In search for gold - The relevance of realist reviews and evaluations to pharmacy research and policy development

A realist evaluation of the development of extended pharmacist roles and services in community pharmacies

BACKGROUND

Internationally, community pharmacy models of care have been moving away from a focus on dispensing to extended, clinically-focused roles for pharmacists.

OBJECTIVES

To identify how community pharmacy strategies were being implemented in Aotearoa New Zealand; how changes were expected to influence health and health system outcomes; what extended services were being delivered; the responses of pharmacists, other health professionals and consumers to these developments; and the contexts and mechanisms supporting the successful implementation of new community pharmacy services.

METHODS

A realist evaluation methodology was employed, to explore a complex policy intervention. Realist evaluation explores the contexts (C) within which initiatives are introduced and identifies the mechanisms (M) triggered by different contexts to produce outcomes (O). Realist evaluation processes iteratively develop, test, and refine CMO configurations. In this study, initial programme theories were developed through key government and professional policy documents, then refined through key informant interviews, a survey and interviews with pharmacists and intern (pre-registration) pharmacists, and finally, 10 case studies of diverse community pharmacies.

RESULTS

Four intermediate health service outcomes were identified: development of extended community pharmacist services; consumers using extended community pharmacist services; more integrated, collaborative primary health care services; and a fit-for-purpose community pharmacy workforce. Enabling and constraining contexts are detailed for each outcome, along with the mechanisms that they trigger (or inhibit).

CONCLUSIONS

There are wide-ranging and disparate levers to support the further development of extended community pharmacy services. These include aligning funding with desired services, undergraduate educators and professional leaders setting expectations for the pharmacists' role in practice, and the availability of sufficient funding and time for both specific extended service accreditation and broader postgraduate training. However, no simple "fix" can be universally applied internationally, nor even in pharmacies within a single jurisdiction, to facilitate service development.

Realist research to inform pharmacy practice and policy

Theory-driven implementation and evaluation of pharmacy services can enhance their contribution to overall healthcare. As complex interventions most pharmacy practice programmes and services will be adopted and modified during their implementation into various healthcare contexts and systems. Realist approaches to theory-driven evaluation consider these variations in programmes, interventions and the contexts of their implementation and establish theories on how they work best, for whom and why. This paper illustrates the practical application of the realist philosophy of science to pharmacy practice relevant areas of healthcare using two case studies, a realist synthesis of existing literature on medication reviews and a realist review and evaluation related to medicines management. Applying realist logic establishes causative explanations of what could be essential factors in the success of programmes, enabling policy makers in their decision-making and pharmacy practice researchers as well as practitioners in optimising service design.