The training of pharmacists, supervised by a multidisciplinary team is very important, especially with regard to the correct inhalation technique. It has been confirmed that such activity improves the everyday practice in community pharmacies [10]. Unfortunately, there are no suitable training programs in Poland, so the courses that were conducted in this study were pioneering. Their main effect was a more efficient and detailed patient consultation. It is worth mentioning that a pharmacist’s empathy and accurate questioning are very important for effective interviewing and providing professional advice for patients in a community pharmacy. Moreover such activity is successfully implemented in many countries and delivers noticeable results in patient care [11]. Providing information on medications, as well as, counseling patients on how to use the inhaler, are the most common elements of the pharmacist’s intervention. Furthermore, it is important for pharmacists to focus on improving patient compliance and the patient's understanding of the disease [12].
The study showed that the training of pharmacists contributed to them asking patients more questions to help assess their health status. It seems obvious to ask e.g. for whom the drug is intended. But sometimes this basic question is omitted by some pharmacists [1]. The Polish study by Tomerska-Kowalczyk et al. showed that following appropriate standards for interviewing patients, significantly influenced the number of questions and improved the quality of pharmaceutical consultations [13]. When counseling patients, a pharmacist should make sure that the drug has been used by the patient in the past. This is of particular importance for the further development of the advice. The counsel of a person who does not know how to use a drug will be different than that of a person for whom the drug has already been prescribed previously. Typically, a patient who has just received a new drug needs more time and attention in the pharmacy. However, even patients who demonstrate a sufficient inhalation technique may forget to take their medications regularly. The patients should understand why and how to use the drug correctly[14]. Trained pharmacists are three times more likely to ask the patient if the drug was used before in comparison to untrained ones. A similar study was carried out in Australia, where it was proven that trained pharmacists conducted ample education of patients, and its effects were clear and measurable [15]. Asking the patient about the reason for prescribing the drug, allows for a more in-depth interview. In this way a pharmacist can obtain information about the disease and provide professional advice, individually tailored for each patient. Conducting a sufficient and comprehensive interview about the patient's health and education on the proper use of the inhaler, influences the consultation time. The conversation with the trained pharmacists lasted almost twice as long than with the untrained ones. It is a pharmacist duty to provide information and advice about the effects of drugs, and to make sure that the patient knows and understands the correct inhalation technique [16, 17]. In the Basheti et al. study it was shown that the majority of patients living in rural areas were unaware of their incorrect inhaler use, but the pharmacist’s educational intervention resulted in an improved inhalation technique [18]. It is worth highlighting that patients will search for health information in different sources like the internet or magazines. For this reason, it is extremely important not to leave the patient to fend on their own, but to answer all of their questions and concerns [19].
According to Emeryk et al. effective education should last at least 6–10 minutes for one type of inhaler. All forms and techniques of education in this field are allowed, but a "live" demonstration is the most effective form of inhalation technique education [20]. This study showed that the education of a patient with the use of a demo version of the inhaler is not popular in Poland. More than half of the trained pharmacists used placebo inhalers, which significantly extended the duration of the consultation. This clearly influenced the improvement in the quality of the provided consultation. Unfortunately, it was confirmed that in many community pharmacies there was a lack of placebo inhalers and patients were instructed verbally. It is worth mentioning that demonstration inhalers provide the best way for educating patients, and are considered a standard in community pharmacies in many countries around the world [21, 22].
The role of pharmacists in enhancing the skills of a patient in inhalation techniques is significant. Very often only after this training, patients are able to demonstrate the correct inhaler technique [18]. According to the research of Lindh et al, most of the mistakes made by patients are associated with the type of the device used and an incorrect inhalation technique. The main problems were the lack of slow, deep exhalation before the start of inhalation, and an insufficient breath-hold time after drug application [23, 24, 25]. Based on the conducted study, it was shown that the trained pharmacists were able to conduct a more detailed consultation than untrained ones. Polish pharmacists are burdened with many administrative functions in a community pharmacy. Despite their training, they still did not implement all of the aspects of correct inhalation. It was most likely associated with the lack of sufficient time to conduct a full training for the patient. The most frequently omitted details were: shaking the inhaler well, taking an interval between doses and replacing the dust cap. It is worth mentioning that each element omitted in the inhaler technique may influence the effectiveness of the treatment, therefore additional attention should be paid to providing patients with more detailed and reliable information. Furthermore, the research confirms that carrying out only one training is often insufficient for the patient to repeat all the activities correctly. It has been proven that it is good to reinforce the given advice three times to achieve full inhalation skills [26]. The quality of the provided education by trained pharmacists was much higher in the subjective mystery patient assessment. Moreover, the scores obtained for the individual activities performed during inhalation education were significantly higher for these pharmacists. Publications indicate that qualified pharmacists have been providing that kind of education in many countries for years. A professional pharmacist consultation may bring many positive effects to the patient's pharmacotherapy, therefore their role is extremely significant. [27, 28, 29]. Patients using inhalers require detailed instructions. Pharmacists should consult patients not only when receiving the first inhaler, but also during each subsequent visit. This provides an ideal opportunity to evaluate the correct use of the device. However, a pharmacist should first undertake appropriate training themselves, in order to be able to educate patients effectively and properly. Research shows that trained pharmacists get practical skills and broaden their knowledge, which has a huge impact on improving asthma and COPD control in patients. Without specific training, they will not have the required skills to provide an effective consultation to patients [7, 30].
Diseases of the respiratory system are a serious health problem, and asthma or COPD are classified in the categories of civilization diseases [7, 31]. The health system in Poland is increasingly struggling with the underdiagnosis of these kinds of patients, who instead of specialists, seek information on the internet, especially during the COVID-19 pandemic, when access to physicians is limited. Poor access to professional care is associated with a high risk of underdiagnosis and perilous therapeutic decisions [32]. The pharmacists definitely play an important role in patient health care. While other specialists closed their doors to patients during the pandemic, community pharmacies remained open despite the risks. Pharmacists are now the most accessible health professionals [33]. Unfortunately, unlike in many countries where pharmaceutical care has been functioning successfully for many years, in Poland we do not have official guidelines for professional pharmacological consultations [34]. It should be emphasized that pharmacists continue to develop their skills constantly. Cyclical training has a positive impact, because pharmacists are able to refresh their knowledge and find motivation. A systematic review of effective inhalation techniques has shown that the effect diminishes over time, therefore it is important to conduct periodic training, not only for the benefit of patients, but also for pharmacists [35]. Pharmacy students also have great potential. During the university classes, they should attend as many practical exercises as possible, for example with the use of the Simulated Patients, which have shown to have a significant influence on the development of adequate skills [36]. It is worth investing in the education of students and pharmacists, because it has a great impact on the effectiveness of a patient’s pharmacotherapy, and significantly reduces unnecessary expenses of health care. The investment in education and training of pharmacists has shown to improve the health of patients with chronic diseases and constitutes a cost-effective alternative [37].