What does it take to change practice? Perspectives of pharmacists in Ontario

Strategizing the removal of barriers to community pharmacist's business management capabilities

The community pharmacist may be challenged by their dual role of being both a health care provider and practice manager. This commentary proposes strategies to address the barriers to the management role of the community pharmacist in practice as perceived by stakeholders: pharmacist owners, pharmacist managers, pharmacists, and pharmacy students. Whilst some community pharmacist owners may believe managerial skills are not required for the profession, all stakeholders for the most part agree on the barriers to the management role of the community pharmacist in practice and the strategies to address these barriers. Three barriers were identified: business versus professional dichotomy, transitioning theoretical learned content into a practice setting, and professional overload. Three strategies are proposed to overcome these barriers: developing a dual thinking process, learning practice management from mentors, and the philosophy of becoming a leader and the team builder. A paradigm shift within the current culture in the profession may be required to overcome the barriers. This commentary also highlights the need to explore leadership in community pharmacy.

Determinants of pharmacists' confidence to participate in antimicrobial stewardship: A confirmatory factor analysis

AIM

Pharmacists are essential members of hospital antimicrobial stewardship (AMS) teams. A lack of self-perceived confidence can limit pharmacists' involvement and contributions. Pharmacists working in AMS have reported a lack of confidence. There is currently a lack of validated measures to assess pharmacists' self-perceived confidence when working in AMS and contributors to this confidence. This study aimed to identify variables contributing to pharmacist self-perceived confidence and validate an AMS hospital pharmacist survey tool using confirmatory factor analysis (CFA).

METHODS

Responses from a survey of Australian and French hospital pharmacists were used to undertake CFA and path analysis on factors related to pharmacists' self-perceived confidence. It was hypothesized that pharmacists' self-perceived confidence would be impacted by time working in AMS, perceived importance of AMS programmes, perceived barriers to participating in AMS and current participation.

RESULTS

CFA demonstrated a good model fit between the factors. Items included in the model loaded well to their respective factors with acceptable reliability. Path analysis demonstrated that time working in AMS had a significant impact on pharmacists' self-perceived confidence, while perceived barriers had a negatively significant relationship. Pharmacy participation in AMS and perceived importance of AMS programmes had a non-significant impact.

CONCLUSION

Findings demonstrated that the survey tool showed good validity and identified factors that can impact pharmacists' self-perceived confidence when working in hospital AMS programmes. Having a validated survey tool can identify factors that can reduce pharmacists' self-perceived confidence. Strategies can then be developed to address these factors and subsequently improve pharmacists' self-perceived confidence.

Emotional intelligence and professional identity formation in pharmacy education

INTRODUCTION

Considering the various professional roles of pharmacists, pharmacy students and pharmacists have had difficulty identifying with a clear professional identity. Thereby there is a need for a professional identity formation (PIF) that conveys a consistent message about the role and value of pharmacists. Having a clear professional identity may also be a driver to advance the pharmacy profession. While achieving PIF is a challenging path, one element that conceivably contributes to PIF is emotional intelligence (EI). EI is acquired through life experiences and relates to personal and social awareness and the management of emotions and relationships. EI is critical for personal and professional success.

PERSPECTIVE

Pharmacy students are exposed to different pharmacists' professional identities. This faces them with challenges as they try to incorporate their roles and expectations into practice. Integrating the core elements of EI into pharmacy education through a variety of teaching and learning methods is essential in the PIF of pharmacy students. PIF will enable pharmacy students to better associate with the profession by "thinking, acting, and feeling like a pharmacist."

IMPLICATIONS

Both EI and PIF need to be integrated in pharmacy curricula. However, there is paucity of literature on how to best develop, integrate and assess EI and PIF. Therefore, a collaborative comprehensive approach by the pharmacy profession is necessary to that end.

Expanded practice for rural community pharmacy: what are we waiting for?

OBJECTIVE

To synthesise stakeholder (consumer, pharmacist and health professional) perspectives of expanded pharmacy practice in rural and remote community pharmacy.

METHODS

Comparison of perspectives of stakeholder groups identified by four studies has highlighted the expected outcomes and anticipated barriers to expanded pharmacy practice. Aligning the studies has identified priority areas of health for which pharmacists may be able to provide expanded service delivery.

KEY FINDINGS

Expanded pharmacy services are supported by consumers, pharmacists and health professionals and are expected to improve health outcomes for rural and remote populations. Barriers will need to be overcome for expanded services to be sustainable in the future.

CONCLUSION

The pharmacy profession will need to undertake a paradigm shift to professional practice and work towards this should begin to reduce the health inequality for rural populations.

Caregivers' Perspectives of Pharmacist Intervention in Children's Antibiotic Prescriptions for Upper Respiratory Tract Infections

Background: Community pharmacists can help fight antimicrobial resistance by intervening in children's antibiotic prescriptions for upper respiratory tract infections (URTIs). However, caregivers' attitudes and perspectives on this are unknown. Objective: To evaluate children's caregivers' acceptability of pharmacists intervening in their antibiotic prescriptions for URTIs with respect to their knowledge of and attitude toward pharmacists and knowledge, beliefs, and behaviors related to antibiotics. Methods: A 69-item survey was created and sent to a panel of caregivers. ANCOVA and path analysis were used to evaluate the relationship between caregiver characteristics and their acceptability of pharmacists intervening in children's antibiotic prescriptions for URTIs. Results: Responses from 246 caregivers who met the inclusion and exclusion criteria were analyzed. Mean caregivers' acceptability of pharmacists intervening in children's antibiotic prescriptions for URTIs was 3.25 out of 5 (±1.01). The ANCOVA model (adjusted R² = .636) showed positive attitude toward pharmacists and being more accepting of health advice from pharmacists since the start of the COVID-19 pandemic were associated with higher caregiver acceptability of pharmacists intervening in children's antibiotic prescriptions. Caregivers with better relationships with their pharmacist also tend to have better attitudes toward pharmacists. Not wanting antibiotics for symptom relief was associated with decreased acceptability scores. Conclusion: Overall caregiver acceptability of pharmacists intervening in antibiotic prescriptions was slightly above neutral. Building a relationship with caregivers could help change their attitude and increase the acceptability of pharmacists intervening in children's antibiotic prescriptions. Caregivers seeking symptomatic relief may be more open to non-antibiotic alternatives.

Identifying barriers, facilitators and behaviour change techniques to the adoption of the full scope of pharmacy practice among pharmacy professionals: Using the Theoretical Domains Framework

BACKGROUND

As pharmacy evolves, pharmacy professionals continue to struggle to practice to their full scope. A theoretically-informed intervention to change practice can support pharmacy professionals in providing full scope services. The Theoretical Domains Framework (TDF) can inform the design of a behaviour change intervention to improve the uptake of full scope services among pharmacy professionals.

OBJECTIVES

This study aimed to: (1) identify barriers and facilitators influencing the adoption of full scope services among pharmacy professionals, and (2) identify optimal behaviour change techniques (BCTs) to address the identified barriers and facilitators.

METHODS

A three-step, mixed method study was conducted. First, a 24-item TDF-based survey was sent via email to users of a national computer-based educational platform (n = 2696). Second, TDF-based interviews were conducted with a convenient sample of survey respondents and analyzed using the framework method. Finally, validated linkages were used to link BCTs with corresponding barriers and facilitators, then interview data were analyzed using a deductive approach to guide the selection of the BCTs.

RESULTS

A total of 225 participants completed the survey and 24 telephone interviews were conducted (17 pharmacists, 7 pharmacy technicians). A number of key barriers were identified on an individual level (e.g., lack of clear professional identity and limited decision-making skills in ambiguous cases) and on an organizational level (e.g., lack of social support from managers and concerns about making more errors with the current workflow). Mapping the barriers and facilitators to BCTs yielded 18 BCTs to support the adoption of full scope services, including modeling, rehearsal/practice, and social support.

CONCLUSIONS

This study highlighted several barriers that need to be addressed to facilitate pharmacy professionals working to their full scope, including professional collaboration, professional identity, and adequate training. A comprehensive intervention combining skills training with modeling, social support, and decision-making tools could encourage practice change.

Exploring multi-stakeholder perceptions of practice-related facilitators to optimising the quality of integration of regulated pharmacy technicians in community pharmacy in Ontario: a qualitative study

OBJECTIVES

The objective of this study was to investigate multi-stakeholder perceptions of practice-related facilitators to optimising the quality of Regulated Pharmacy Technician (RPT) integration into the community workforce in Ontario. Facilitators to incorporating technicians into the workflow and supporting their optimal scope of practice were explored.

METHODS

A qualitative exploratory study comprising a series of one-to-one interviews using a piloted, semi-structured interview guide was conducted with four community pharmacy stakeholder groups; pharmacists, RPTs, pharmacy assistants and pharmacy owners. Interviews were conducted until saturation of themes. Verbatim transcripts were coded inductively using the software, NVivo v12 (QSR International) and general inductive analysis identified key findings.

KEY FINDINGS

Twenty-seven interviews were conducted consisting of seven pharmacists, seven RPTs, eight assistants and five pharmacy owners working within community pharmacy and/or academia or hospital. All participants from every stakeholder group acknowledged that the promise of regulation of pharmacy technicians was unfulfilled in practice. Three major themes of practical significance were derived: (i) A viable business plan that incorporates RPT remuneration and ensures sustainability is a facilitator to fuller integration of RPTs, (ii) Planning the pharmacy workflow to support RPTs' and pharmacists' evolving scopes is a facilitator to RPT integration and (iii) Schedule planning to incorporate RPTs and appropriate staffing ratios in relation to prescription volume and pharmacy services allows for optimal utilisation of RPT skills and facilitates their integration.

CONCLUSIONS

Achieving integration of RPTs into the business of a community pharmacy has educational, workplace and regulatory implications, requiring the effective engagement of all stakeholders in pharmacy.

Relational professional identity: How do pharmacy students see themselves in relation to others?

BACKGROUND

As the pharmacy profession moves towards patient-centred care, pharmacy schools have updated their curricula to prepare students for a full scope of practice. A critical objective of the new curricula is the professional socialization of pharmacy students into relational aspects of the profession: how pharmacists should interact with patients and other health care professionals. Through an examination of how one cohort of pharmacy students perceives its relationship to patients and physicians, this study aims to determine how these relational aspects of professional identity evolve with time spent in the program.

METHODS

At 3 time points over a 2-year period, pharmacy students were asked to detail in writing how they would communicate with a physician concerning a hypothetical drug allergy scenario. A directed content analysis of their responses was conducted based on 3 main analytic categories: patient-centredness, physician collaboration and physician deference. These categories were further divided into 6 subcategories that were used as the variables for analysis. Statistical analyses examined longitudinal group trends for these variables.

RESULTS

Over the 2 years of observation, an examination of the proportion of messages demonstrating the subcategories of interest showed that the only measure of the pharmacy students' relational professional identity that changed significantly over time occurred for the perception of a sense of shared care for the patient. All other aspects of their relational identity were stagnant and did not change as they progressed through training (χ2; 12.772, df = 2, p < 0.002).

CONCLUSION

Our results suggest that the relational professional identity of participants was poorly developed with regards to both patients and physicians. Pharmacy educators must reexamine the methods currently being employed to foster students' professional identity development to ensure that new graduates are prepared to meet the challenges of a changing scope of practice. Can Pharm J (Ott) 2021;154:xx-xx.

Pharmacists' "Full Scope of Practice": Knowledge, Attitudes and Practices of Rural and Remote Australian Pharmacists

Purpose

Poor health outcomes for patients living in rural and remote areas of Australia are often attributed to the lack of a range of accessible health professionals delivering health services. Community pharmacists are already an integral part of these communities and as such are often the most frequently consulted health professionals. The aim of this study was to explore rural pharmacist knowledge and experiences of expanded pharmacy and to identify the barriers and enablers to remote pharmacists providing expanded pharmacy services (EPS), which can be described as services outside of usual medication management tasks.

Methods

Rural and remote pharmacists (Modified Monash Model (MMM) categories 2–7) participated in an online survey. Descriptive statistics and chi-squared tests were performed and data from open-ended questions were analyzed, categorized into themes and quantitized.

Results

Two-thirds (n=13, 68%) of rural pharmacists surveyed (n=19) had knowledge of EPS in rural pharmacies and the majority (n=17, 89%) agreed that these services would benefit rural communities. Mental health service referral was considered very/extremely important by the majority (n=16, 84%) of respondents; however, no pharmacists were currently providing mental health screening services while (n=15, 79%) were willing to provide these services. While staff shortages, costs, time and training were indicated to be the main barriers to the provision of EPS, enablers included accessibility of rural pharmacies and a perceived need.

Conclusion

This study indicated that pharmacists are already providing some EPS and see value in their implementation; however, what constitutes an expanded service was unclear to some participants. Mental health services were highlighted as most important demonstrating a recognized burden of mental illness in rural and remote locations. Findings from this pilot study will provide further understanding for future development of the pharmacist’s scope of practice and implementation of EPS.

Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

Educational needs of community pharmacy staff in minor ailment service delivery: A systematic scoping review

BACKGROUND

Minor ailment services (MASs) are structured, protocol driven pharmacy services established locally or nationally. Community pharmacy staff may benefit from education and training to deliver MASs. Our objective was to examine the evidence regarding training, education, and assessment requirements associated with the delivery of MASs by community pharmacists and other community pharmacy staff.

METHODS

Two independent literature search strategies were conducted to examine the grey literature and scientific literature. Inclusion criteria consisted of English written literature related to the training of pharmacists, medicine counter assistants (MCAs), pharmacy technicians, and pharmacy students in the context of MASs.

RESULTS

Sixty-six grey literature records (n = 57) and scientific articles (n = 9) met inclusion criteria. Most trainings targeted community pharmacists and focused on clinical care aspects that did not include guidance on service parameters and MAS delivery. Training lacked uniformity and varied in terms of time commitment, cost, curricula, and assessment processes. Limited training was identified for community pharmacy staff, particularly MCAs.

IMPLICATIONS

MAS training is primarily provided for community pharmacists, with scant MAS training for community pharmacy support staff. Furthermore, existing training for any stakeholder group did not include guidance pertaining to service delivery. A structured training approach for the entire community pharmacy team is recommended to promote MAS outcomes and deliver a robust, high quality service. Detailed protocols and guidelines may be needed to ensure skilled MAS providers can deliver quality patient care.

Role Theory: A Framework to Explore Health Professional Perceptions of Expanding Rural Community Pharmacists' Role

Pharmaceutical care is a concept which has moved the pharmacy profession from their primary focus on the product to optimising drug therapy for the individual patient. Expanded pharmacy practice beyond pharmaceutical care will further challenge the role perceptions that other health professionals have about pharmacists. Role theory as a philosophical perspective was used to explore rural and remote health professionals' beliefs on pharmacists expanding their clinical role by conducting twenty-three semi-structured interviews. Five role theory categories described the data, role ambiguity, role conflict, role overload, role identity and role insufficiency. The health professionals interviewed were found to be uncertain about the boundaries between the traditional roles of the pharmacist compared to that of the expanded roles. A perceived lack of accountability by pharmacists was seen as a major contributor to role conflict, which in turn was found to impact the ability of pharmacists and other health professionals to work collaboratively. Perspectives of other health professionals on pharmacists adopting expanded practice models has highlighted significant concerns with role conflict and role identity. Acknowledging and developing clear strategies to address these concerns is essential to ensure that expanded pharmacy practice can be effectively integrated to improve access to health services and thus health outcomes for rural Australians.

A Review of Strategies for Enhancing Clarity and Reader Accessibility of Qualitative Research Results

Objective. To characterize elements of the results section of qualitative research reports that make findings more accessible to readers. Methods. Two analytical methods were used for this review. First, published reviews and textbooks written by experts outlining how to evaluate qualitative research were retrieved and reviewed to identify common elements that enhance clarity of the results section. In the second analysis, the authors analyzed the results sections of a subset of qualitative studies to identify, from a reader's point of view, aspects that enhanced and detracted from communication of the results. Findings. Four elements improve accessibility of the results section for readers of qualitative research reports. Content, the first element, describes what information the reader should look for in the results section. Style of results, the second element, identifies wording choices that improve reader accessibility and understanding. Narrative flow, the third element, describes a results section that flows smoothly and logically. Structural cohesiveness, the final element, outlines effective organization of the results section. Results. While authors take several approaches to the presentation of results in qualitative research reports, some strategies appear to be more common and effective than others. The efficient presentation of results can impact a reader's assessment of the quality and credibility of a study. Identified content and stylistic elements should be considered by authors hoping to make the results of their qualitative research more accessible and comprehensible to readers.

Learning Needs of Pharmacists for an Evolving Scope of Practice

Around the world, changes in scope of practice regulations for pharmacists have been used as a tool to advance practice and promote change. Regulatory change does not automatically trigger practice change; the extent and speed of uptake of new roles and responsibilities has been slower than anticipated. A recent study identified 9 pre-requisites to practice change (the 9Ps of Practice Change). The objective of this study was to describe how educationalists could best apply these 9Ps to the design and delivery of continuing professional development for pharmacists. Twenty community pharmacists participated in semi-structured interviews designed to elicit their learning needs for scope of practice change. Seven supportive educational techniques were identified as being most helpful to promote practice change: (i) a coaching/mentoring approach; (ii) practice-based experiential learning; (iii) a longitudinal approach to instructional design; (iv) active demonstration of how to implement practice change; v) increased focus on soft-skills development; (vi) opportunities for practice/rehearsal of new skills; and (vii) use of a 360-degree feedback model. Further work is required to determine how these techniques can be best applied and implemented to support practice change in pharmacy.

What makes pharmacists successful? An investigation of personal characteristics

OBJECTIVES

The primary objective of this study was to identify characteristics of pharmacists that contribute to their success.

DESIGN

A working definition of success in pharmacy practice was derived from a scoping literature review and is based on the premise that successful pharmacists practice to full scope within the context of their practice setting. Semistructured individual interviews were conducted with selected pharmacists. Potential candidates were nominated by leading pharmacists in the field with the use of our prespecified definition of success. Lists from the nominators were compared, and pharmacists who appeared on more than 1 list were invited to participate. The interview tool was developed with the use of previous research on success in health care professions.

SETTING AND PARTICIPANTS

Participants were 10 practicing pharmacists in a variety of locations (5 urban/5 rural) and practice settings (5 hospital/4 community/1 ambulatory care).

OUTCOME MEASURES

Themes related to successful pharmacists practicing to full scope.

RESULTS

Pharmacists meeting our definition of success were engaged in assessment and care planning, other expanded scope activities, and interpersonal activities and collaboration. The 10 interviewed pharmacists described motivation, critical thinking, emotional intelligence, core competencies, and work-life balance as significant contributors to their success.

CONCLUSION

Several characteristics were identified as potentially related to success. These characteristics may be useful in pharmacists identifying areas for personal growth and development.

Training Needs of Manitoba Pharmacists to Increase Application of Assessment and Prescribing for Minor Ailments into Practice: A Qualitative and Quantitative Survey

Current literature demonstrates the positive impact of pharmacists prescribing medication on patient outcomes and pharmacist perceptions of the practice. The aim of this study was to understand the factors affecting prescribing practices among Manitoba pharmacists and identify whether additional training methods would be beneficial for a practice behavior change. A web-based survey was developed and participation was solicited from pharmacists in Manitoba. Descriptive statistics were calculated to summarize the frequency of demographic characteristics. Chi-square tests were used to explore possible correlations between variables of interest and thematic analysis of qualitative data was completed. A total of 162 participants completed the survey. The response rate was 12.3%. Of those who had met the requirements to prescribe, none were doing so on a daily basis and 23.5% had not assessed or prescribed since being certified. Respondents identified the top barriers for providing this service as a lack of sufficient revenue and a lack of time. Qualitative analysis of responses identified additional barriers including a limiting scope and inadequate tools. Approximately half (54.4%) of respondents expressed that additional training would be of value. The themes identified from the survey data suggest that practice-based education would help pharmacists apply skills. In addition, expansion of prescribing authority and strategies addressing remuneration issues may help overcome barriers to pharmacists prescribing within Manitoba.