Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory

Provision of Patient Care Services and Goals for Expansion in Community and Ambulatory Care Pharmacies in Southeastern North Carolina

In February 2022, the North Carolina legislature expanded pharmacist dispensing authority without a prescription. We conducted a cross-sectional interview of currently licensed pharmacy managers of outpatient pharmacies located in five counties in southeastern North Carolina. Pharmacy managers were eligible to participate if their pharmacy was either a community pharmacy, clinic-based pharmacy, or outpatient health system pharmacy. Forty-four of 116 eligible pharmacy managers participated (38% response rate). The most common services offered by pharmacies included medication synchronization services (93.2%), on-site immunizations (90.9%), and refill reminders (88.6%). The least common services offered include INR screens (0%), A1c screens (7%), and 'incident-to' billing services associated with CPT codes: annual wellness visits (0%), chronic care management (0%), transitional care management (0%), and remote patient monitoring (2.4%). The services that pharmacy managers wanted to learn more about through continuing education included: oral/transdermal contraceptives (60.5%), administration of long-acting injectables (LAIs) (36.8%), and dispensing of HIV post-exposure prophylaxis (PEP) (23.7%).

The Pharmacy of the Future: Pharmacy Professionals' Perceptions and Contributions Regarding New Services in Community Pharmacies

The use of information and communication technologies (ICTs) has revolutionized the provision of health services, often referred to as eHealth, benefiting community pharmacies that can offer new services in innovative formats, namely through telepharmacy. This study aimed to explore the perceptions of pharmacy professionals (i.e., pharmacists and pharmacy technicians) on the provision of new services. The study consisted of administering an online questionnaire to pharmacy professionals nationwide. The questionnaire was developed by the research team, based on focus group methodology, from which an inductive analysis led to the categories that made up the dimensions of the survey. Participants were 95 pharmacy professionals with a mean age of 33.69 years old (SD = 10.75). Almost 79% were women. The results show overall receptivity to the development of new services in community pharmacies. Suggestions for the development of the new services, conditions necessary for their implementation, potential obstacles, and strategies to promote adherence to the new services, among others, are identified. The knowledge thus acquired will help community pharmacies to develop innovative solutions in counselling, pharmacotherapy monitoring, and pharmacovigilance, for example, of herb/dietary supplement-drug adverse reactions and interactions. Based on this information, new services can become more accessible, namely through the use of ICTs.

Evaluating nursing opinion and perception of maggot therapy for hard-to-heal wound management

OBJECTIVE

Maggot therapy (MT) or larval debridement therapy is a recognised, effective but underutilised treatment for the management of hard-to-heal wounds and infected ulcers. It is available on NHS prescription in the UK, where wound management is predominantly nurse-led. Anecdotal reports and published literature suggest that nurses may be reluctant to utilise the therapy. The aim of this study was to evaluate the feelings and opinions of nurses regarding the use of MT.

METHOD

The first stage of this mixed-methods study was a focus group held to discuss MT and opinions of specialist nurse clinicians. Next, an anonymised web-based online survey was launched through the Nursing Times journal and distributed through social media targeting all nurses. Finally, in-depth interviews were held with specialist and generalist nurses.

RESULTS

Awareness of MT among all nurses was extremely high. A breakdown of results showed that MT was much more highly regarded by wound specialist nurses than non-wound specialist nurses. The latter exhibited a greater level of reluctance to administer the therapy, with almost one-third of these nurses surveyed saying they found maggots disgusting and that the idea of MT made their skin crawl. In-depth interviews revealed that a lack of knowledge about MT was a prime concern.

CONCLUSION

Wound specialist nurses are more likely to embrace MT than non-wound nurse specialists, who report a varying degree of wariness to MT. Our study highlights a need for better education and training in MT for all nurses, to address issues with acceptance and willingness to treat or help treat patients with hard-to-heal wounds which are suitable for MT.

Attitudes towards adherence and deprescribing among polypharmacy patients: a cross-sectional study

Objectives

Deprescribing is the process of optimization of medication regimens through cessation of potentially inappropriate or unnecessary medications or adjustment of doses with the goal of managing polypharmacy and improving outcomes. Deprescribing potentially improves adherence by reducing polypharmacy. This study aimed to assess polypharmacy patients’ adherence attitudes and their attitudes towards deprescribing.

Methods

A cross-sectional study that targeted polypharmacy patients at outpatient clinics at King Abdullah University Hospital. The inclusion criteria were (1) patients ≥18 years old, (2) patients taking five or more medications, and (3) patients who do not require a caregiver or assistance at home. We excluded patients that showed any signs of moderate or severe cognitive impairment. Patients who met the inclusion/exclusion criteria were interviewed by a clinical pharmacist and completed two survey instruments: revised Patients’ Attitudes Toward Deprescribing (rPATD) and Adherence Attitude Inventory (AAI).

Key findings

In total, 501 patients took part in this study. Over half of the participants were not satisfied with their current medicines and over 70% of them perceived that their current medications are a burden to them and would like their prescribers to initiate deprescribing. The majority of the participants have low to medium adherence attitudes primarily due to ineffective patient–provider communication. Logistic regression analysis revealed that self-efficacy, commitment to adherence, education and age were significantly associated with participants’ willingness to stop one or more of their medications.

Conclusions

Our findings suggest that polypharmacy patients have negative attitudes towards their medication therapy and favour deprescribing. These reported attitudes had been associated with negative adherence attitudes. Study findings offer schematic direction for future investigations of the role of adherence on key health-related outcomes in patients on polypharmacy. Furthermore, research is warranted to investigate the impact of deprescribing on polypharmacy patients’ medication adherence.

Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals

Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: "understanding of the practice and perceived benefits", "acceptance and adherence to the practice, and "hindrances to the practice". The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals

Abstract Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: “understanding of the practice and perceived benefits”, “acceptance and adherence to the practice, and “hindrances to the practice”. The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Increased self-reported pharmacist prescribing during the COVID-19 pandemic: Using the Theoretical Domains Framework to identify barriers and facilitators to prescribing

Background

Community pharmacists are positioned to improve access to medications through their ever-expanding role as prescribers, with this role becoming more pronounced during the COVID-19 pandemic.

Objectives

Our research aimed to determine the extent of self-reported pharmacist prescribing pre-COVID-19 and during the COVID-19 pandemic, to identify barriers and facilitators to pharmacist prescribing, and to explore the relationship between these factors and self-reported prescribing activity.

Methods

A questionnaire based on the Theoretical Domains Framework (TDFv2) assessing self-reported prescribing was electronically distributed to all direct patient care pharmacists in NS (N = 1338) in July 2020. Wilcoxon signed-rank tests were used to examine temporal differences in self-reported prescribing activity. TDFv2 responses were descriptively reported as positive (agree/strongly agree), neutral (uncertain), and negative (strongly disagree/disagree) based on the 5-point Likert scale assessing barriers and facilitators to prescribing from March 2020 onward (i.e., ‘during’ COVID-19). Simple logistic regression was used to measure the relationship between TDFv2 domain responses and self-reported prescribing activity.

Results

A total of 190 pharmacists (14.2%) completed the survey. Over 98% of respondents reported prescribing at least once per month in any of the approved prescribing categories, with renewals being the most common activity reported. Since the pandemic, activity in several categories of prescribing significantly increased, including diagnosis supported by protocol (29.0% vs. 58.9%, p < 0.01), minor and common ailments (25.3% vs 34.7%, p = 0.03), preventative medicine (22.1% vs. 33.2%, p < 0.01). Amongst the TDFv2 domains, Beliefs about Consequences domain had the largest influence on prescribing activity (OR = 3.13, 95% CI 1.41–6.97, p < 0.01), with Social Influences (OR = 2.85, 95% CI 1.42–5.70, p < 0.01) being the next most influential.

Conclusion

Self-reported prescribing by direct patient care community pharmacists in Nova Scotia increased during the COVID-19 pandemic, particularly for government-funded services. Key barriers to address, and facilitators to support pharmacist prescribing were identified and can be used to inform future interventions.

Implementation of medicinal cannabis in Australia: innovation or upheaval? Perspectives from physicians as key informants, a qualitative analysis

OBJECTIVE

We sought to explore physician perspectives on the prescribing of cannabinoids to patients to gain a deeper understanding of the issues faced by prescriber and public health advisors in the rollout of medicinal cannabis.

DESIGN

A thematic qualitative analysis of 21 in-depth interviews was undertaken to explore the narrative on the policy and practice of medicinal cannabis prescribing. The analysis used the Diffusion of Innovations (DoI) theoretical framework to model the conceptualisation of the rollout of medicinal cannabis in the Australian context.

SETTING

Informants from the states and territories of Victoria, New South Wales, Tasmania, Australian Capital Territory, and Queensland in Australia were invited to participate in interviews to explore the policy and practice of medicinal cannabis prescribing.

PARTICIPANTS

Participants included 21 prescribing and non-prescribing key informants working in the area of neurology, rheumatology, oncology, pain medicine, psychiatry, public health, and general practice.

RESULTS

There was an agreement among many informants that medicinal cannabis is, indeed, a pharmaceutical innovation. From the analysis of the informant interviews, the factors that facilitate the diffusion of medicinal cannabis into clincal practice include the adoption of appropriate regulation, the use of data to evaluate safety and efficacy, improved prescriber education, and the continuous monitoring of product quality and cost. Most informants asserted the widespread assimilation of medicinal cannabis into practice is impeded by a lack of health system antecedents that are required to facilitate safe, effective, and equitable access to medicinal cannabis as a therapeutic.

CONCLUSIONS

This research highlights the tensions that arise and the factors that influence the rollout of cannabis as an unregistered medicine. Addressing these factors is essential for the safe and effective prescribing in contemporary medical practice. The findings from this research provides important evidence on medicinal cannabis as a therapeutic, and also informs the rollout of potential novel therapeutics in the future.

The implementation of a pharmacy residency program – A qualitative study on the diffusion of an innovation

Background

Structured workplace training supports pharmacists in achieving individual career goals as well as health services to meet workforce development goals. Hospital pharmacy residency programs offer structured training pathways for early career pharmacists. A residency program was introduced in Australia, modelled on formal programs already established in other countries.

Objective

This qualitative study explored key stakeholders' expectations and early experiences with the implementation of a pharmacy residency program using an analytical framework derived from implementation science.

Methods

Three focus groups and seven semi-structured interviews were conducted over a 24-months period with pharmacy managers, senior pharmacists and resident and non-resident pharmacists from different Australian State and hospital settings. They were audio recorded and transcribed verbatim. Transcripts were analysed via thematic analysis using Diffusion of Innovation Theory as a categorising framework.

Results

Thirty stakeholders participated in focus groups and interviews. Three of the five main factors that influenced the adoption of an innovation according to Diffusion of Innovation Theory were identified as prominent, two as weaker themes. The relative or perceived advantage of adopting or participating in a residency program was identified as a major theme. Pharmacy managers and resident pharmacists regarded individual and workforce advancement as creating a potential advantage for them. The complexity of the program's implementation, with concerns about its resourcing requirements and sustainability, influenced uptake. The compatibility of the program with already existing training pathways was explored, with the residency sharing similar objectives with current pharmacy education and workforce development goals. Observability and trialability played lesser roles in facilitating program uptake.

Conclusion

The implementation and diffusion of the pharmacy residency program can be interpreted by referring to key principles of Diffusion of Innovation Theory. Findings from this study and consideration of theory can inform the diffusion and ongoing maintenance of pharmacy workplace training and education programs.

Pharmacist dispensing of the abortion pill in Canada: Diffusion of Innovation meets integrated knowledge translation

BACKGROUND

Since Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks - Diffusion of Innovation in Health Service Organizations and integrated knowledge translation.

METHODS

We conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders.

RESULTS

We completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants' experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists.

CONCLUSIONS

We illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.

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.

A theoretically informed, mixed-methods study of pharmacists' aspirations and readiness to implement pharmacist prescribing

Background Studies have highlighted advancing clinical pharmacy practice in Qatar. Objective To explore pharmacists’ aspirations and readiness to implement pharmacist prescribing. Setting Hamad Medical Corporation (HMC), the main provider of secondary and tertiary care. Method A sequential explanatory mixed-methods design. Questionnaire items were derived from the Consolidated Framework of Implementation Research (CFIR), in domains of: awareness/support; readiness; implementation; and facilitators and barriers. Following piloting, all pharmacists (n = 554) were invited to participate. Questionnaire data were analysed using descriptive and inferential statistics with principal component analysis of attitudinal items. Focus groups were recorded, transcribed and analysed using the Framework Approach. Main outcome measure Aspirations and readiness to implement pharmacist prescribing. Results The response rate was 62.8% (n = 348), with respondents highly supportive of implementation in Qatar (median 4, scale 0–5, extremely supportive). The majority (64.9%, n = 226) considered themselves ready, particularly those more senior (p < 0.05) and classifying themselves innovative (p < 0.01). Outpatient (72.9%, n = 221 agreeing) and inpatient (71.1%, n = 218 agreeing) HMC settings were those perceived as being most ready. PCA identified 2 components, with ‘personal attributes’ being more positive than ‘prescribing support’. Facilitators were access to records, organizational/management support and the practice environment, with physician resistance and scope of practice as barriers. Focus groups provided explanation, with themes in CFIR domains of innovation characteristics, characteristics of individuals and the inner setting. Conclusion HMC pharmacists largely aspire, and consider themselves ready, to be prescribers with inpatient and outpatient settings most ready. CFIR domains and constructs identified as facilitators and barriers should be focus for implementation.

Evaluation of health care providers' use of the 'Exercise and Depression Toolkit': a case study

BACKGROUND

Exercise is now recommended as a primary treatment for mild-moderate depression in Canada. The 'Exercise and Depression Toolkit' was developed to help health care providers (HCP) integrate these treatment guidelines into practice. The purpose of this study was to evaluate acceptability and perceived effectiveness of the toolkit in practice by HCPs working with individuals with depression.

METHODS

A case study design was utilized. The toolkit was given to 6 HCPs to use in practice for 4 weeks. Pre- and post-intervention phone interviews were conducted, and weekly logs were provided to track use and satisfaction of interactions with individuals with depression when using the toolkit. The study was conceptually guided by a hybrid theoretical approach using the Diffusion of Innovation Theory and the Theoretical Framework of Acceptability.

RESULTS

All HCPs used the toolkit at least once. Participants viewed their interactions when using the toolkit to be successful (considering individuals' receptiveness, its usefulness and general satisfaction.) The average success score for all participants was 5.5/7. HCPs found the toolkit to be acceptable. All participants (n = 6) viewed the toolkit as having relative advantage in helping them to discuss exercise with individuals with depression, and as relatively simple and easy to use (not complex) and adaptable to their practice needs (having trialability). Participants liked the toolkit and had mostly positive things to say about it. Participants had mixed feelings about whether changes in the people they worked with (such as mood and activity levels) could be observed (observability) and whether the toolkit changed their belief in their ability to recommend or discuss exercise (self-efficacy). Recommended dissemination strategies were adopted in promoting the toolkit.

CONCLUSIONS

Future work should address observability and the ability for health care providers to see other providers using it, as well as effectiveness considering outcomes for people with depression such as mood and activity changes. The results of this initial evaluation seem promising for uptake and future adoption of the toolkit by health care providers working with adults with depression in Canada.

Identifying Community Pharmacist Preferences For Prescribing Services in Primary Care in New Zealand: A Discrete Choice Experiment

OBJECTIVE

Given increasing patient populations, general practitioner (GP) workforce constraints and increasing demand for health services in New Zealand (NZ), the development and provision of pharmacist prescribing services may need to increase to improve people's access to medicines. A discrete choice experiment (DCE) was utilised to determine community pharmacist preferences for prescribing services in primary care in NZ, and to understand how these factors could improve the provision of pharmacist prescribing services.

METHODS

A D-efficient design generated 30 labelled choice questions in three blocks of ten, and three alternatives per choice question. The online DCE was emailed to practising community pharmacists in NZ. The DCE included two attributes with five levels (prescribing model, educational requirements) and three attributes with three levels (location, professional fee, change in income). A mixed multinomial logit model was used to estimate preferences.

RESULTS

A total of 264 respondents completed the survey with 2640 observations for analyses. This DCE found pharmacists preferred pharmacy services with the following characteristics: ability to prescribe using minor ailments and independent prescribing models relative to the pharmacist-only medicines prescribing model; prescribing education by accredited learning modules relative to PGDipClinPharm + PGCertPharmPres; remuneration via a professional fee; and pharmacist prescribing services located in community pharmacies rather than in GP practices.

CONCLUSIONS

Prescribing policy could incorporate these pharmacist preferences to help develop accessible and effective pharmacist prescribing services that not only improve access to medicines, but also address inequity of access to medicines in NZ. These DCE results are encouraging as they signal that the community pharmacists also see themselves and their pharmacies as part of the prescribing team in primary care in NZ.

Pharmacist non-medical prescribing in primary care. A systematic review of views, opinions, and attitudes

BACKGROUND

Uptake of non-medical prescribing by pharmacists working in primary care has been slow. This is despite benefits such as quicker and more efficient access to medicines for patients, a reduction in doctor workload, and enhanced professional satisfaction. This systematic review explores the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing.

METHODS

Medline, ScienceDirect, Embase, and the University of Reading Summon Service were searched to identify qualitative and mixed methods papers that examined the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. Papers published between January 2003 and September 2017 were included. Studies were quality assessed using the CASP checklist and then analysed using thematic synthesis.

RESULTS

After 85 full-text articles were assessed, a final 14 studies were eligible for inclusion. The included studies assessed pharmacists who currently prescribe, and other pharmacists and graduates with familiarity of non-medical prescribing. Thematic synthesis identified two themes: (1) practice environment, and (2) pharmacist's role. Non-medical prescribing was considered a natural extension to the role of a pharmacist despite difficulties in completing the required training. The ability to then prescribe was dependent on funding and access to medical records, time, and support staff. Pharmacists experienced professional rivalry with both support and resistance from members of the primary care team. The provision of training was frequently referred to as unsatisfactory. Pharmacists were motivated to prescribe, deriving increased job satisfaction and a sense of professionalism; however, they often felt underprepared for the reality of unsupervised practice. Furthermore, pharmacists reported a cautious approach with a fear of making errors frequently discussed.

CONCLUSIONS

This review has identified themes and subsequent barriers and facilitators to non-medical prescribing. Many of the barriers are more perceived than real and are diminishing. Consideration of these will assist and advance pharmacist prescribing in primary care, leading to positive outcomes for both patient care and the pharmacy profession.

Applying a diffusion of innovations framework to the scale-up of direct-acting antiviral therapies for hepatitis C virus infection: Identified challenges for widespread implementation

BACKGROUND AND AIMS

Interferon-free, direct-acting antivirals (DAAs) for hepatitis C virus (HCV) offer much promise to achieve World Health Organization targets by 2030. However, impediments at the practitioner and health-system level will continue to obstruct the scale-up of DAAs worldwide unless identified and acted upon. Applying a diffusion of innovations framework, the aim of this study was to identify structural factors impacting practitioner experiences of managing HCV treatment.

METHODS

In-depth, semi-structured, telephone interviews took place between September 2018 and April 2019 to investigate barriers and facilitators for engaging in HCV management and DAA therapy amongst general practitioners (GPs) who prescribe opioid agonist therapy and drug and alcohol specialists in Australia. Interviews were transcribed verbatim, de-identified, and coded, and data were analysed with iterative categorisation and thematic analysis using Everett Rogers's diffusion of innovation framework.

RESULTS

amongst 30 participants (12 GPs, 18 drug and alcohol specialists), several structural factors were reported to impede practitioner efforts to deliver optimal HCV care. Two primary themes were explored: contextual factors for the diffusion of DAA therapies, including attempts by participants to shift clinic culture and respond to siloed health structures, and adopter factors. Some participants chose to 'rock the boat' by circumventing clinic protocol and HCV guidelines to treat more clients, effectively shifting adopter categories to become greater advocates in HCV care. Also, while a role for GPs as the 'new adopters' in HCV management was discussed, many participants expressed uncertainty as to how much GPs should become involved in the diffusion of DAA therapies more widely.

CONCLUSIONS

Reducing the global burden of HCV infection will not be possible without the widespread delivery of HCV treatment amongst practitioners. Practitioners and health workers require leadership and resources from health authorities so that the individual and population-level benefits of DAA therapy are realised.

Pharmacists' Prescribing in Saudi Arabia: Cross-Sectional Study Describing Current Practices and Future Perspectives

Pharmacist prescribing is being increasingly undertaken to better use their skills and reduce the workload of existing prescribers such as doctors, often using formal processes to legitimate these activities. In developing countries like Saudi Arabia, however, pharmacists' prescribing remains informal with no legislation or formal training and there is a lack of research and understanding into such practices. Therefore, we aimed to describe current pharmacist prescribing practices in Saudi Arabia and explore pharmacists' views about pharmacists' prescribing. This is a cross-sectional survey study using an online questionnaire of hospital pharmacists in Saudi Arabia about pharmacists' prescribing, and associated views about prescribing legislation and barriers to implementing pharmacist prescribing. Over a quarter (28.5%) of pharmacists reported themselves as prescribers, 49% were following a collaborative prescribing model, 18% independent prescribing, and 33% were doing both. Ninety percent of prescribers reported confidence in prescribing the appropriate treatment and 92.3% perceived they will benefit from more prescribing training. Healthcare practice culture and pharmacist's competency were identified as barriers. There is an overall support for pharmacists' prescribing in Saudi Arabia among this sample of hospital pharmacists, with limitations in resources and the absence of standardized prescribing training being perceived as key barriers to pharmacists' prescribing.

Community Pharmacists' Motivation and Barriers to Providing and Billing Patient Care Services

Recently, California (CA) pharmacists’ scope of practice has expanded to include independently prescribing self-administered hormonal contraceptives, nicotine replacement therapy medications, travel health medications, routine vaccinations, naloxone hydrochloride, and HIV preexposure and postexposure prophylaxis. However, previous reports indicate that practicing within this expanded scope has remained limited. Therefore, a 26-item, web-based survey was emailed to CA community pharmacists to assess pharmacists’ knowledge, intent, and barriers to prescribing and billing for these patient care services. A total of 216 chain, supermarket-based, independent, mass merchant, and health-system outpatient pharmacists were included. The primary services provided and medications prescribed are for vaccinations and naloxone. Most pharmacists agree that engagement in and implementation of new strategies to enhance patients’ access to care is important. Common barriers include patient unawareness of pharmacist-provided services, lack of payment for services, and difficulty incorporating services within pharmacy workflow. Pharmacists are confident in their ability to provide patient care services but are less knowledgeable and confident about billing for them. Enhancing promotion of pharmacist-provided services to patients, developing strategies to efficiently incorporate them into the workflow, and payment models can help overcome barriers to providing these services.

Assessing Performance and Engagement on a Computer-Based Education Platform for Pharmacy Practice

A computer-based education platform was developed using a theory-based approach to help Canadian pharmacy professionals adopt their full scope of practice. Data from the platform were used to identify factors that impacted user performance and engagement. A de-identified dataset included response data for 21 unique modules, including quiz responses and self-reflection questions. Outcome measures included user performance (mean quiz score) and engagement (completion rate for attempted modules). Analysis of variance (ANOVA), multivariate regression modelling, and machine learning cluster analysis were used to analyze the data. Of the 5290 users, 68% were pharmacists, 11% were technicians, 13% were pharmacy students, and 8% were pharmacy technician students. Four clusters were identified separately for pharmacists and technicians. Clusters with the higher performance and engagement tended to have more users practicing in community pharmacies while the lower performing clusters tended have more internationally trained users. In the regression modelling, pharmacists performed better than technicians and students while students were more engaged (p < 0.0001). Further, internationally trained pharmacists had slightly lower scores but similar engagement compared to domestically trained pharmacists (p < 0.0001). Users demonstrated higher performance on modules related to scope of practice than on clinical topics, and were most engaged with topics directly impacting daily practice such as influenza vaccinations and new and emerging subjects such as cannabis. The cluster analysis suggests that performance and engagement with a computer-based educational platform in pharmacy may be more related to place of practice than to personal demographic factors such as age or gender.

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.

Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences

Objectives

Non-medical prescribers, including pharmacists, have been found to achieve comparable clinical outcomes with doctors for certain health conditions. Legislation supporting pharmacist prescribing (PP) has been implemented in the United Kingdom (UK), Canada and New Zealand (NZ); however, to date, Australian pharmacists have not been extended prescribing rights. The purpose of this review was to describe the barriers to PP found in the literature from the UK, Canada, NZ and Australia, and examine the implications of these for the development of PP in Australia.

Methods

We conducted a scoping review, which included peer-reviewed and grey literature, and consultation with stakeholders. Sources – Scopus, PubMed and CINAHL; Google Scholar, OpenGrey and organisational websites from January 2003 to March 2018 in the UK, Canada, NZ and Australia. Inclusion criteria – articles published in English, related to implementation of PP and articulated barriers to PP.

Key findings

Of 863 unique records, 120 were reviewed and 64 articles were eligible for inclusion. Three key themes emerged: (1) Socio-political context, (2) Resourcing issues and (3) Prescriber competence. The most common barriers were inadequate training regarding diagnostic knowledge and skills, inadequate support from authorities and stakeholders, and insufficient funding/reimbursement.

Conclusions

If implementation of PP is to occur, attention needs to be focused on addressing identified barriers to PP implementation, including fostering a favourable socio-political context and prescriber competence. As such, a concerted effort is required to develop clear policy pathways, including targeted training courses, raising stakeholder recognition of PP and identifying specific funding, infrastructure and resourcing needs to ensure the smooth integration of pharmacist prescribers within interprofessional clinical teams.

Family physicians' perceptions of pharmacists prescribing in Alberta

Canadian pharmacists now have prescribing authority and little is documented about the physicians' perception, experience and relational dynamics evolving around the pharmacists' prescribing practice. The objective of this study was to explore Albertan family physicians' perceptions and experiences of pharmacists' prescribing practice. We used purposeful and maximum variation sampling method and semi-structured face to face or telephone interviews to collect data. From October 2014 to February 2016, we interviewed 12 family physicians in Alberta, having experience with pharmacist prescribing. Interviews were audio recorded and transcribed verbatim for analysis using an interpretive description method, guided by "Relational Coordination" theory. NVivo software was used to manage the data. Three key beliefs (i.e., renewal versus initiate new prescription, community versus team pharmacists, and "I am responsible") about pharmacist prescribing were identified. Trust and communication were prominent themes which shaped participants' collaboration with pharmacist prescribers. Participants were classified as either "collaborative" or "consultative". Participants had greater collaboration with the team pharmacist prescribers compared to community pharmacists due to a higher level of trust and ease of communication. Renewal prescribing by any pharmacist was well accepted but participants showed hesitancy in accepting pharmacist-initiated prescriptions. Our findings provide insight into interprofessional collaboration and communication between physician and pharmacist prescribers.

Influence of strategic planning on product marketing and health service orientation of community pharmacies-A national survey in Finland

The aim of this study was to explore pharmacy owners' views on the strategic development of community pharmacies, particularly how strategic planning at the pharmacy level influences on product marketing and health service orientation of individual community pharmacies. The study was carried out as a national cross-sectional e-mail survey sent to all privately-owned Finnish community pharmacies (n = 581) in March 2013 (response rate 34%, n = 198). The pharmacy owners were asked about their strategy, product marketing and health services activities at the time of the survey and what they regarded as potential strategic developments by 2020. Of the responding pharmacy owners (n = 198), 63% reported their pharmacy had a strategy. The strategy was more common if the pharmacy owner had >10 years of experience as a pharmacy owner, the pharmacy had a high prescription volume (annually >100,000 prescriptions) and sales volume (annual turnover >5 million euros). Pharmacy owners' strategic vision by 2020 concerning health service orientation was the same regardless of having a strategy. Having a strategy was associated with the following variables indicating active product marketing orientation: the pharmacy had a person responsible for marketing campaigns and monitoring their success, and the pharmacy actively invested in add-on sales. Economic uncertainty of community pharmacies is an unresolved issue driving them towards active product marketing even they strategically prioritized health service orientation.

Characterizing pharmacist prescribers in Alberta using cluster analysis

Objectives

Legislative and regulatory bodies in Canada have authorized pharmacists to prescribe in different provinces. Albertan pharmacists have the broadest prescribing scope. Our objective was to cluster Albertan pharmacists into different prescriber groups based on their self-reported prescribing practice and to compare the groups according to practice settings, the proportion of Additional Prescribing Authority (APA) pharmacists and support experiences.

Methods

A cross-sectional survey was administered among a sample of 700 Albertan practicing registered pharmacists in 2013 to identify their involvement in different types of prescribing activities. Cluster analysis was used to group participants based on their reported prescribing practices. Chi-squared test was used to compare prescriber groups by practice settings and the proportion of APA pharmacists. One-way analysis of variance was used to compare the groups by their support experiences.

Key findings

Three major groups of pharmacist prescriber were identified – ‘renewal prescriber’ (74%), ‘Modifier’ (17%) and ‘Wide ranged prescriber’ (9%). Prevalence of ‘renewal prescriber’ in the community setting was 85.8% whereas ‘Modifier’ was predominant (66.7%) in the collaborative setting. Higher support experience facilitated the wide range prescribing. Pharmacists with APA were most likely to be classified into ‘Modifier’ (17.6%) or ‘Wide ranged prescriber’ (13.8%) groups than the ‘renewal prescriber’ group (3.1%).

Conclusions

Although legislation allowed Albertan pharmacists to have the broadest scope of prescribing authority, few are practicing with the fullest scope. Prescribing practice varies based on practice setting and support experience. Future research could explore factors influencing the types of adoption and measure the shifting of prescribing type over time.

An Investigation of Pharmacists' Acceptance of NHI-PharmaCloud in Taiwan

Taiwan's National Health Insurance (NHI) is one of the most successful insurance programs in the world. The National Health Insurance Administration (NHIA) established the NHI-PharmaCloud as a platform to reduce medication duplication and other medication errors among the NHI-contracted facilities. The NHI-PharmaCloud can help pharmacists access patient medication information from the preceding 3 months to improve drug safety. The use of NHI-PharmaCloud can improve the quality of healthcare, but improvements cannot occur if pharmacists are unwilling to use the platform. Therefore, the main objective of our study is to investigate the factors affecting pharmacists' adoption of the NHI-PharmaCloud. This study develops a research model using theories of technology adoption, self-efficacy, and perceived risk and uses randomly distributed survey questionnaires to collect data from local pharmacists. The results show that self-efficacy, perceived usefulness, and perceived psychological risk are 3 critical factors that could affect pharmacists' willingness to use the NHI-PharmaCloud. The research results may also help NHIA to effectively promote the usage of the NHI-PharmaCloud in Taiwan. In addition, governments in other countries may refer to the results of this study when implementing their own PharmaCloud-type systems to improve drug safety.

Classic e-Delphi survey to provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services in Wales

OBJECTIVE

To provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services.

DESIGN

Classic e-Delphi survey.

SETTING

National study in Wales.

PARTICIPANTS

Pharmacists, nurses and allied health professionals with the independent/supplementary prescribing qualification.

RESULTS

A total of 55 non-medical prescribers agreed to become members of the expert panel of whom 42 (76%) completed the round 1 questionnaire, 40/42 (95%) completed round 2 and 34/40 (85%) responded to round 3. Twenty-one statements were developed, and consensus was achieved on nine factors representing those necessary for the successful implementation of non-medical prescribing and five representing actions required for its continued development. Strategic fit between non-medical prescribing and existing service provision, organisation preparedness, visible benefits, good managerial and team support, and a clear differentiation of roles were each important influences.

CONCLUSION

Given the high degree of consensus, this list of factors and actions should provide guidance to managers and commissioners of services wishing to initiate or extend non-medical prescribing. This information should be considered internationally by other countries outside of the UK wishing to implement prescribing by non-medical healthcare professionals.

Stakeholders' views and experiences of pharmacist prescribing: a systematic review

AIMS

The aims of this systematic review were to: (1) critically appraise, synthesize and present the available evidence on the views and experiences of stakeholders on pharmacist prescribing and; (2) present the perceived facilitators and barriers for its global implementation.

METHODS

Medline, CINAHL, International Pharmaceutical Abstracts, PsychArticles and Google Scholar databases were searched. Study selection, quality assessment and data extraction were conducted independently by two reviewers. A narrative approach to data synthesis was undertaken due to heterogeneity, the nature of study types and outcome measures.

RESULTS

Sixty-five studies were identified, mostly from the UK (n = 34), followed by Australia (n = 13), Canada (n = 6) and USA (n = 5). Twenty-seven studies reported pharmacists' perspectives, with fewer studies focusing on patients' (n = 12), doctors' (n = 6), the general public's (n = 4), nurses' (n = 1), policymakers' (n = 1) and multiple stakeholders' (n = 14) perspectives. Most reported positive experiences and views, regardless of stage of implementation. The main benefits described were: ease of patient access to healthcare services, improved patient outcomes, better use of pharmacists' skills and knowledge, improved pharmacist job satisfaction, and reduced physician workload. Any lack of support for pharmacist prescribing was largely in relation to: accountability for prescribing, limited pharmacist diagnosis skills, lack of access to patient clinical records, and issues concerning organizational and financial support.

CONCLUSION

There is an accumulation of global evidence of the positive views and experiences of diverse stakeholder groups and their perceptions of facilitators and barriers to pharmacist prescribing. There are, however, organizational issues to be tackled which may otherwise impede the implementation and sustainability of pharmacist prescribing.

Will I lose my license for that? A closer look at Canadian disciplinary hearings and what it means for pharmacists' practice to full scope

Objective

Concerns about liability from clinical errors have been cited as a barrier preventing greater adoption of practice change. Our objective was to determine the most common actions or omissions that result in disciplinary action for pharmacists and the restrictive actions imposed.

Methods

Canadian disciplinary reports were reviewed. Cases were coded as charges of professional misconduct, unskilled practice or dishonest business practices.

Results

There were 558 disciplinary cases from 10 provinces that occurred between January 2010 and July 2017. Professional misconduct charges commonly involved stealing/diverting or inappropriately dispensing narcotic drugs, pharmacy supervision/premises charges and refusing to cooperate with the college. Charges of unskilled practice included dispensing the wrong drug, failing to assess the appropriateness of a drug order, providing the wrong dose and failing to counsel. Fraudulent billing practices and accepting rebates from generic drug companies were the most common dishonest business practices. Professional misconduct, unskilled practice and dishonest business practice charges were involved in 342 (61%), 169 (30%) and 191 (34%) cases, respectively. Most cases occurred in community pharmacies and were not caused by an isolated clinical error. Fines were the most common penalty, followed by temporary license suspensions, professional development and reprimands. License revocations were the least common (4%), often involving professional misconduct.

Conclusion

This review suggests that disciplinary action against a pharmacist for an isolated, unintentional clinical error is uncommon and that losing a license is rare. Fear of disciplinary action should not be a barrier to practice change or the provision of full-scope patient care services.

Survey of pharmacist prescribing practices in Alberta

PURPOSE

Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported.

METHODS

A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors.

RESULTS

Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%).

CONCLUSION

A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently.

Technological appropriations as workarounds

Purpose

The purpose of this paper is to further adaptive structuration theory (AST) by associating technological appropriations with health information technology workarounds. The author argues that appropriating electronic health record (EHR) technology ironically – in a way other than it is designed to be used – and divergently across an organization results in enhanced perceptions of EHR technology and its implementation.

Design/methodology/approach

Data were collected from 345 healthcare employees in a single healthcare organization that was switching to EHRs from paper records. Two major constructs of AST – unfaithfulness and dissension in appropriation – were operationalized and analyzed using multivariate regressions to test the relationship between the type of appropriation and perceptions of EHR technology’s relative advantage and implementation success.

Findings

Results reveal that both ironic (unfaithful) technological appropriation and dissension in technological appropriation across the organization predicted employees’ perceptions of EHR’s relative advantage and perceptions of EHR implementation success. Furthermore, physicians are the least likely to perceive EHR’s relative advantage or EHR implementation success. These results exemplify that EHR workarounds are taking place and reaffirm AST’s principle that employees evolve technology to better suit their working environments and preferences.

Originality/value

The survey and scales used in this study further demonstrate that there are meaningful statistical measures to accompany the qualitative methods frequently used in the AST literature. In addition, this paper expands AST research by exploring the positive outcomes that follow ironic and divergent technology appropriations.

Development and validation of a survey instrument to measure factors that influence pharmacist adoption of prescribing in Alberta, Canada

Objective

Study objectives were to develop a questionnaire to assess factors influencing pharmacists' adoption of prescribing (i.e., continuing, adapting or initiating therapy), describe use of pre-incentive and mixed mode survey, and establish survey psychometric properties.

Methods

Questions were developed based on prior qualitative research and Diffusion of Innovation theory. Expert review, cognitive testing, survey pilot, and main survey were used to test the questionnaire. Six content experts reviewed the questionnaire to establish face and content validity. Ten pharmacists from diverse practice settings were purposefully recruited for a cognitive interview to verify question readability. Content analysis was used to analyze the results. A pre-survey introduction letter with a monetary incentive was mailed via post to 100 (i.e. pilot) and 700 (i.e., main survey) randomly selected pharmacists. This was followed by an e-mail with a personalized link to the online questionnaire, e-mail reminders, and a telephone reminder if required. The psychometric properties of scales were evaluated with an exploratory factor analysis and Cronbach's alpha. Scale responses were described.

Results

Engagement of six experts and ten pharmacists clarified definitions (e.g., prescribing), terminology, recall periods, and response options for the 34-item response scale. Fifty-six pharmacists completed the online pilot survey. Based on this data, ambiguous questions and routing issues were addressed. Three hundred and seventy-eight pharmacists completed the online main survey for a response rate of 54.6%. The factors analysis resulted in 27 questions in eight scales: (1) self-efficacy, (2) support from practice environment, (3) support from interprofessional relationship, (4) impact on professionalism, (5) impact on patient care), (6) prescribing beliefs, (7) technical use of electronic health record (EHR) and (8) patient care use of the EHR. Prescribing beliefs and technical use of the EHR scales had low reliability while the remaining six scales had strong evidence for reliability and validity.

Conclusion

Through a multi-stage process, a survey instrument was developed to capture pharmacists' perceptions of prescribing influences. This questionnaire may support future research to develop interventions to enhance adoption of prescribing and enhance direct patient care by pharmacists.

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

BACKGROUND

This is a time of rapid change in the profession of pharmacy. Anecdotally, there are concerns that the pace, extent and rate of practice evolution are lagging. There is little evidence documenting the influencers and mechanisms that drive practice changes forward in pharmacy in Canada.

METHODS

An exploratory qualitative method was selected, using both one-on-one interviews with self-categorized typical pharmacists and larger focus groups to provide context and confirmation of themes generated through interviews. Data were analyzed and coded using a constant-comparative iterative method, in order to generate themes related to the factors influencing pharmacists to actually change their practice.

RESULTS

A total of 46 pharmacists meeting inclusion criteria participated in this study in focus groups, interviews or both. Nine themes were identified: 1) permission, 2) process pointers, 3) practice/rehearsal, 4) positive reinforcement, 5) personalized attention, 6) peer referencing, 7) physician acceptance, 8) patients' expectations and 9) professional identity supportive of a truly clinical role. One theme that did not emerge was payment, or remuneration, as a specific or isolated motivational factor for change.

INTERPRETATION

The complexity of practice change in pharmacy and the multiple factors highlighted in this study point to a more deliberate and concerted effort being needed by diverse pharmacy organizations (educators, regulators, employers, professional associations, etc.) to support pharmacists through the change management process.

CONCLUSIONS

The "9 Ps of practice change" identified through this study can provide pharmacists with guidance in terms of how to better support evolution of the profession in a more time-efficient and effective manner.

Pharmacists as vaccinators: An analysis of their experiences and perceptions of their new role

OBJECTIVES

In 2012, Ontario pharmacists were granted immunization privileges to administer influenza vaccines to the public. This study explored the experiences and practices of pharmacist vaccinators and the impact of vaccination pain on their practice.

METHODS

Semi-structured interviews were conducted with 12 pharmacists in the Greater Toronto Area. Transcribed interview data were coded and analyzed via thematic analysis.

KEY FINDINGS

Data analysis revealed 4 main themes: 1) expanded scope of practice as an enhancement and challenge to relationships; 2) professional satisfaction and workload demands; 3) knowledge and attitudes regarding pain and fear; 4) practices regarding pain and fear management. Pharmacists reported satisfaction in their new role, despite the associated increased workload. Pharmacists felt that vaccination pain was not a key consideration when administering vaccines and that pain management was generally not necessary. Fear was identified as more important than pain and vaccinating children was challenging and time intensive. Pharmacists' main focus was on injection techniques in managing pain.

CONCLUSION

These findings suggest that pharmacists are accepting of their role as vaccinators but more research is needed to examine impact on workload and pharmacist knowledge and perceptions of injection-related pain and fear.

Evaluating the potential for pharmacists to prescribe oral anticoagulants for atrial fibrillation

Background

Oral anticoagulant therapy (OAC) to prevent atrial fibrillation (AF)-related strokes remains poorly used. Alternate strategies, such as community pharmacist prescribing of OAC, should be explored.

Methods

Approximately 400 pharmacists, half with additional prescribing authority (APA), randomly selected from the Alberta College of Pharmacists, were invited to participate in an online survey over a 6-week period. The survey consisted of demographics, case scenarios assessing appropriateness of OAC (based on the 2014 Canadian Cardiovascular Society AF guidelines) and perceived barriers to prescribing. Regression analysis was performed to determine predictors of knowledge.

Results

A total of 35% (139/397) of pharmacists responded to the survey, and 57% of these had APA. Depending on the case scenario, 55% to 92% of pharmacists correctly identified patients eligible for stroke prevention therapy, but only about a half selected the appropriate antithrombotic agent; there was no difference in the knowledge according to APA status. In multivariable analysis, predictors significantly associated with guideline-concordant prescribing were having the pharmacist interact as part of an interprofessional team (p = 0.04) and direct OAC (DOAC) self-efficacy (confidence in ability to extend, adapt, initiate or alter prescriptions; p = 0.02). Barriers to prescribing OAC for APA pharmacists included a lack of AF and DOAC knowledge and preference for consulting the physician first, but these same pharmacists also identified difficulty in contacting the physician as a major barrier.

Interpretation and Conclusion

Community pharmacists can identify patients who would benefit from stroke prevention therapy in AF. However, physician collaboration and further training on AF and guidelines for prescribing OAC are needed.

Positioning pharmacists' roles in primary health care: a discourse analysis of the compensation plan in Alberta, Canada

BACKGROUND

A comprehensive Compensation Plan for pharmacy services delivered by community pharmacists was implemented in Alberta, Canada in July 2012. Services covered by the Compensation Plan include care planning services, prescribing services such as adapting prescriptions, and administering a drug or publicly-funded vaccine by injection. Understanding how the Compensation Plan was framed and communicated provides insight into the roles of pharmacists and the potential influence of language on the implementation of services covered by the Compensation Plan by Albertan pharmacists. The objective of this study is to examine the positioning of pharmacists' roles in documents used to communicate the Compensation Plan to Albertan pharmacists and other audiences.

METHODS

Publicly available documents related to the Compensation Plan, such as news releases or reports, published between January 2012 and December 2015 were obtained from websites such as the Government of Alberta, Alberta Blue Cross, the Alberta College of Pharmacists, the Alberta Pharmacists' Association, and the Blueprint for Pharmacy. Searches of the Canadian Newsstand database and Google identified additional documents. Discourse analysis was performed using social positioning theory to explore how pharmacists' roles were constructed in communications about the Compensation Plan.

RESULTS

In total, 65 publicly available documents were included in the analysis. The Compensation Plan was put forward as a framework for payment for professional services and formal legitimization of pharmacists' changing professional roles. The discourse associated with the Compensation Plan positioned pharmacists' roles as: (1) expanding to include services such as medication management for chronic diseases, (2) contributing to primary health care by providing access to services such as prescription renewals and immunizations, and (3) collaborating with other health care team members. Pharmacists' changing roles were positioned in alignment with the aims of primary health care.

CONCLUSIONS

Social positioning theory provides a useful lens to examine the dynamic and evolving roles of pharmacists. This study provides insight into how communications regarding the Compensation Plan in Alberta, Canada positioned pharmacists' changing roles in the broader context of changes to primary health care delivery. Our findings may be useful for other jurisdictions considering implementation of remunerated clinical services provided by pharmacists.

Ready or not? Pharmacist perceptions of a changing injection scope of practice before it happens

Background

Since 2012, Ontario pharmacists have been authorized to administer the influenza vaccine. In April 2016, the Ontario College of Pharmacists (OCP) proposed to expand the Pharmacy Act to allow pharmacists to vaccinate against 13 additional conditions. The OCP held an online public consultation and invited pharmacists, members of the public and organizations to weigh in on the proposed changes. Our objective was to explore the factors influencing how Ontario pharmacists may adopt or reject an expanding scope of practice, using data from the public consultation.

Methods

We coded the responses to the public consultation in 2 ways: 1) sentiment analysis and 2) an integrative approach to coding using Rogers's diffusion of innovations theory across 5 domains: relative advantage, compatibility, complexity, trialability and observability.

Results

Responses from pharmacists, the public and organizations were moderately positive on average. Pharmacists most commonly mentioned relative advantages, including benefits for patients, pharmacists, physicians and the health system. Positive responses focused on accessibility for patients, improved vaccine coverage, lower health care spending and freed physician time but cited lack of prescribing privileges as a barrier to the proposed changes. Negative responses focused on increased workload, patient safety concerns and the complexity of travel medicine.

Conclusions

The expanded immunization services are likely to be well received by most pharmacists. Convenience and accessibility for patients were commonly cited benefits, but the changes will be only a slight improvement over the current system unless pharmacists can prescribe these vaccines. Although employers responded positively, the question remains whether they will support pharmacists in a way that aligns with pharmacists' values and expectations. Decision makers must pay close attention to the pharmacy infrastructure and how this will affect uptake of these services. Recognition of this, combined with pharmacists' positive perceptions of the expanded scope, will facilitate smooth integration of this legislation into Ontario pharmacy practice.

Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review

QUESTION

What are the factors that affect the implementation or utilisation of independent non-medical prescribing (iNMP)?

DESIGN

Mixed-methods systematic review. Two reviewers independently completed searches, eligibility and quality assessments.

DATA SOURCES

Pre-defined search terms were utilised to search electronic databases. Reference lists, key journals and grey literature were searched alongside consultation with authors/experts.

ELIGIBILITY CRITERIA FOR INCLUDED STUDIES

Qualitative and quantitative studies investigating independent prescribing by any non-medical professional group. Study participants included any stakeholders involved in actual or proposed iNMP. Measurements reported on data describing stakeholders' perceptions and experiences of the barriers to/facilitators of iNMP.

RESULTS

A total of 43 qualitative and seven quantitative studies from three countries (n=12, 117 participants) were included. Quality scores varied from 9 to 35 (Quality Assessment Tool for Studies with Diverse Designs, 0 to 48). Qualitative data were synthesised into four themes (and subthemes): systems (government and political, organisational, formulary); education and support (non-medical prescribing (NMP) courses/continuous professional development (CPD)); personal and professional (medical profession, NMP professions, service users); and financial factors. Quantitative data corroborated the qualitative themes. Integration of the qualitative themes and quantitative data enabled the development of a NMP implementation framework.

CONCLUSION

Barriers to and facilitators of the implementation and utilisation of iNMP are evident, demonstrating multifactorial and context-specific variables within four explicit themes. Professional bodies, politicians, policy and healthcare managers and clinicians could use the resulting NMP implementation framework to ensure the safe and successful implementation and utilisation of NMP. Clinical physiotherapists and other clinicians should consider whether these variables have been adequately addressed prior to adopting NMP into their clinical practice.

REGISTRATION

PROSPERO CRD42015017212. [Noblet T, Marriott J, Graham-Clarke E, Rushton A (2017) Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. Journal of Physiotherapy 63: 221-234].

Making Electronic Health Records (EHRs) Work: Informal Talk and Workarounds in Healthcare Organizations

A key provision of the American Recovery and Reinvestment Act of 2009 mandated that electronic health records (EHR) be adopted in US healthcare organizations by 2015. The purpose of this study is to examine the communicative processes involved as healthcare workers implement an EHR and make changes, known as workarounds. Guided by theories in social influence, and diffusion of innovations, we conducted a survey of healthcare professionals using an EHR system in an organization. Our structural equation modeling (SEM) and multiple regression results reveal coworker communication, in the form of informal social support and feedback, play an important role in whether people engage in workarounds. Understanding this relationship is important because our study also demonstrates that workarounds predict healthcare employees' overall satisfaction with the EHR system. Specifically, workarounds are associated with higher perceptions of the EHR's relative advantage, higher perceptions of EHR implementation success, and lower levels of resistance to EHR change. This study offers a health communication contribution to the growing research on EHR systems and demonstrates the persuasive effects that coworkers have on new technology use in healthcare organizations.

Development and implementation of the compensation plan for pharmacy services in Alberta, Canada

OBJECTIVE

To describe experiences with development and implementation of a compensation plan for pharmacy services delivered by pharmacists in community pharmacies.

SETTING

Community pharmacy practice in Alberta, Canada.

PRACTICE DESCRIPTION

Pharmacists in Alberta have one of the most progressive scopes of practice in North America. They have authority to prescribe drugs independently, administer drugs by injection, access electronic health records, and order laboratory tests.

PRACTICE INNOVATION

A publicly funded compensation plan for pharmacy services was implemented in 2012. Principles that guided development of the compensation plan aimed to 1) ensure payment for pharmacy services, 2) support pharmacists in using their full scope of practice, 3) enable the development of long-term relationships with patients, 4) facilitate expansion of services delivered by pharmacists, and 5) provide access to pharmacy services for all eligible Albertans. Services covered by the compensation plan include care planning, prescribing, and administering drugs by injection.

EVALUATION

The guiding principles were used to evaluate experiences with the compensation plan.

RESULTS

Claims for pharmacy services covered by the compensation plan increased from 30,000 per month in July 2012 to 170,000 per month in March 2016. From September 2015 to August 2016, 1226 pharmacies submitted claims for services provided by 3901 pharmacists. The number of pharmacists with authorization to prescribe and administer injections continued to increase following implementation of the plan.

CONCLUSION

Alberta's experiences with the development and implementation of the compensation plan will be of interest to jurisdictions considering implementation of remunerated pharmacy services. The potential impact of the plan on health and economic outcomes, in addition to the value of the services as perceived by the public, patients, pharmacists, and other health care providers, should also be explored.

How are pharmacists in Ontario adapting to practice change? Results of a qualitative analysis using Kotter's change management model

BACKGROUND

The pace of practice change in community pharmacy over the past decade has been significant, yet there is little evidence documenting implementation of change in the profession.

METHODS

Kotter's change management model was selected as a theoretical framework for this exploratory qualitative study. Community pharmacists were interviewed using a semistructured protocol based on Kotter's model. Data were analyzed and coded using a constant-comparative iterative method aligned with the stages of change management outlined by Kotter.

RESULTS

Twelve community pharmacists were interviewed. Three key themes emerged: 1) the profession has successfully established the urgency to, and created a climate conducive for, change; 2) the profession has been less successful in engaging and enabling the profession to actually implement change; and 3) legislative changes (for example, expansion of pharmacists' scope of practice) may have occurred prematurely, prior to other earlier stages of the change process being consolidated.

INTERPRETATION

As noted by most participants, allowing change is not implementing change: pharmacists reported feeling underprepared and lacking confidence to actually make change in their practices and believe that more emphasis on practical, specific implementation tactics is needed.

CONCLUSIONS

Change management is complex and time and resource intensive. There is a need to provide personalized, detailed, context-specific implementation strategies to pharmacists to allow them to take full advantage of expanded scope of practice.

Adaptation and psychometric validation of a scale to assess student pharmacists' beliefs in simplifying complicated medication regimens

OBJECTIVES

To validate a scale in order to identify the most relevant survey constructs to measure student pharmacists' beliefs of providing a novel cognitive service of simplifying complicated medication regimens of community dwelling patients using a pill card.

METHODS

A pre-existing scale was used to construct an adapted questionnaire in the context of simplifying complicated drug regimens in patients taking >five Rx meds daily. The adapted 14-item questionnaire was administered to 126 student pharmacists immediately after they performed a mandatory community pharmacy advanced pharmacy practice experience (APPE) exercise to simplify complicated drug regimens of patients. All students had rehearsed this service with standardized patients before their APPEs assignment. In this APPE assignment the student pharmacists consolidated the dose timings of the daily medications while attempting to improve their likelihood of efficacy and reduce their risk of adverse events. The psychometric properties of the adapted questionnaire were assessed using parallel analysis and principal component analysis. Internal consistency was established using Cronbach's α.

RESULTS

Out of 126 students, 116 (92%) responded to the questionnaire. Factor analysis produced a 3-factor solution of the 14-item scale which accounted for 56% of the explained variance. The factors relate to self-efficacy (α = 0.956), intention to practice (α = 0.89) and mattering (α = 0.885). The overall internal consistency as measured by Cronbach's α was 0.936. The mean values obtained using these scales were 6.01 ± 0.823, 4.88 ± 0.742, and 4.45 ± 0.556, respectively, indicating stronger beliefs in this cognitive service.

CONCLUSIONS

The adapted 14-question instrument can be used to reliably measure the self-efficacy, intention and mattering of fourth-year student pharmacists who can simplify complicated drug regimens by consolidating routinely prescribed medications.

Health Care Professionals' Opinions and Expectations of Clinical Pharmacy Services on a Surgical Ward

BACKGROUND

Pharmacists have made significant contributions to patient care and have been recognized as integral members of the interprofessional team. Health care professionals differ in their opinions and expectations of clinical pharmacy services. Very little has been published about health care professionals' perspectives on advanced clinical pharmacy roles, such as prescriptive authority or administration of vaccines. In 2013, clinical pharmacy services were introduced in a vascular and general surgery ward where a pharmacist had not previously been assigned.

OBJECTIVES

To explore surgical nurses' and physicians' opinions and expectations of clinical pharmacy services and to determine how these views changed over time; to compare pharmacists' views of clinical pharmacy services with those of nurses and physicians; and to develop validated survey tools.

METHODS

Three survey tools were created and validated, one for each profession. Surveys were distributed to nurses and physicians assigned to the general and vascular surgery ward before introduction of clinical pharmacy services and 8 months after implementation. Hospital pharmacists were invited to complete the survey at one time point.

RESULTS

Differences existed in the opinions of nurses, physicians, and pharmacists about some traditional activities. Nurses and physicians indicated stronger agreement with pharmacists participating in medication reconciliation activities than did pharmacists (p < 0.001), whereas a greater proportion of pharmacists felt that they were the most appropriate health care professionals to provide medication discharge counselling, relative to nurses and physicians (p = 0.001). Respondents supported advanced roles for pharmacists, such as collaborative practice agreements, but there was less support for prescribing, physical assessments, and administration of vaccines. Nurses indicated the strongest agreement with pharmacist prescribing (82% versus 69% among pharmacists and 27% among physicians; p < 0.001). Nurses and physicians expressed strong endorsements of clinical pharmacy services in the surveys' comment sections.

CONCLUSIONS

The introduction of clinical pharmacy services to a surgical health care team resulted in high levels of satisfaction among nurses and physicians who responded to this survey. Differences in perceptions of traditional clinical pharmacy service activities and advanced practice roles need to be studied in more depth to better understand the factors influencing health care professionals' views.