Patient perspectives on the vital primary care role of community pharmacists in Nova Scotia, Canada: qualitative findings from the PUPPY Study.

OBJECTIVES: Community pharmacists play an important role in primary care access and delivery for all patients, including patients with a family physician or nurse practitioner ("attached") and patients without a family physician or nurse practitioner ("unattached"). During the COVID-19 pandemic, community pharmacists were accessible care providers for unattached patients and patients who had difficulty accessing their usual primary care providers ("semi-attached"). Before and during the pandemic, pharmacist services expanded in several Canadian provinces. The aim of this qualitative study was to explore patient experiences receiving care from community pharmacists, and their perspectives on the scope of practice of community pharmacists. METHODS: Fifteen patients in Nova Scotia, Canada, were interviewed. Participant narratives pertaining to pharmacist care were analyzed thematically. KEY FINDINGS: Attached, "semi-attached," and unattached patients valued community pharmacists as a cornerstone of care and sought pharmacists for a variety of health services, including triaging and system navigation. Patients spoke positively about expanding the scope of practice for community pharmacists, and better optimization of pharmacists in primary care. CONCLUSIONS: System decision-makers should consider the positive role community pharmacists can play in achieving primary care across the Quintuple Aim (population health, patient and provider experiences, reducing costs, and supporting equity in health).

Community pharmacists' expanding roles in supporting patients before and during COVID-19: An exploratory qualitative study.

BACKGROUND: Timely access and attachment to a primary healthcare provider is associated with better population health outcomes. In Canada, community pharmacists are highly accessible and patients struggling to access a family physician or nurse practitioner (i.e., "unattached") may seek care from a community pharmacist. Community pharmacists took on additional roles during the COVID-19 pandemic; however, little is known about how community pharmacists managed the needs of attached and unattached patients before and during the COVID-19 pandemic. AIM: To describe Nova Scotian community pharmacists' roles in caring for unattached patients before and during the COVID-19 pandemic and identifying barriers and facilitators to optimizing patient access. METHOD: Semi-structured interviews with community pharmacists (n = 11) across the province of Nova Scotia (Canada) were conducted. RESULTS: Five key themes were noted: (1) rising pressure on pharmacists to meet unique health needs of attached and unattached patients; (2) what pharmacists have to offer (e.g., accessibility, trustworthiness); (3) positioning pharmacists in the system (e.g., how pharmacists can address gaps in primary healthcare); (4) pharmacist wellbeing; and, (5) recommendations for practice post-pandemic (e.g., maintain some policy changes made during the COVID-19 pandemic). CONCLUSION: Before and during the pandemic, community pharmacists played a significant and increasing role providing care to patients, especially unattached patients. With growing numbers of unattached patients, it is vital that community pharmacists are supported to provide services to care for the health needs of patients.

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.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Demonstrating institutional trustworthiness: A framework for pharmacy regulatory authorities.

BACKGROUND: Self-regulation is well suited for health care providers as the distinctive knowledge requirements can be effectively managed by those with the specific knowledge base compared to national or provincial/state governments. Despite their prevalence and long history in health care, self-regulating professions have become a topic of increasing debate as a result of evidence of declines in trust in a number of institutional contexts. OBJECTIVE: It is important that Pharmacy Regulatory Authorities (PRAs), as the regulating body for a critical health profession, can demonstrate and proactively respond to issues related to public trust. Such capabilities are needed to address an overall decline in trust in self-regulated professions and allow PRAs to quickly address issues that may impact public trust within their own jurisdiction. However, a process and best practices that allow PRAs to demonstrate institutional trustworthiness to the public is lacking. Given the need from both a research and practice perspective, this research develops a conceptual framework of how PRAs can demonstrate institutional trustworthiness to the public. METHODS: The literature was reviewed to identify dominant themes associated with regulatory practice that would serve to demonstrate institutional trustworthiness of PRAs to the public. Eight best practice themes emerged: public interest objective, transparency, engagement, accountability, independence, collaboration, adaptability, and awareness. RESULTS: The conceptual framework is comprised of six key steps, related to defining public interest orientation, implementing trust-related best practices, developing a communication strategy to increase public awareness of PRA activities, monitoring symbolic capital, assessing public trust in registrants (interpersonal trust), and assessing public and registrant trust in the regulator (institutional trust). CONCLUSION: Future research should develop pharmacy-focused instruments related to trust, establish baseline measures of registrant and public trust in pharmacy regulatory authorities, and explore issues of public trust in PRAs between different cultures and developed and developing countries.

Awareness, Familiarity, and Pharmacist Trust: A Structural Equation Model Analysis.

Background: Trust in health care professionals is critical in the health care system and is needed for a patient to seek care, reveal sensitive information, and follow a specified treatment plan, among other things. Objective: To better understand trust in community pharmacists, this research develops a model of how patient awareness of the different community pharmacy roles (role awareness) and pharmacist familiarity influences pharmacist trust. Methods: A survey of pharmacy patients in Nova Scotia, Canada, occurred in November and December 2019, with quota sampling used to achieve representativeness by age, gender, and household income. A total of 640 usable surveys were obtained. Consistent partial least squares was deployed to test and refine the model. Results: Overall, the final model highlights that both role awareness and pharmacist familiarity influence patient assessments of pharmacist trust and explains 38.7% of its variance. Pharmacist familiarity has a stronger influence than role awareness on pharmacist trust. Results of the consistent partial least squares multigroup analysis found no statistically significant differences in the model based on patient gender. Conclusion: This research provides a means to capture interpersonal trust in community pharmacists and identifies 2 key determinants of such trust. This research also provides guidance on how to assess pharmacist trust, the value of patients knowing their pharmacist, and the value of patient awareness of the roles of the various professionals behind the counter. Such knowledge will help pharmacy managers, associations, and regulatory authorities develop evidence-informed plans to assess, rebuild, and sustain trust.

Media Generation and Pharmacy Regulatory Authority Awareness.

Background: Professional regulatory authorities play a critical role in protecting public interest. Yet, there is a growing view that trust in regulatory authorities may be on the decline. Objective: Awareness has been identified as important for maintaining trust. However, research that examines public awareness and trust in pharmacy regulatory authorities (PRAs) is lacking. This research explores public awareness and trust of PRAs and presents recommendations to enhance PRA communication strategies. Methods: An online survey was conducted with the Nova Scotia (Canada) public in 2020. Adopting classifications from the Communications literature, 3 media generations were explored: newspaper, television, and the Internet. The χ2 test of independence and Kruskal-Wallis H test were adopted to explore differences between the generations. Results: Six hundred sixty-two usable surveys were obtained. Over 80% of those surveyed were aware of the existence of the PRA. Those who had heard of the PRA were most aware of its operational responsibilities and less aware of its governance. The Internet Generation was more aware that the PRA includes members of the public in its decision making than expected and showed increased trust toward the PRA versus the other media generations. Conclusion: The findings should help inform PRA communication plans and set baselines to assess whether such plans enhance awareness. Future studies should explore additional aspects of PRA awareness and trust, perform comparisons across pharmacy jurisdictions, and develop and test models of the relationship between PRA awareness and various dimensions of institutional trust.

Barriers to the use of patient safety information sources by community pharmacies.

BACKGROUND: When patient safety information is communicated across a regulatory jurisdiction or country, the potential to enhance the safety of community pharmacy practice is significant. While there currently exists a number of sources for patient safety information (e.g., websites, safety bulletins, online tools), knowledge of the barriers that may inhibit the use of such information sources within community pharmacies is limited. OBJECTIVE: This research explores community pharmacy manager use of Canadian patient safety information sources and the barriers that may limit the use of such sources. METHODS: A qualitative research study design using semi-structured interviews was conducted with 15 community pharmacy managers in the Halifax Regional Municipality of Nova Scotia, Canada. The study explored how pharmacists access and engage a variety of information sources, including corporate intranets, websites, and tools provided by third party data base repositories. Interview data were analyzed using thematic analysis. RESULTS: Five general barriers were identified: lack of time to access information sources and its contents; too many sources of available information; too much information not relevant to community pharmacy practice; complexity navigating online information sources; and lack of community pharmacy involvement in source design. CONCLUSION: While pharmacies do use safety information sources to enhance practice safety, their ability to incorporate this information is inhibited by their general lack of time available to access and read safety information, lack of knowledge about where to get this information, and lack of tailored information for the community pharmacy context. Future initiatives should address increasing information awareness of available sources, consolidating and reducing information overload of such sources, and packaging information to better fit with pharmacists' needs.

Pharmacist work stress and learning from quality related events.

BACKGROUND: Among the many stresses faced by pharmacy staff, quality related event (QRE) learning can be among the most significant. In the absence of a supportive organizational culture, the potential for blaming individuals, versus identifying key process flaws, is significant and can be very intimidating to those involved in such discussions and may increase an already stressful work environment. OBJECTIVE: This research develops and tests a model of the relationship between the work stress faced by pharmacists and the extent of QRE learning in community pharmacies. Building upon recent research models that explore job characteristics and safety climate, the model proposes that work stress captured by the effort that the pharmacist invests into job performance, the extent to which the pharmacist is rewarded for such efforts, and the extent of pharmacist work-related commitment to their job, influence pharmacist assessment of the working conditions within their community pharmacy. It is further proposed that working conditions influence the extent of a blame culture and safety focus in the pharmacy, which, in turn, influences organizational learning from QREs. METHODS: This research formed part of a larger study focused on QRE reporting in community pharmacies. As part of the larger study, a total of 1035 questionnaires were mailed to community pharmacists, pharmacy managers, and pharmacy owners in the Canadian province of Saskatchewan during the fall of 2013 and winter and spring of 2014. Partial least squares (PLS) using SmartPLS was selected to test and further develop the proposed model. An examination of the statistical significance of latent variable paths, convergent validity, construct reliability, discriminant validity, and variance explained was used to assess the overall quality of the model. RESULTS: Of the 1035 questionnaire sent, a total of 432 questionnaires were returned for an initial response rate of approximately 42%. However, for this research, only questionnaires from staff pharmacists were used thereby reducing the number of usable questionnaires to 265. The final model highlights that pharmacist work stress greatly influences perceptions of the working conditions in the pharmacy (R(2) = 0.52), which, in turn, influence assessments of the safety focus (R(2) = 0.27) and blame culture (R(2) = 0.14) in the pharmacy. The model also found that the extent of a safety focus and blame culture within the pharmacy both influence the extent of organizational learning from QREs (R(2) = 0.44) within the pharmacy. CONCLUSIONS: In an environment where financial rewards are not always possible, ensuring that pharmacy staff feel respected and encouraged in providing safe care may help enhance QRE learning. Given the importance placed on organizational reporting of, and learning from, QREs in many jurisdictions in North America, the findings from this study suggest that a number of working conditions and perceptions of blame culture and organizational safety need to be explored before such processes can become entrenched in work flow.

Public perceptions of pharmacist expanded scope of practice services in Nova Scotia.

BACKGROUND: Community pharmacists have been transitioning from traditional dispensing roles toward a much broader scope of practice. The objective of this research was to explore public perceptions of expanded scope of practice (ESOP) services as they relate to pharmacy and pharmacist characteristics. METHODS: The Survey on New Services Offered by Nova Scotia Pharmacists was developed and deployed using in-pharmacy intercept surveys and online public surveys in Nova Scotia. The survey focused on 4 key ESOP elements/services: 1) prescribing for minor ailments (ambulatory conditions), 2) injections and vaccinations, 3) prescription renewals and 4) medication reviews. Data were analyzed using comparisons between groups (multivariate analysis of variance) and principal component analysis. RESULTS: A total of 385 surveys were obtained from the public regarding their perceptions and use of ESOP services (online n = 237, in-pharmacy intercept n = 148). A number of significant differences were found on the basis of respondent sex, age and the location of survey deployment. DISCUSSION: Overall, public perceptions of pharmacists' knowledge and skills in providing ESOP services are positive. A pharmacist's ability to communicate, protect confidentiality and provide quality information regarding medications is important to the public. CONCLUSION: Respondents who already have a good relationship with their pharmacist are more likely to see value in ESOP services. Future public education strategies should focus on factors positively affecting the public's perceptions of ESOP services and should encourage public use of these services through intentional patient education of the benefits of ESOP services and strengthening of the patient-provider relationship.