of demonstrating empathy; however, the caring behaviours they reported less frequently were those that could be associated with higher-level activities, such as coaching patients to cope with their disease and helping patients to facilitate self-efficacy. The practice environment, namely the ‘favourability’, or organisational culture of employers, was positively associated with caring behaviours, as was respondents’ commitment to their employing organisation. The findings can help to inform educational pedagogy, job recruitment, pharmacy personnel management and policy for scope of practice for pharmaconomists and perhaps other various workforce cadres in pharmacy.

Declarations

Conflict of interest

The Author(s) declare(s) 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.

Authors’ contributions

SPD coneptualized project, primary author of paper, analyzed data. RH assisted with literature review and analysis, identified some measured used in the study, collected data, implemented survey and reminders. CR secondary write of paper to provide Danish context. ERH assisted with conceptualization of project, consultation on past research on technicians. AG assisted with literature review and analysis, consultation of writing some paper components. LZ assisted with literature review and analysis, consultation on writing some paper components

Acknowledgements

The authors would like to acknowledge the assistance of Esben Hansen, Technical Consultant with the Danish Association of Pharmaconomists for his assistance with survey distribution and modification of survey language.