Pharmacists' perceptions of their practice: a comparison between Alberta and Northern Ireland

Abstract

Objective  To explore how community pharmacists from Alberta, Canada, and Northern Ireland, UK, describe what a pharmacist does and to compare their responses.

Methods  Two hundred community pharmacists were interviewed using the telephone. The interviewer who introduced himself as a researcher asked two questions about the period over which the participants had been practising pharmacy and the way they describe what a pharmacist does. Responses were categorised into three categories: patient-centred, product-focused and ambiguous. Word-cloud analysis was used to assess the use of patient-care-related terms.

Key findings  Of the responses from community pharmacists in Alberta, 29% were categorised as patient-centred, 45% as product-focused and 26% as ambiguous. In Northern Ireland, 40% of the community pharmacists' responses were categorised as patient-centred, 39% as product-focused and 21% as ambiguous. Community pharmacists in Northern Ireland provided more patient-centred responses than community pharmacists in Alberta (P = 0.013). The word-cloud analysis showed that ‘medicine’ and ‘dispense’ were the most frequently reported terms. It also highlighted a relative lack of patient-care-related terms.

Conclusions  The findings of the present study are suggestive of some movement towards patient-centredness; however, product-focused practice still predominates within the pharmacy profession in Alberta and Northern Ireland. The relative lack of patient-care-related terms suggests that patient care is still not the first priority for pharmacists in both Alberta and Northern Ireland.

Introduction

Through patient-centred interventions, pharmacists have demonstrated a positive impact on patient outcomes in a range of different settings. In community settings, it has been clearly demonstrated that community pharmacists can deliver effective services in smoking cessation, and in blood pressure, blood sugar and blood cholesterol screening and monitoring.^[1–5] Community pharmacists can also provide effective interventions (i.e. assessment, goal setting, monitoring and review) to asthma patients.^[6] It has also been shown that community pharmacists can improve the quality of repeat dispensing^[7] and provide effective medicine management services.^[8]

Based on the evidence from the literature that pharmacists can deliver effective interventions in different diseases,^[1–8] organisations from around the world are now calling on pharmacists to transition from their focus on drug products to concentrate more on a patient-centred role (improving patient outcomes).^[9] For instance, the World Health Organization reported that the main role for a pharmacist is to provide care;^[10] the Department of Health in the UK is encouraging pharmacists to take on more patient-centred roles;^[11,12] and the Canadian Pharmacists Association has articulated the vision of pharmacy as: ‘optimal drug therapy outcomes for Canadians through patient-centred care’.^[13] Also, contemporary pharmacy courses are increasingly focusing on the patient-centred role of pharmacists.^[14] Despite these ambitious goals and statements, unfortunately only a few programmes involving patient-centred practice have proven to be sustainable over the long term.^[15–19]

Efforts to better understand the lack of advancement in pharmacy patient-centred practice have generally involved the study of the views and opinions of pharmacists towards practice change.^[20–23] The same barriers have been constantly reported over the years, and this raises the question as to whether these barriers are really true barriers, or just excuses to explain the non-provision of patient-centred services.^[24] The way pharmacists think may play a major role in the profession's movement towards patient-centredness.^[25] One of the major contributors to the way pharmacists think is the culture of pharmacy. Culture which is a pattern of shared values, beliefs and assumptions which are considered to be the appropriate way to think or act in that particular environment.^[26] Culture plays a pivotal role in change management. The saying goes ‘culture eats strategy for breakfast,’ in other words if the culture does not align with the progression strategy, culture can hinder the change.^[27] In the literature there has been only limited research which has addressed the culture of pharmacy.^[28] Clark and Mount^[29] evaluated whether placement sites in the USA were incorporating the ideals of patient-centredness, quality of care and professionalism using a mailed survey. In two papers, Scahill et al.^[30,31] used concept mapping (a technique usually used in social science) in three stages (face-to-face brain storming; statement reduction; statement categorisation) to study the culture of community pharmacy in New Zealand in an effort to develop an instrument which can be used to study the culture of pharmacy. However, there are no published studies to date which have evaluated the way community pharmacists describe what a pharmacist does.

The present study compares two progressive jurisdictions with regards to patient-centred care, Alberta which led the pharmacy profession progression in Canada being the first province to provide pharmacists with independent prescribing authorities^[32] and Northern Ireland in the UK where pharmacists are already providing certain patient-centred services, such as smoking cessation and minor ailments management.^[33] Pharmacy practice research groups are very active in these two jurisdictions; they provided the literature with some examples about the positive impact of community pharmacy based patient-centred services.^[1–3]

The aim of the present study was to compare how community pharmacists from Alberta and Northern Ireland describe what a pharmacist does.

Methods

Study participants

The study population was composed of community pharmacists from Northern Ireland and Alberta. Ethical approval was granted to carry out the different aspects of the present study by the School of Pharmacy Ethics Committee, Queen's University Belfast and the Health Research Ethics Board of the University of Alberta. Participants who agreed to answer the questions were assumed to have consented to their participation, therefore written informed consent was not obtained.

Sampling

The lists of all community pharmacies in Alberta and Northern Ireland were obtained from the Alberta College of Pharmacists' website (http://www.pharmacists.ab.ca), and the Ulster Chemist Association Diary respectively. All registered community pharmacies in Northern Ireland and Alberta were placed in a numbered list and called in a random order (using a random-number generator) until the desired sample size of community pharmacists was obtained. Pharmacy type (independent or chain for Alberta and independent, small chain (two to five pharmacies) or multiple (six pharmacies or more) for Northern Ireland) and location (urban or rural) were also recorded.

For the purpose of sample size calculation it was estimated that 35% (±10%) of participants would use language related to patient-centred care to describe what a pharmacist does. Using EPI INFO v6. (CDC, Atlanta, Georgia, USA), Stat Calc for population surveys it was determined that 85 pharmacists from each jurisdiction were required to achieve the previous estimate at a confidence level of 95%. This figure was rounded to a total of 100 pharmacists per jurisdiction.

Data collection

The present study methodology, which involved short telephone interviews with community pharmacists as the data collection vehicle, has been outlined elsewhere.^[34]

Community pharmacists were interviewed by telephone. The interviewer introduced himself as a researcher who was examining how various health professionals use language to describe what they do and then asked the interview questions. The interview was composed of two questions: (a) How many years have you been practising pharmacy? (b) In three or four words (or phrases), from your perspective, could you please tell me ‘What does a pharmacist do?’ The brevity of the telephone conversations enabled the researcher to document participants' responses by hand.

The intention of using this methodology was to prevent pharmacists from thinking too much about their answer, thereby eliciting a ‘top of mind’ or automatic response. This approach was used because it engages certain unconscious mental processes which affect and influence the judgements, feelings and behaviours of the person.^[35] In the literature it has been reported that individuals' automatic response does not usually match their self-reported attitudes.^[36] The slight deception and restriction of response were intended to remove some of the effects of social desirability bias.^[37]

Data analyses

The first phase of data analysis involved two researchers independently coding the responses using qualitative content analysis. The definitions of product-focused (dispensing) and patient-centred care, obtained from the Canadian Pharmacist Association's Blueprint for Pharmacy: Implementation Plan^[38] (see Table 1 for definitions), were applied to further refine the analysis. A final ‘ambiguous’ theme was used for those responses which could not be placed into either of the two themes. More specifically if the response could be classified as either patient-centred or product-focused (e.g. educate patients, provide information) or if the context of it did not allow categorisation, the response was placed in the ‘ambiguous’ theme.^[34] After completing the independent analysis, the two researchers worked together to discuss their coding and come to consensus regarding any differences in the individual coding. If a consensus could not be reached, a consultation with a third researcher who was not involved in the initial analysis was used to reach consensus.

Table 1.  Definitions of themes

Theme	Definition
Patient-centred care	The merging of several models of healthcare practice including patient education, self-care and evidence-based care into four broad areas of intervention: communication with patients, partnership with patients, health promotion and delivery of care.^[38]
Drug-focused	Interpretation and evaluation of a prescription, selection and manipulation or compounding of a pharmaceutical product, labelling and supply of the product in an appropriate container according to legal and regulatory requirements and the provision of information and instructions by a pharmacist, to ensure the safe and effective use by the patient.^[38]

The second phase of analysis involved word clouding. Word clouding is ‘a visualization of a set of related tags or words in which frequencies of use are reflected visually, often in the size of the text or tag’.^[39] This method can be used to analyse any textual data to give the reader a chance to see the most commonly used terms in the text. Word clouds have been used mostly in social and commercial settings, however their use in education and research has started recently as the use of word clouds provide a quick way to analyse textual data. Gill and Griffin,^[39] who assessed the efficacy of the word-cloud use in analysing policy documents (Good Medical Practice documents), reported that word-cloud analysis provides a quick and practical way to analyse textual data, helps in reducing the data without bias as it analyses the words as they appear and not as the researcher sees them and suggested that the use of word clouds in different fields of research can provide promising results.

In word clouding, font size expresses the frequency of use of different words, i.e. larger font size expresses a higher frequency of use. In the present study, the most frequently reported word was given the largest font size (24 point). The font sizes of the remainder of the words were calculated by multiplying the largest font size by the frequency of their reporting divided by the highest frequency of reporting. Word clouds were created using the free software available on http://www.wordle.net.

During word clouding every effort was made not to alter the terms used by the participants; however, at times it was necessary to merge terms with similar meaning (e.g. medicine, medicines, medication, medications, drug and drugs were merged into ‘medicine’).

In the present study word clouding was used to assess the use of patient-care-related terms.

For the third phase of analysis comparisons between responses of the participants in each group (Northern Ireland and Alberta) were conducted based on the location of the pharmacy (urban versus rural), the pharmacy type or years in practice. Data were compared using chi-square test. The Northern Ireland Statistics and Research Agency website (http://www.nisra.gov.uk) was used to classify the location (urban versus rural) of community pharmacies in Northern Ireland. In Alberta the location was classified as follows urban: population 10 000; rural: population <10 000.

Results

Qualitative content analysis

In Alberta, a total of 111 pharmacists were telephoned in order to achieve the target sample size of 100 (10 pharmacists declined participation because they reported that they did not have enough time to participate, one pharmacist's response was unusable). Out of the 100 community pharmacists who participated in the present study, 81 were based in an urban setting while the remaining 19 were based in a rural setting. The average number of years in practice was 15.0 years (range 1–50 years). A total of 76 pharmacists practised in chain pharmacies, while 24 pharmacists practised in independent pharmacies. A total of 278 discrete responses, to the second question in the interview, were provided by all the participants, with an average of 2.8 responses per participant. Out of these 278 responses, 29% were characterised as patient-centred, 45% were characterised as product-focused and 26% were characterised as ambiguous (see Table 2 for examples of responses for each of the categories).

Table 2.  Examples of responses by theme

Theme	Examples
BP, blood pressure.
Patient-centred	▪ “Advise the public and work with them to improve their health”
	▪ “Providing health promotion services”
	▪ “Measure and monitor BP”
	▪ “Responding to patient's symptoms”
	▪ “Alter the dose or change the medicine if the patient is not improving”
	▪ “Educate, counsel and provide information about health, disease state and wellbeing to the patient”
	▪ “Monitoring patient's response to therapy”
Drug-focused	▪ “Check and dispense prescriptions”
	▪ “Dispense and monitor controlled medicines”
	▪ “Prepare and make suspensions”
	▪ “Verify and check new medicines orders”
Ambiguous (responses that did not fit into either of the above categories)	▪ “First contact point with the patient”
	▪ “Train pharmacy students”
	▪ “Supervise the other staff and look after the pharmacy”
	▪ “Organise the work load in the pharmacy”

In Northern Ireland, a total of 135 pharmacists were telephoned, in order to achieve a sample size of 100 (35 pharmacists declined participation because they reported that they did not have enough time to participate). Out of the 100 community pharmacists who participated in the present study, 76 were based in an urban setting while the other 24 were based in a rural setting. The average number of years in practice was 12.3 years (range 1–40 years). A total of 38 pharmacists practised in multiple pharmacies, 17 pharmacists practised in small chains and 45 pharmacists practised in independent pharmacies. A total of 433 discrete responses, to the second question in the interview, were provided by all the participants, with an average of 4.3 responses per participant. Out of these 433 responses 40% were characterised as patient-centred, 39% were characterised as product-focused and 21% were characterised as ambiguous (see Table 2 for examples of responses for each of the categories).

Statistical analyses

Community pharmacists in Northern Ireland provided more patient-centred responses than community pharmacists in Alberta (P = 0.013; chi-square test). Further statistical analyses did not show any significant differences between community pharmacist responses in Alberta and Northern Ireland with regard to the location of the pharmacy, the pharmacy type or years in practice.

Word-cloud analysis

The word-cloud analysis (Figures 1 and 2) showed that ‘medicine’ and ‘dispense’ were the most frequently reported terms for both Alberta and Northern Ireland. This analysis also highlighted the relative lack of patient-care-related terms, suggesting that when it comes to the pharmacists' practice in both Alberta and Northern Ireland patient care is still not their first priority.

Figure 1. Word-cloud representation of responses of community pharmacists in Alberta, Canada.

Figure 2. Word-cloud representation of responses of community pharmacists in Northern Ireland, UK.

Discussion

Summary of the main findings

Research to date on the evolution of pharmacy practice has generally focused on barriers to practice change and on the efforts made to remove these barriers^[16–23] using traditional methodologies (surveys and in-depth interviews). While this is an important work, it does not fully explain the slow and incomplete transition towards patient-centred care. We wonder if pharmacists' own mental barriers are a missing piece. In our comparison of two legislatively progressive jurisdictions, community pharmacists in Northern Ireland provided more patient-centred responses than community pharmacists in Alberta (P = 0.013), although both described product-focused roles in 39–45% of their responses. The product focus of pharmacists was also borne out in the word-cloud analyses, with very little use of patient-care terminology to describe what a pharmacist does.

Strengths and limitations

To our knowledge this is the first study to use short telephone interviews which elicit a ‘top of mind’ or automatic response to compare how community pharmacists from Alberta and Northern Ireland describe what a pharmacist does. This approach engages certain unconscious mental processes which affect and influence the judgements, feelings and behaviours of the person.^[35] In the literature it has been reported that individuals' automatic response does not usually match their self-reported attitudes.^[36] The slight deception and restriction of response were intended to remove some of the effects of social desirability bias.^[37]

We think that our findings are generalisable to pharmacy practice in Alberta and Northern Ireland because the key demographic features of our samples are similar to regional averages (Table 3).

Table 3.  Comparison between the present study sample and community pharmacies in Alberta, Canada, and Northern Ireland, UK

Characteristic	Present study: Alberta (%)	Alberta overall (%)	Present study: Northern Ireland (%)	Northern Ireland overall (%)
Pharmacy type
Independent	24	31	45	42.4
Small chain	–	–	17	13.9
Chain (multiple)	76	69	38	43.7
Pharmacy location
Urban	81	79	76	70.1
Rural	19	21	24	29.9

A potential limitation of the present study relates to the fact that pharmacists' responses were restricted by the study question and our request for a brief response. If they had more time to think about their responses there is a chance that they would have been different. Nevertheless, the intention of using this methodology was to prevent pharmacists from thinking too much about their answer, thereby eliciting a ‘top of mind’ or automatic response and to avoid some of the effects of social desirability bias.

Another potential limitation is the use of word clouding which represents a visualisation of the frequency of the reported words. This method may not take into account the context in which the words were used. Also the use of open questions has the potential to introduce recall bias as this approach assumes that if a term was not reported then that term is not relevant.

Comparison with the existing literature and the contribution made to the field

The higher degree of patient-centred responses provided by Northern Ireland pharmacists might be explained by the differences in contracts and payment schemes between Northern Ireland and Alberta. In Northern Ireland community pharmacists are paid for offering certain patient-centred services such as smoking cessation and minor ailments management,^[33] while in Alberta (and Canada in general) the current model of reimbursement provides pharmacists with dispensing fees only (as in the traditional system of practice).^[13,40]

While the findings of the present study, when compared with some previous research in the area,^[41] are indicative of some movement towards patient-centredness, they also suggest that there is much more work to be done within the profession to encourage the concept of patient-centred pharmaceutical care. This conclusion aligns with that reached by Hughes et al.^[42] when they evaluated the level of pharmaceutical care provided by community pharmacists within 13 European countries using the Behavioral Pharmaceutical Care Scale of pharmaceutical care in community pharmacies.

The relative lack of patient-care-related terms and the fact that ‘medicine’ and ‘dispense’ were the most frequently reported terms indicate that medicines rather than the patients are the main current focus of pharmacists when they consider their role.^[43] Rosenthal et al.^[24] reported that pharmacists' reluctance to become more involved in patient-centred care provision can be explained by certain passive pharmacists' characteristics, such as not having enough confidence in themselves, fear of taking risks and waiting for physicians' approval.

The findings of the present study suggest that product-focused practice still predominates within the pharmacy profession in both Alberta and Northern Ireland. This may be explained by the fact that the pharmacists' mental model, which is an internal image on the way the pharmacy profession works which prevents the pharmacist from thinking or acting in a different way,^[25] still links pharmacy profession to product-focused practice.

While the findings of the present study helped to explore certain aspects of current pharmacy culture in Northern Ireland and Alberta, there is a need for further exploration into pharmacy culture. A better understanding of the current pharmacy culture will help to use improved progression strategy to move the pharmacy profession into patient-centredness. Pharmacy culture must align with the desired changes, if a transition in pharmacy practice to a more patient-centred approach is to take place.^[27]

Conclusions

Community pharmacists in Northern Ireland provided more patient-centred responses when compared to community pharmacists in Alberta. This could be explained by the fact that community pharmacists in Northern Ireland are paid to provide certain patient-centred services, such as minor ailments management and smoking cessation. This can lead to the conclusion that community pharmacists may offer patient-centred services if they were offered sustainable remuneration. The relative lack of patient-care-related terms suggests that when it comes to the pharmacists' practice in both Alberta and Northern Ireland patient care is still not their first priority. The findings of the present study suggest that product-focused practice still predominates within the pharmacy profession in both Alberta and Northern Ireland.

Declarations

Conflict of interest

The Author(s) declare(s) that they have no conflicts of interest to disclose.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profits sectors.

Acknowledgements

All community pharmacists who participated in this study.