A typology of vaccine hesitancies: Results from a study of community pharmacists administering COVID-19 vaccinations during the pandemic.

Pharmacists were integral to the vaccine administration process during the first two years of the COVID-19 pandemic. As such, they encountered a variety of different forms of vaccine resistance. This qualitative study explored 33 community pharmacists (from varying geographical and practice types) responses to vaccine resistance and tactics utilized to support vaccination amongst diverse community members. A typology of 8 different variants of vaccine hesitancy emerged, each with its own root cause and potential opportunities for intervention. Pharmacists in this study described techniques to support adherence to public health guidance based on their assessment of root causes for resistance demonstrated by patients. Importantly, all pharmacists in this study described feelings of anger towards truly anti-vax patients and unwillingness to actually engage or even try to address this group in their practice.

Understanding the psychology of trust between patients and their community pharmacists.

BACKGROUND: Pharmacists need patients to trust them in order to support best possible health outcomes. There has been little empirical work to test the widely stated claim that pharmacists are the "most trusted" health care professional. This study was undertaken to characterize the factors that shape public trust of individual pharmacists and the profession as a whole. METHODS: An exploratory qualitative study was undertaken. Semistructured interviews with 13 patients from 5 different community pharmacies were completed. Interview data were transcribed, coded and categorized to identify trust-enhancing and trust-diminishing factors influencing patients' perceptions of pharmacists. RESULTS: Four trust-diminishing factors were identified, including the business context within which community pharmacy is practised, lack of transparency regarding pharmacists' remuneration, lack of awareness of how pharmacists qualify and are regulated and inconsistent previous experiences with pharmacists. Four trust-enhancing factors were identified, including accessibility, affability, acknowledgement and respect. DISCUSSION: This study illustrates that trust-diminishing factors appear to be somewhat outside the day-to-day control of individual community pharmacists, while trust-enhancing factors are elements that pharmacists may have greater personal control over. Further research is required to better understand these factors and to develop a more generalizable understanding of how patients develop trust in their pharmacists. Can Pharm J (Ott) 2021;154:xx-xx.

COVID-19: How did community pharmacies get through the first wave?

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic of early 2020 was one of the most impactful events in living memory. As an essential service, community pharmacies remained open to provide care and service. The unprecedented nature and scale of the pandemic triggered considerable change in daily practice. In anticipation of future pandemic waves and similar mass-scale civil disruptions, it is important to understand how community pharmacies adapted and responded in the early weeks of COVID-19. METHODS: A combination of convenience, snowball and purposive sampling methods was used to recruit staff from community pharmacies across Ontario, from a variety of different practice locations and types. A semistructured focus group interview protocol was used to elicit experiences. Data gathering was undertaken until the point of saturation. Thematic analysis was used to surface common experiences and to describe how community pharmacies adapted and responded. RESULTS: A total of 39 participants (pharmacists, registered technicians and assistants) from 11 different pharmacies participated in this study. Data were coded based on 1) what happened, 2) how community pharmacies responded, and 3) what worked and did not work to support pharmacy staff in continued provision of service and care. Key findings included the collapse of provision of nondispensing remunerated services, the central role of managerial decisions in supporting resilience (e.g., change to 8-hour shifts from 12-hour shifts) and the central role of technology in supporting continuity of quality pharmacy services. DISCUSSION: With anticipated future pandemic waves, preparedness of community pharmacy will be essential. This study provides important insights based on participants' own experiences regarding ways employers can better support staff in provision of care and service to patients during times of mass-scale civil disruption. Can Pharm J (Ott) 2020;153:xx-xx.

The role of disengagement in the psychology of competence drift.

BACKGROUND: The framing of competence as a binary "either-or" process may be shaped by the measurement tools and assessment methods used to define it. Blunt measures such as passing or failing a licensure examination, or revoking/suspending a license after a single dispensing error fosters anxiety amongst professionals and potentially leads to behaviours where learning needs are actually hidden from educators, employers or regulators. Such framing may not accurately capture the lived experience of those labelled "incompetent" and in fact may be counterproductive to remediation and skills enhancement. OBJECTIVES: To examine the construct of competence as a lived experience amongst pharmacists who had been identified and labelled as incompetent by their regulatory body. METHODS: A multiple single-case research design (described by Kratochwill and Levin) involving 14 practicing pharmacists identified as not meeting competence standards by their regulatory body in Ontario, Canada was used for this research. Constant-comparative qualitative analysis of semi-structured interview data was coded, categorized and used to identify and describe major research themes. RESULTS: Two major themes were identified, related to the personal and professional consequences of being labelled "incompetent" by one's regulatory body, and the importance of psychological engagement in one's own profession in facilitating maintenance of competence. CONCLUSIONS: This study highlighted the importance of disengagement as both a cause and consequence of competence drift and pointed to the impact of regulatory policies, practices, and assessment systems that may actually inadvertently contribute to this disengagement.

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.

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.

Conflict in community pharmacy practice: The experience of pharmacists, technicians and assistants.

BACKGROUND: Intraprofessional conflict among pharmacists, regulated technicians and assistants may undermine attempts to advance patient care in community pharmacy. There is no available research examining this issue in light of the evolution of the profession and roles within the profession. METHODS: A combination of interviews and focus groups involving pharmacists, technicians and assistants was undertaken. Each participant completed the Conflict Management Scale as a way of identifying conflict management style. Data were analyzed and coded using a constant-comparative, iterative method. RESULTS: A total of 41 pharmacy team members participated in this research (14 pharmacists, 14 technicians and 13 assistants). Four key themes were identified that related to conflict within community pharmacy: role misunderstanding, threats to self-identity, differences in conflict management style and workplace demotivation. INTERPRETATION: As exploratory research, this study highlighted the need for greater role clarity and additional conflict management skills training as supports for the pharmacy team. The impact of conflict in the workplace was described by participants as significant, adverse and multifactorial. CONCLUSIONS: To support practice change, there has been major evolution of roles and responsibilities of pharmacists, technicians and assistants. Conflict among pharmacy team members has the potential to adversely affect the quality of care provided to patients and is an issue for managers, owners, regulators and educators.

Trust in interprofessional collaboration: Perspectives of pharmacists and physicians.

BACKGROUND: Trust is integral to effective interprofessional collaboration. There has been scant literature characterizing how trust between practitioners is formed, maintained or lost. The objective of this study was to characterize the cognitive model of trust that exists between pharmacists and family physicians working in collaborative primary care settings. METHODS: Pharmacists and family physicians who work collaboratively in primary care were participants in this study. Family health teams were excluded from this study because of the distinct nature of these settings. Through a snowball convenience sampling method, a total of 11 pharmacists and 8 family physicians were recruited. A semistructured interview guide was used to guide discussion around trust, relationships and collaboration. Constant-comparative coding was used to identify themes emerging from these data. RESULTS: Pharmacists and family physicians demonstrate different cognitive models of trust in primary care collaboration. For pharmacists, trust appears to be conferred on physicians based on title, degree, status and positional authority. For family physicians, trust appears to be earned based on competency and performance. These differences may lead to interprofessional tension when expectations of reciprocal trust are not met. CONCLUSIONS: Further work in characterizing how trust is developed in interprofessional relationships is needed to support effective team formation and functioning.

How do community pharmacists make decisions? Results of an exploratory qualitative study in Ontario.

BACKGROUND: As the complexity of pharmacy practice increases, pharmacists are required to make more decisions under ambiguous or information-deficient conditions. There is scant literature examining how pharmacists make decisions and what factors or values influence their choices. The objective of this exploratory research was to characterize decision-making patterns in the clinical setting of community pharmacists in Ontario. METHODS: The think-aloud decision-making method was used for this study. Community pharmacists with 3 or more years' experience were presented with 2 clinical case studies dealing with challenging situations and were asked to verbally reason through their decision-making process while being probed by an interviewer for clarification, justification and further explication. Verbatim transcripts were analyzed using a protocol analysis method. RESULTS AND DISCUSSION: A total of 12 pharmacists participated in this study. Participants experienced cognitive dissonance in attempting to reconcile their desire for a clear and confrontation-free conclusion to the case discussion and the reality of the challenge presented within each case. Strategies for resolving this cognitive dissonance included strong emphasis on the educational (rather than decision-making) role of the pharmacist, the value of strong interpersonal relationships as a way to avoid conflict and achieve desired outcomes, the desire to seek external advice or defer to others' authority to avoid making a decision and the use of strict interpretations of rules to avoid ambiguity and contextual interpretation. This research was neither representative nor generalizable but was indicative of patterns of decisional avoidance and fear of assuming responsibility for outcomes that warrant further investigation. CONCLUSION: The think-aloud method functioned effectively in this context and provided insights into pharmacists' decision-making patterns in the clinical setting. Can Pharm J (Ott) 2016;149:90-98.

Pharmacists' experience of conflict in community practice.

BACKGROUND: Interpersonal conflict may be characterized as intellectual disagreement with emotional entanglement. While interpersonal conflict has been studied and described in different health care settings, there is little research that focuses on community pharmacists and the ways in which they experience conflict in professional practice. OBJECTIVE: To describe and characterize the experience of interpersonal conflict within community pharmacy practice. METHODS: A self-reporting narrative log was developed in which actively recruited pharmacists reported and reflected upon their day-to-day experiences of interpersonal conflict in professional practice. Focus groups of pharmacists were convened following data analysis to provide context and confirmation of identified themes. Based on this analysis, an explanatory model for interpersonal conflict in community pharmacy practice was generated. Participants were actively recruited from community pharmacy settings in the Toronto (Canada) area. A total of 41 community pharmacists participated. RESULTS: Interpersonal conflict in pharmacy practice is ubiquitous and results from diverse triggers. A conflict stance model was developed, based on the worldview and the communication style of the individual pharmacist. CONCLUSIONS: Specific conflict stances identified were: imposing, thwarting, settling, and avoiding. Further testing and refinement of this model is required.

"I just don't know what I'm supposed to know": evaluating self-assessment skills of international pharmacy graduates in Canada.

BACKGROUND: Self-assessment skills are an integral part of pharmacy education and practice, yet there is very little empirical evidence in health professions to indicate that students and practitioners possess adequate and appropriate self-assessment skills. OBJECTIVES: To evaluate self-assessment skills of international pharmacy graduates (pharmacists from outside Canada or the United States seeking licensure in Canada). METHODS: An 8-station objective structured clinical examination was used. Within each station, 2 trained and experienced pharmacist raters completed analytical and global assessments of participants. After each station, participants themselves completed the same assessments, as well as providing additional anecdotal feedback regarding their performance. In stations possessing sufficient interrater reliability, comparisons were made between raters' assessments and self-assessments. RESULTS: Across all performance quartiles there was a discrepancy between self-assessments and rater assessments of clinical performance. The discrepancy was largest in the lowest quartiles, suggesting impairment of self-assessment may be greatest amongst those who have the weakest skills. CONCLUSIONS: Not all individuals possess adequate and appropriate self-assessment skills. Further work is required to elucidate the link between clinical competence and self-assessment and to determine methods for improving self-assessment skills.

Evaluating the accuracy of pharmacy students' self-assessment skills.

OBJECTIVES: To evaluate the accuracy of self-assessment skills of senior-level bachelor of science pharmacy students. METHODS: A method proposed by Kruger and Dunning involving comparisons of pharmacy students' self-assessment with weighted average assessments of peers, standardized patients, and pharmacist-instructors was used. RESULTS: Eighty students participated in the study. Differences between self-assessment and external assessments were found across all performance quartiles. These differences were particularly large and significant in the third and fourth (lowest) quartiles and particularly marked in the areas of empathy, and logic/focus/coherence of interviewing. CONCLUSIONS: The quality and accuracy of pharmacy students' self-assessment skills were not as strong as expected, particularly given recent efforts to include self-assessment in the curriculum. Further work is necessary to ensure this important practice competency and life skill is at the level expected for professional practice and continuous professional development.

Pharmacy practice in times of civil crisis: The experience of SARS and the blackout in Ontario, Canada.

BACKGROUND: Crises affecting civilian infrastructure (including electricity supply, clean water, and access to institutional health services) may have an effect on the delivery of pharmacy services in the community. OBJECTIVES: The objectives were to describe and analyze the impact of 2 major crises (the severe acute respiratory syndrome [SARS] outbreak, and the electrical system failure ["blackout"]) on pharmacy practice and pharmacists in Toronto, Canada. METHODS: An exploratory, qualitative study was undertaken. Pharmacists were recruited, provided informed consent, and were interviewed. Data from transcripts were coded and categorized to identify themes related to adaptive strategies undertaken by pharmacists during times of civil crisis. RESULTS: Five key themes emerged from this research: (1) during times of crisis, pharmacies become frontline health care facilities, (2) a vacuity of leadership/lack of utility of emergency preparedness guidelines and policies, (3) role of and reliance on experience and professional judgment, (4) importance of documentation, and (5) the importance of "teamness" in enabling successful adaptation during times of crisis. CONCLUSIONS: Emergencies and civil crises will continue to occur. Findings of this study include the importance of effective documentation systems and teamwork practices, as well as confident reliance on professional judgment and experience, as determinants of successful adaptation to civil crises.

Negotiation of interprofessional culture shock: the experiences of pharmacists who become physicians.

Professions generally operate within a shared set of values, symbols, and norms; in short, professions may be characterized as having somewhat unique sub-cultures. As inter-professional teamwork and collaboration gain prominence, understanding the inter-cultural dimensions of professional interactions may be useful in explaining how and why such teams function. One way of examining the unique (and common) elements of professional sub-cultures is to study the experiences of professionals who have "migrated" from one field to another. In this paper, the "culture shock" experience of pharmacists who have become physicians is described and discussed. Results from interviews with 32 pharmacist-physicians were used to frame four major themes that depict salient and unique characteristics of the cultures of pharmacy and medicine.

Characterizing the professional relationships of community pharmacists.

BACKGROUND: The use of the term "patient" to describe individuals served by pharmacists may affect expectations, roles, and responsibilities. Whereas this term has been widely accepted and embraced within the profession, there is little empirical evidence to justify its use in the pharmacy practice context. OBJECTIVES: To describe and characterize the type of relationships that form between community pharmacists and the individuals they serve. METHODS: A qualitative study was undertaken with pharmacist-volunteers. Participants were asked to maintain a written diary over a 10-day period, in which their workplace experiences were documented. Responses to cued questions as well as free-form notes were analyzed to form a typology. Through successive iterations using confirmatory focus groups consisting of study participants, a final typology was developed. RESULTS: A total of 45 pharmacists participated in this study. The final typology describes 5 distinct idealized types of relationships formed by pharmacists: analytic-authoritative, emotive-interactive, opportunistic-expedient, reliant-paternalistic, and autonomous-informative. CONCLUSIONS: The complexity of practice suggests that the "patient-pharmacist" paradigm for understanding relationships in pharmacy does not adequately capture the variety of day-to-day interactions that pharmacists encounter. Pharmacists engage in a variety of adaptive and responsive strategies to meet expressed and implicit needs of the individuals they serve.

"Testwiseness" among international pharmacy graduates and Canadian senior pharmacy students.

OBJECTIVE: To compare the test-taking skills and abilities (testwiseness) of Canadian senior-level pharmacy students with those of international pharmacy graduates. METHODS: A 20-item testwiseness questionnaire was developed and administered to 102 participants: 35 senior-level pharmacy students, 34 international pharmacy graduates, and 34 practicing pharmacists who served as a control group. RESULTS: Mean testwiseness scores indicated significant differences in performance between senior-level pharmacy students and international pharmacy graduates. Testwiseness deficiencies of international pharmacy graduates were particularly severe in domains requiring discerning use of English language. CONCLUSIONS: Differences in testwiseness appear to exist between Canadian senior-level pharmacy students and international pharmacy graduates. The genesis and implications of these differences must be evaluated further in order to determine whether testwiseness affects learning, professional development, or clinical practice.