Barriers and facilitators to pharmacists integrating into the ward-based multidisciplinary team: A systematic review and meta-synthesis

Prevalence, pandemic, preventions and policies to overcome antimicrobial resistance

Antimicrobial resistance (AMR) is a growing concern in Asia, and it is essential to understand the prevalence, pandemic, prevention, and policies to overcome it. According to the World Health Organization (WHO), AMR is one of the main causes of death; in 2019, it was linked to 4.95 million fatalities and caused about 1.27 million deaths. A core package of actions has been provided by WHO to help countries prioritize their needs when creating, carrying out, and overseeing national action plans on antimicrobial resistance. Using a people-cantered approach to AMR, the interventions address the needs and obstacles that individuals and patients encounter when trying to obtain healthcare. The people-cantered core package of AMR treatments seeks to improve public and policymakers; awareness and comprehension of AMR by changing the narrative of AMR to emphasize the needs of people and systemic impairments. Additionally, it backs a more comprehensive and programmatic national response to AMR, which emphasizes the value of fair and inexpensive access to high-quality healthcare services for the avoidance, identification, and management of drug-resistant diseases. The report signals increasing resistance to antibiotics in bacterial infections in humans and the need for better data. In conclusion, the prevalence of AMR in Asia is a significant public health concern, and it is crucial to implement policies and interventions to overcome it.

Exploration of 'micro' level factors that affect the involvement of clinical pharmacists in interprofessional ward rounds in hospitals: Through the lens of social cognitive theory

BACKGROUND

Macro and meso level factors that influence the participation by clinical pharmacists in ward rounds include pharmacy management culture, commitment to ward rounds and adequate time for ward rounds being included in workload models. The 'micro' level factors that affect the involvement of clinical pharmacists in ward rounds have not been widely explored.

OBJECTIVE

Explore 'micro' level factors to gain insight into clinical pharmacists' participation in interprofessional ward rounds in inpatient settings through the lens of social cognitive theory.

METHOD

A qualitative focused ethnographic study with five clinical pharmacists, four medical practitioners, one allied health professional and one nurse was conducted in three metropolitan hospitals in Southern Australia. Seven hours of semi-structured interview (n = 11) and 76-h of observations (n = 5) were conducted. A qualitative descriptive analysis was conducted (guided by Spradley) followed by reflexive thematic-analysis (according to Braun and Clarke's technique).

RESULTS

Three micro level factors influencing clinical pharmacist participation in ward rounds are: (1) Cognitive mindset of clinical pharmacists, (2) Behavioural conduct of clinical pharmacists, and (3) Social rules of the ward. Clinical pharmacists that did not participate in ward round reconciled their moral distress by transferring information without clinical judgement or interpretation of the patient scenario to medical practitioners. Clinical pharmacists that did participate in ward rounds demonstrated credibility by making relevant recommendations with a holistic lens. This enabled clinical pharmacists to be perceived as trustworthy by medical practitioners. Positive experiences of participating in ward rounds contributed to their cognitive upward spiral of thoughts and emotions, fostering continued participation.

CONCLUSION

Clinical pharmacists participate in ward rounds when they develop a positive mindset about ward round participation and perceive ward rounds as an enabler to the establishment of trusted professional relationships with medical practitioners. This trusted relationship creates an environment where the pharmacist develops confidence in making relevant recommendations.

Barriers and facilitators of pharmacists' integration in a multidisciplinary home care team: a qualitative interview study based on the normalization process theory

BACKGROUND

There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team.

METHODS

Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data.

RESULTS

Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists' competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists' contributions positively impacted the multidisciplinary practice.

CONCLUSION

Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists' skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team.

Embedded on-site aged care pharmacists in Australia: Insights from early adopters of a new workforce model

OBJECTIVE

To explore the roles of early adopters of Australia's embedded on-site pharmacist model in supporting quality use of medications in residential aged care facilities (RACFs).

METHODS

Qualitative semistructured interviews were conducted with 15 pharmacists working as embedded on-site pharmacists, or beyond the scope of traditional consultant pharmacist roles in Australian RACFs. Interviews were audio-recorded, transcribed and thematically analysed independently by two investigators using an inductive approach. Deductive analysis was also undertaken using a knowledge broker framework: knowledge manager, linkage agent and capacity builder.

RESULTS

Dominant themes were roles and benefits of embedded pharmacists, factors associated with success and challenges. Roles and benefits included (1) resident-level interventions and an enhanced ability to provide collaborative outcome-focussed resident-centred care, including timely input and follow-up, and improved relationships with residents, family and interdisciplinary team; and (2) system-level interventions such as contributing to clinical governance and quality improvement. Factors associated with success included personal capabilities and approach of the pharmacist, and organisational culture and sector-wide support. Challenges included pharmacist workforce shortages, perceived lack of pharmacist readiness and difficulty determining an appropriate service model. Deductive coding demonstrated roles of embedded pharmacists were consistent with all three activities of a knowledge broker.

CONCLUSIONS

This study highlights the resident- and system-level roles and benefits of embedded on-site pharmacists, and provides a framework for defining this emerging workforce model in Australian RACFs.

Validation of the Identification of Medication Adherence Barriers Questionnaire (IMAB-Q); a Behavioural Science-Underpinned Tool for Identifying Non-Adherence and Diagnosing an Individual's Barriers to Adherence

Purpose

To validate the Identification of Medication Adherence Barriers Questionnaire (IMAB-Q) as a tool to guide practitioners to identify patients who require support to take their medicines as prescribed, their key barriers to adherence and select relevant behaviour change techniques.

Patients and Methods

Adults prescribed medication for cardiovascular disease prevention were recruited from nine community pharmacies in England. Participants completed the IMAB-Q comprising 30 items representing potential barriers to adherence developed from our previous mixed methods study (scoping review and focus groups) underpinned by the Theoretical Domains Framework. Participants also self-reported their adherence on a visual analogue scale (VAS) ranging from perfect adherence (100) to non-adherence (1). A subgroup of 30 participants completed the IMAB-Q twice to investigate test-retest reliability using weighted Kappa. Mokken scaling was used to investigate IMAB-Q structure. Spearman correlation was used to investigate IMAB-Q criterion validity compared to the VAS score.

Results

From 1407 invitations, 608 valid responses were received. Respondents had a mean (SD) age of 70.12 (9.9) years and were prescribed a median (IQ) 4 (3, 6) medicines. Worry about unwanted effects (n = 212, 34.5%) and negative emotions evoked by medicine taking (n = 99, 16.1%) were most frequently reported. Mokken scaling did not organise related IMAB-Q items according to the TDF domains (scalability coefficient H = 0.3 to 0.6). Lower VAS self-reported adherence correlated with greater IMAB-Q reported barriers (rho = -0.14, p = 0.001). Test-retest reliability of IMAB-Q items ranged from kappa co-efficient 0.9 to 0.3 (p < 0.05).

Conclusion

The IMAB-Q is valid and reliable for identifying people not adhering and their barriers to adherence. Each IMAB-Q item is linked to a TDF domain which in turn is linked to relevant behaviour change techniques. The IMAB-Q can therefore guide patients and practitioners to select strategies tailored to a patient's identified barriers.

Practices, barriers and facilitators to the delivery of pretravel health services by community pharmacists: A scoping review using the theoretical domains framework

BACKGROUND

The involvement of community pharmacists (CPs) in the provision of pretravel health services is increasing due to the increase in international travelers, the increased risk of travel-related diseases, and the expansion of pharmacists' scope of practice in some countries. In order to improve the quality and effectiveness of pretravel health care provided by CPs, a greater understanding of the practices, barriers, and facilitators is required.

OBJECTIVE

This scoping review aimed to identify and describe existing studies on pretravel health services provided by CPs, and the barriers, and facilitators.

METHODS

The PubMed, Science Direct, Scopus, and Web of Science databases were searched for pertinent studies from their inception to February 2023. A manual search was also conducted of prominent travel medicine journals, Google Scholar, and the reference lists of the included studies. Potential barriers and facilitators were mapped to the 14 domains of the Theoretical Domains Framework (TDF).

RESULTS

There were twelve studies included in the review. Pretravel health advice was the most prevalent form of pretravel health services. Within ten domains of the TDF, various factors that either facilitate or impede the provision of pretravel health services by CPs were identified.

CONCLUSION

The provision of pretravel health services by CPs may be affected by a number of practitioner and organizational factors. The provision of pretravel health services can be facilitated by informational resources, training and education in travel medicine, and collaboration amongst healthcare providers.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BACKGROUND

Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.

METHODS

Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.

RESULTS

The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).

CONCLUSION

The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.

TRIAL REGISTRATION

NCT03695081.

Factors influencing clinical pharmacists' integration into the clinical multidisciplinary care team

Objectives: To investigate the factors influencing clinical pharmacists' integration into the clinical multidisciplinary care team, using interprofessional collaboration between clinical pharmacists and physicians as the focus. Methods: Through stratified random sampling, a cross-sectional questionnaire survey was conducted among clinical pharmacists and physicians in secondary and tertiary hospitals in China from July to August 2022. The questionnaire, comprising the Physician-Pharmacist Collaborative Index (PPCI) scale to reflect the collaboration level and a combined scale to measure influencing factors, was made available in two versions for clinical pharmacists and physicians. Multiple linear regression was adopted to analyze the association between the collaboration level and influencing factors, as well as the heterogeneity of the significant factors in hospitals of different grades. Results: Valid self-reported data from 474 clinical pharmacists and 496 paired physicians were included, who were serving in 281 hospitals from 31 provinces. In terms of participant-related factors, standardized training and academic degree, respectively, exerted significant positive effects on the perceived collaboration level by clinical pharmacists and physicians. In terms of context characteristics, manager support and system construction were the main factors for improving collaboration. In terms of exchange characteristics, clinical pharmacists having good communication skills, physicians trusting others' professional competence and values, and both parties having consistent expectations had significant positive effects on collaboration. Conclusion: The study provides a baseline data set on the current level and associated factors of clinical pharmacists' collaboration with other professionals in China and other countries with a related health system, providing references for individuals, universities, hospitals, and national policymakers to facilitate the development of clinical pharmacy and multidisciplinary models and further improve the patient-centered integrated disease treatment system.

Clinical pharmacists' participation in ward rounds in hospitals: responses from a national survey

OBJECTIVES

The inclusion of clinical pharmacists in ward rounds (WRs) can reduce adverse drug events, improve communication and enable collaborative decision-making. The aim of this study is to investigate the level of and factors that influence WR participation by clinical pharmacists in Australia.

METHODS

An online administered, anonymous survey of clinical pharmacists in Australia was conducted. The survey was open to pharmacists aged ≥18 years, who had worked in an Australian hospital in a clinical role in the previous two weeks. It was distributed via The Society of Hospital Pharmacists of Australia and on pharmacist-specific social media threads. Survey questions related to the extent of WR participation and factors that influence WR participation. Cross-tabulation analysis was conducted to determine whether there was an association between WR participation and factors that influence WR participation.

KEY FINDINGS

Ninety-nine responses were included. The level of WR participation by clinical pharmacists in Australian hospitals was low, with only 26/67 (39%) pharmacists who had a WR in their clinical unit actually attending the WR in the previous 2 weeks. Factors that influenced WR participation included having recognition of the role of the clinical pharmacist within the WR team, support from pharmacy management and the broader interprofessional team, and having adequate time and expectation from pharmacy management and colleagues to participate in WRs.

CONCLUSIONS

This study highlights the need for ongoing interventions such as restructuring workflows and increasing the awareness of the role of a clinical pharmacist in WR to increase participation of pharmacists in this interprofessional activity.

Barriers and enablers to deprescribing for older people in care homes: The theory-based perspectives of pharmacist independent prescribers

BACKGROUND

Over 70% of care home residents are prescribed potentially inappropriate medications (PIMs) associated with morbidity and mortality. Deprescribing is a common recommendation by pharmacists performing medication reviews in care homes, however requiring prescriber authorisation is a barrier. Care home Independent Pharmacist Prescribing Study (CHIPPS), a cluster randomised control trial integrated pharmacist independent prescriber (PIPs) into care homes to improve medication management, providing a unique opportunity to identify their barriers and enablers to deprescribing.

OBJECTIVES

To identify barriers and enablers to PIPs deprescribing medications in care homes.

METHODS

Secondary qualitative framework analysis was performed on interviews with CHIPPS' PIPs. A maximum variation sampling approach was used to select from the 14 PIPs included in the process evaluation to achieve diversity of PIPs' contextual factors e.g., previous experience in care homes. Transcripts were coded inductively for barriers and enablers to deprescribing and then mapped to Theoretical Domains Framework (TDF).

RESULTS

Eleven PIP's interviews were sampled. Factors acted as enablers and barriers were PIP relationship with General Practitioner (GP), care home staff and residents/families, awareness of the PIP role and family trust in PIPs' deprescribing activities (social influences); PIPs' independent prescribing confidence, previous experience and ability dealing with residents' medications (beliefs about capabilities); understanding of PIP role and PIP confidence in their role as an independent prescriber (Social/professional role and identity); access to residents' records, deprescribing decision support, regular follow-up from care home staff, resident difficulties with medications, teamwork, and time restraints (Environmental context and resources). One factor acted as a barrier: believing negatives of deprescribing outweigh benefits regarding certain medications (Beliefs about consequences).

CONCLUSION

PIPs' involvement in deprescribing within care homes is influenced by multiple barriers and enablers. Data mapped to TDF domains represent barriers that need addressing and enablers that should be highlighted to enhance PIPs' effectiveness in future interventions.

Pharmacist-independent prescriber deprescribing in UK care homes: Contextual factors associated with increased activity

AIMS

The Care Home Independent Pharmacist Prescriber Study (CHIPPS) process evaluation hypothesized that contextual factors influenced the likelihood of deprescribing by pharmacist-independent prescribers. The aim of this paper is to test this hypothesis.

METHODS

From CHIPPS study data, medications deprescribed totalled 284 for 370 residents in UK care homes. Regression analysis was used to describe the relationship between the number of medicines stopped and contextual factors (number of residents cared for, pharmacist employment within associated medical practice, previous care home experience, hours active within trial, years' experience as a pharmacist and as a prescriber).

RESULTS

Number of residents and pharmacist-independent prescriber employment within a medical practice were positive predictors of deprescribing.

CONCLUSION

Previous experiences were not related to deprescribing likelihood. Increasing the number of residents increases the opportunity for deprescribing and therefore this relationship is intuitive. The location within a medical practice is an interesting finding that requires further exploration to understand its exact nature.

General practitioners' perceptions of pharmacists working in general practice: a qualitative interview study

BACKGROUND

Pharmacists are being increasingly employed as part of general practice teams globally, and their input has been associated with several clinical and economic benefits. However, there is a paucity of research focussing on general practitioners' (GPs') perceptions of pharmacist integration into practices in countries where this novel role for pharmacists is yet to become commonplace.

OBJECTIVE

To explore GPs' perceptions of integrating pharmacists into general practices and to identify the behavioural determinants of GPs integrating pharmacists into practices.

METHODS

Semistructured interviews were conducted with GPs practising in Ireland, who were sampled using a combination of purposive, convenience, and snowball sampling. Interviews were audio-recorded and transcribed verbatim, which then were analysed using conventional content analysis and directed content analysis employing the Theoretical Domains Framework (TDF).

RESULTS

Seventeen GPs were interviewed between November 2021 and February 2022. Seven TDF domains were identified as predominant in influencing GPs' perceptions of pharmacist integration into general practices. These perceptions were mostly positive, especially regarding patient outcomes, cost savings, and improving access to care. However, there were concerns about funding the role, affecting others' workloads, and pharmacists' training needs to work in practices.

CONCLUSION

This study's theory-informed insight provides a deeper understanding of GPs' perceptions of pharmacists working in general practice and behaviours which can be targeted to help optimize integration. These findings should be utilized in future service development to preempt and address GPs' concerns ahead of pharmacist integration, as well as to inform the development of general practice-based pharmacist roles going forward.

Viewing interprofessional collaboration through the lens of networked ecological systems theory

Interprofessional collaboration (IPC) is key to ensuring safe quality care for patients. However, IPC intervention outcomes are variable, leading to calls for systems theories to understand complex interactions in healthcare. Using networked ecological systems theory (NEST), we aimed to uncover facilitators and barriers impacting the interactions between nurses and physicians in a specialty healthcare center. A qualitative study involving 55 non-participant observations and 17 individual semi-structured interviews was conducted at the National Neuroscience Institute of Singapore from April 2019 to March 2021. Template analysis was used to analyze the data. The most important IPC facilitators were exosystemic institutional support and physicians' willingness to engage in IPC in the microsystems that together enabled the establishment of disease-based outpatient programs fostering patient-centered interactions among different healthcare professionals (HCP). We also found that patient-, disease-, and systems-related knowledge played an important role in facilitating IPC. Macrosystemic entrenchments such as intraprofessional composition of ward rounds emerged as a significant barrier. However, microsystemic efforts such as chat groups connecting all HCP involved in the care of the patients in the wards have fostered IPC. Although still preliminary, these findings suggest NEST can be useful to inform systematic interventions to improve IPC.