The role and impact of the pharmacist in long-term care settings: A systematic review.

OBJECTIVE: Older adults in long-term care (LTC) are often frail and comorbid and have multiple medications. Although medication review by pharmacists has been integrated into LTC practice in many countries through policy and reimbursement models, the impact is variable in the literature. The purpose of our study was to review the literature regarding the impact of the pharmacist in LTC. DATA SOURCES: Four databases were searched from inception to September 2017, including Ovid MEDLINE, Ovid Embase, Ovid Evidence-Based Medicine Reviews (Cochrane Library), and Ovid International Pharmaceutical Abstracts. STUDY SELECTION: Studies in any language were included if they met the following criteria: (1) pharmacist involved in care, (2) quasi-experimental or experimental design, and (3) conducted in LTC. DATA EXTRACTION: Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met inclusion criteria, with a third researcher resolving discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. RESULTS: Twenty-six studies (total N = 20,228, median study duration = 12 months) met the inclusion criteria. Medication review was the most common intervention, evaluated in 24 studies (92%). Eleven studies (42%) reported on the total number of medications per patient, with 7 studies finding a statistically significant reduction in medication usage. Six studies focused on psychotropic medications, with 4 of those leading to a reduction in medication. Explicit medication appropriateness criteria showed improvement in 5 studies. Medication and health care costs were evaluated in 14 studies (54%), with 4 reporting a statistically significant reduction. Studies reporting hospitalizations (10, 38%) were moderately heterogeneous (I2 = 59%) and failed to demonstrate an impact. Studies reporting mortality (8, 31%) were less heterogeneous (I2 = 0%), but they also failed to show a change. CONCLUSION: There is evidence to support pharmacist intervention, primarily through medication review, to improve measures in medication appropriateness.

What makes pharmacists successful? An investigation of personal characteristics.

OBJECTIVES: The primary objective of this study was to identify characteristics of pharmacists that contribute to their success. DESIGN: A working definition of success in pharmacy practice was derived from a scoping literature review and is based on the premise that successful pharmacists practice to full scope within the context of their practice setting. Semistructured individual interviews were conducted with selected pharmacists. Potential candidates were nominated by leading pharmacists in the field with the use of our prespecified definition of success. Lists from the nominators were compared, and pharmacists who appeared on more than 1 list were invited to participate. The interview tool was developed with the use of previous research on success in health care professions. SETTING AND PARTICIPANTS: Participants were 10 practicing pharmacists in a variety of locations (5 urban/5 rural) and practice settings (5 hospital/4 community/1 ambulatory care). OUTCOME MEASURES: Themes related to successful pharmacists practicing to full scope. RESULTS: Pharmacists meeting our definition of success were engaged in assessment and care planning, other expanded scope activities, and interpersonal activities and collaboration. The 10 interviewed pharmacists described motivation, critical thinking, emotional intelligence, core competencies, and work-life balance as significant contributors to their success. CONCLUSION: Several characteristics were identified as potentially related to success. These characteristics may be useful in pharmacists identifying areas for personal growth and development.

Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxACTION).

BACKGROUND: Hypertension control rates remain suboptimal. Pharmacists' scope of practice is evolving, and their position in the community may be ideal for improving hypertension care. We aimed to study the impact of pharmacist prescribing on blood pressure (BP) control in community-dwelling patients. METHODS AND RESULTS: We designed a patient-level, randomized, controlled trial, enrolling adults with above-target BP (as defined by Canadian guidelines) through community pharmacies, hospitals, or primary care teams in 23 communities in Alberta. Intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist). Control group patients received a wallet card for BP recording, written hypertension information, and usual care from their pharmacist and physician. Primary outcome was the change in systolic BP at 6 months. A total of 248 patients (mean age, 64 years; 49% male) were enrolled. Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg. The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group, an adjusted difference of 6.6±1.9 mm Hg (P=0.0006). The adjusted odds of patients achieving BP targets was 2.32 (95% confidence interval, 1.17-4.15 in favor of the intervention). CONCLUSIONS: Pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policy makers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00878566.

Understanding pharmacist success in practice: A scoping review.

OBJECTIVES: The objective was to identify literature providing a description of characteristics contributing to pharmacists' individual level success in providing advanced patient care. DESIGN: An interpretive scoping review was conducted to synthesize knowledge and address the study objective. SETTING: Searches were undertaken in Ovid MEDLINE (1946-2015), EMBASE (1974-2015), and International Pharmaceutical Abstracts (1970-2015). PARTICIPANTS: Not applicable. MAIN OUTCOME MEASURES: Specific keywords used in the search included: motivation, attitude, career, clinical competence, certification, pursuit of an expanded scope of practice, pharmacist, and success. This was not intended to be an exhaustive list, and every effort was made to be inclusive as the search revealed additional words and phrases of interest. RESULTS: A total of 93 articles were initially identified, 10 articles met inclusion criteria and were retained for full-text analysis. Most of the included articles were published in the United States (70%). One-third of the articles conducted semi-structured interviews, one-third of the articles were editorials or commentaries, and the remaining articles collected data using surveys, knowledge assessments, and observation. Content analysis of the extracted definitions of success yielded 2 themes; "what successful pharmacists do" and "what successful pharmacists should be." CONCLUSION: Professional organizations representing pharmacy have made significant strides in advocating for pharmacists' provision of advanced patient care. If pharmacists are to successfully provide advanced patient care a more specific and practically-oriented understanding that accounts for individual and environmental factors of how to achieve individual-level success is needed.

Pay-for-performance remuneration for pharmacist prescribers' management of hypertension: A substudy of the RxACTION trial.

BACKGROUND: To be sustainable, pharmacists providing direct patient care must receive appropriate payment for these services. This prespecified substudy of the RxACTION trial (a randomized trial of pharmacist prescribing vs usual care in patients with above-target blood pressure [BP]) aimed to determine if BP reduction achieved differed between patients whose pharmacist was paid by pay-for-performance (P4P) vs fee-for-service (FFS). METHODS: Within RxACTION, patients with elevated BP assigned to the pharmacist prescribing group were further randomized to P4P or FFS payment for the pharmacist. In FFS, pharmacists received $150 for the initial visit and $75 for follow-up visits. P4P included FFS payments plus incentives of $125 and $250 for each patient who reached 50% and 100% of the BP target, respectively. The primary outcome was difference in change in systolic BP between P4P and FFS groups. RESULTS: A total of 89 patients were randomized to P4P and 92 to the FFS group. Patients' average (SD) age was 63.0 (13.2) years, 49% were male and 76% were on antihypertensive drug therapy at baseline, taking a median of 2 (interquartile range = 1) medications. Mean systolic BP reductions in the P4P and FFS groups were 19.7 (SD = 18.4) vs 17.0 (SD = 16.4) mmHg, respectively (p = 0.47 for the comparison of deltas and p = 0.29 after multivariate adjustment). CONCLUSIONS: This trial of pharmacist prescribing found substantial reductions in systolic BP among poorly controlled hypertensive individuals but with no appreciable difference when pharmacists were paid by P4P vs FFS.

Professional Fulfillment and Burnout in Fourth-Year Pharmacy Students and Risk Factors for the Future: A Mixed Methods Study.

OBJECTIVE: Many factors shape the professional identity of pharmacy students; however, little is known about the influence of well-being. Two aspects of well-being explored in this study include professional fulfillment and burnout. We describe the current levels of each among fourth-year pharmacy students, identify possible predictors, and uncover themes. METHODS: The Stanford Professional Fulfillment Index was used to measure professional fulfillment and burnout among students in the prior 2 weeks. Multivariable linear regressions were conducted to identify individual characteristics and activities as predictors of professional fulfillment and burnout. Upon completion of activities to foster personal wellness, student self-reflections were analyzed using thematic analysis to describe student-perceived barriers and facilitators of professional fulfillment and burnout. RESULTS: In total 54 students completed the Professional Fulfillment Index, wellness activities, and self-reflection. Having already completed the jurisprudence examination required for licensure and having a job upon graduation were statistically significantly associated with higher professional fulfillment scores. We identified that working in a non-pharmacy-related job, while completing practicums, was statistically significantly associated with higher work exhaustion scores. Themes uncovered from student self-reflections included a definition of wellness, how doing what you are supposed to be doing and working in a psychologically and physically safe environment contributes to professional fulfillment, and system-level factors leading to burnout. CONCLUSION: This study provides evidence of the importance of supporting pharmacy students in the completion of the steps to licensure, the value of exposure to a variety of pharmacist-related activities through experiential education, and well-being as foundational to professional identity.

What Types of Data are Pharmacy Education Scholars Using in their Abstracts for Poster Presentations?

OBJECTIVE: The objective of this study was to describe the data being used to support poster presentations in pharmacy education scholarship. METHODS: Research and education posters presented at the 2020 American Association of Colleges of Pharmacy Annual Meeting were unitized to isolate text to be coded, and two coders categorized the quantitative and qualitative data by type and source. Questionnaires, instruments, and exams were categorized as new (ie developed and used for this particular inquiry) vs. existing. Qualitative data types were categorized as interviews, focus groups, self-reflections, analysis of student work products (eg lab reports assessed for student understanding), comments (ie written or verbal comments), and other (eg course reports). RESULTS: Two hundred and sixteen abstracts were included in the analysis, with 80 (37%) of abstracts relying on data derived from respondent's perceptions. Further, 143 abstracts (66%) used at least one new questionnaire, instrument, or exam. In 57% of the cases where multiple data sources were used, the study involved interprofessional education (eg multiple health professions learners) or pharmacy student-investigator combinations, and 28 abstracts (13%) did not use pharmacy students as a source. Less than 5% of all abstracts analyzed used traditional qualitative methods of interviews and focus groups. CONCLUSION: This study can open conversations around how to improve the quality of pharmacy education research and the identification of areas within the scholarship of teaching and learning that may benefit from improvement.

Clinical decision-making by fourth-year pharmacy students: Towards an understanding of their uncertainty.

INTRODUCTION: Clinical decision-making is a critical process underpinning much of a pharmacist's daily activities. While it is known that pharmacists hesitate to make decisions, it remains unclear whether pharmacy students experience similar hesitancy. The objective of this study was to better understand the phenomenon of decision-making in pharmacy students. METHODS: This study was designed from a social constructivist paradigm using qualitative case study methodology. The purpose was to investigate issues related to hesitancy in clinical decision-making by fourth-year pharmacy students. Data were collected through observation of students engaging in simulations, post-simulation interviews, and written reflections. Data analysis included multiple stages of coding, followed by pattern identification and discovery of interrelationships. RESULTS: The primary themes relating to issues in pharmacy student clinical decision-making were relational factors, teaching and learning, degree of certainty, and personal characteristics. Relational factors include elements of relationships with patients and physicians as well as a sense of autonomy. The theme of teaching and learning included the sub-themes of formal education and learning in the real world. Degree of certainty included patient complexity, weighing risks and benefits, comfort in ambiguity, and a lack of information. Finally, personal characteristics associated with decision-making include personal experiences, leadership skills, and confidence. CONCLUSIONS: Pharmacy education needs to focus on ensuring preceptors can help model comfort in ambiguity, that assessments include the reality of practice, and ensuring ample practice of decision-making in a simulated environment.

Commentary: Making Space for Reading as a Faculty Member.

In academia, significant emphasis is given to the importance of writing. However, reading may be given less prominence in faculty work lives. The purpose of this commentary is to explore the educator's relationship with academic reading, habits that support this practice, and points of reflection for creating space for reading in our professional lives. The authors engaged in a reflexivity exercise and discussion of our own motivations, emotions, and experiences associated with reading, and how these may change across our careers. We discuss the need to make space for reading in our work, and additionally, provide recommendations for better integrating the habit of reading into our professional lives.

Moving beyond professionalism: Pharmacy students understanding of professionalism and professional identity.

INTRODUCTION: Professional identity is who we are in the context of our chosen profession, a complex and dynamic process. The purpose of this study was to describe pharmacy students' understanding of the terms professionalism and professional identity and the elements of formal and informal curricular activities that may contribute to professional identity formation. METHODS: This anonymous cross-sectional survey was administered to pharmacy students in years one through five at all 10 Canadian pharmacy schools with the help of local Canadian Association of Pharmacy Students and Interns representatives. Students were first asked to define professionalism and professional identity and then were provided with a definition of professional identity to support their statements as to what experiences were meaningful in its development. Both an inductive and deductive approach were used for thematic analysis of written responses alongside descriptive statistics. RESULTS: A total of 172 students responded. Most students were from the University of Alberta and were evenly distributed through years one through four of pharmacy. Key themes emerged of the traditional view of professionalism, expanding the six tenets defined by the American College of Clinical Pharmacy to include responsibility and accountability. Pharmacy students' definitions of professional identity more often included facets of professionalism, but when prompted acknowledged teaching related opportunities, professional development, and role-modelling as playing a key role in professional identity development. CONCLUSIONS: Most pharmacy students were unable to formally define professional identity; however when prompted they did understand what it was and which experiences nurtured its development.

Reflective Practice: Co-Creating Reflective Activities for Pharmacy Students.

Reflective practice is important in pharmacy education to support skill development for decision-making, critical thinking, problem-solving, and in continuing professional development and beyond. Despite the importance of reflective practice in higher education and professional practice, reflection assignments are not universally embraced by students. This project was initiated due to recent interest in the co-creation of pharmacy curriculum by students and faculty. The purpose of this project was to develop reflection assignments for pharmacy students. The principles of the analysis, design, development, implementation, evaluation (ADDIE) instructional design framework guided the development of reflection assignment templates for three focus areas: personal development, professional development, and professional identity formation. Templates included background and definitions for these specific focus areas as well as objectives, instructions, guiding questions, assessment methods, and submission requirements. A previously tested assessment rubric was adopted for reflection assignments. Development involved target audience and expert reviews and a trial implementation was held in a year 3 patient care skills course. The co-creation process enriched the experiences of students and faculty involved in it. Future co-creation projects including groups of students, formal evaluation of outcomes, and impact on the program will further support integration of reflective practice in the pharmacy curriculum.

A descriptive study evaluating Health Canada's risk communications.

PURPOSE: Risk assessment for natural health products (NHPs) may not be evaluated similarly to therapeutic products by Health Canada in terms of notification of harms to consumers and health professionals. In this descriptive study, we evaluated risk communications (RCs) issued by Health Canada for NHPs and for therapeutic products, looking for differences in a number of variables. METHODS: Risk communications issued by Health Canada in 2006 were independently evaluated by two investigators for whether the harm was actual or potential, for the seriousness and nature of harm, the origin of report, publication type, and degree of association. Disagreements were brought before a third reviewer for adjudication. RESULTS: During the study period, Health Canada issued 42 RCs for each of NHPs and therapeutic products. Most (86%) NHP RCs were issued for potential harm from contamination and adulteration, whereas 69% of therapeutic product RCs were issued due to actual harms (p < 0.0001). Two deaths had been associated with NHP use, compared with 15 deaths associated with the use of therapeutic products (p = 0.0048). The degree of association between product and harm was higher among NHP RCs compared with that among therapeutic product RCs (p < 0.0001). All reports issued for NHPs originated from foreign sources or Health Canada, whereas 69% of therapeutic product RCs were issued by drug manufacturers. CONCLUSIONS: We identified important differences in the RCs issued for NHPs versus those for therapeutic products. Standardized formats for RCs are recommended.

The impact of the COVID-19 pandemic on pharmacy students' personal and professional learning.

INTRODUCTION: The COVID-19 pandemic impacted both healthcare delivery and the education of healthcare students, with a shift to remote delivery of coursework and assessment alongside the expansion of the scope of practice of Alberta pharmacists. The objective of this research was to understand how the learning of pharmacy students at the University of Alberta was impacted by the COVID-19 pandemic. METHODS: A cross-sectional survey was distributed to 397 pharmacy students in years one through three. Students responded to three short-answer reflection questions: (1) how has the COVID-19 pandemic situation affected your learning; (2) from a pharmacy and pharmacy school perspective, what have you learned since the COVID-19 pandemic began; and (3) from a personal perspective, what have you learned about yourself since the COVID-19 pandemic began? A thematic analysis was undertaken of students' responses to these reflection questions. RESULTS: A total of 53 students responded to the survey (response rate 13%). Two major themes were identified across all three reflection questions, with several subthemes: remote learning (learning environment, knowledge transfer, knowledge retention, assessment) and mental health (appreciation, stress, extroversion, motivation). Adaptability, routine, professional identity, and the role of the pharmacist were also identified as less prevalent themes. CONCLUSIONS: Pharmacy students' responses led to the identification of several themes related to their learning given the changes brought about by the COVID-19 pandemic. This increased understanding of student perceptions has the potential to improve the remote delivery of education, support increased university-wide mental health resourcing, and shape pharmacy curriculum development.

Pharmacy and medical students' competence and confidence with prescribing: A cross-sectional study.

INTRODUCTION: Previous research has shown that prescribing competence is weakly correlated with prescribing confidence. This questions whether undergraduate programs adequately prepare students and junior practitioners for safe and rational prescribing. The goal of this project was to investigate whether there are differences in prescribing competence and confidence between fourth year pharmacy and medical students at the University of Alberta. METHODS: A cross-sectional design measured prescribing competence using five case scenarios and prescribing confidence with a survey. All fourth-year pharmacy and medical students at the University of Alberta were eligible to participate. Answers to the cases were graded based on therapeutic appropriateness and inclusion of all legal requirements. The confidence survey assessed self-rated confidence of both assessment and prescribing skills. Chi-square tests were used to compare frequencies of prescribing errors and self-rated confidence. The Spearman correlation coefficient was used to explore the correlation between prescribing competence and confidence for both cohorts independently. RESULTS: Thirty-one pharmacy students and 16 medical students (response rate 24% and 10%, respectively) completed the assessment between December 2018 and March 2019. Pharmacy students had significantly more appropriate prescriptions and fewer inappropriate prescriptions than medical students. Both rated themselves as confident or very confident with prescribing, however neither group consistently included all the legal requirements of a prescription. There were no significant correlations between competence and confidence. CONCLUSIONS: There are differences in prescribing competence and confidence between pharmacy and medical students. This assessment identified deficits in prescribing skills that could be targeted by future educational initiatives.

Competence and confidence with prescribing in pharmacy and medicine: a scoping review.

OBJECTIVES: Prescribing is a growing scope of practice for pharmacists. The objective of this scoping review is to explore themes within the literature related to prescribing competence and confidence in the disciplines of pharmacy and medicine. METHODS: Online databases MEDLINE, EMBASE and Global Health were used to identify articles from inception to October 2018. Articles describing either the competence or confidence of physician, pharmacist or student prescribing, including inappropriate prescribing and prescribing errors were included. KEY FINDINGS: After applying the inclusion and exclusion criteria, 33 eligible articles remained. Many studies demonstrate that medical students and junior doctors are not competent in prescribing when they enter practice, and their perceived confidence is often higher than their assessed competence. There were fewer studies about pharmacist competence and confidence with prescribing; however, they described pharmacists that felt competent to prescribe but lacked confidence. Themes from the review included self-awareness, lack of education and educational improvements, prescribing errors and resources, prescribing culture and barriers to prescribing, gender differences and benefits to prescribing. CONCLUSIONS: There is little consensus from the outcomes of these studies related to prescribing competence or confidence. While some reflect positively on prescribing competence and confidence, others show major deficits in competence and lack of confidence. Further research needs to be done to evaluate pharmacist competence and confidence with respect to prescribing.

Systematic reviews of pharmacy practice research: methodologic issues in searching, evaluating, interpreting, and disseminating results.

Although there has been a large number of trials on pharmacist care, often demonstrating clinically significant benefits, the trials generally have not changed practice or healthcare policy. What is needed are focused evidence syntheses, such as a systematic review. A systematic review is defined as a summary that addresses a focused clinical question, using methods to reduce the likelihood of bias. These reviews, which are the highest level of evidence, can help to impact policy by bringing together results of various trials. However, systematic reviews of practice research pose some unique methodologic challenges, including issues with searching, interpreting, and evaluating the available research. Well-conducted systematic reviews of pharmacist interventions could go a long way toward changing pharmacy practice and healthcare policy to recognize the important impact that pharmacists could have in the healthcare system.

Pharmacist care of patients with heart failure: a systematic review of randomized trials.

BACKGROUND: While the role of multidisciplinary teams in the treatment of patients with heart failure (HF) is well established, there is less evidence to characterize the role of individual team members. To clarify the role of pharmacists in the care of patients with HF, we performed a systematic review evaluating the effect of pharmacist care on patient outcomes in HF. METHODS: We searched PubMed, MEDLINE, EMBASE, International Pharmaceutical Abstracts, Web of Science, Scopus, Dissertation Abstracts, CINAHL, Pascal, and Cochrane Central Register of Controlled Trials for controlled studies from database inception to August 2007. We included randomized controlled trials that evaluated the impact of pharmacist care activities on patients with HF (in both inpatient and outpatient settings). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of all-cause hospitalization, HF hospitalization, and mortality. RESULTS: A total of 12 randomized controlled trials (2060 patients) were identified. Extent of pharmacist involvement varied among studies, and each study intervention was categorized as pharmacist-directed care or pharmacist collaborative care using a priori definitions and feedback from primary study authors. Pharmacist care was associated with significant reductions in the rate of all-cause hospitalizations (11 studies [2026 patients]) (OR, 0.71; 95% CI, 0.54-0.94) and HF hospitalizations (11 studies [1977 patients]) (OR, 0.69; 95% CI, 0.51-0.94),and a nonsignificant reduction in mortality (12 studies [2060 patients])(OR, 0.84; 95% CI, 0.61-1.15). Pharmacist collaborative care led to greater reductions in the rate of HF hospitalizations (OR, 0.42; 95%CI, 0.24-0.74) than pharmacist-directed care (OR, 0.89; 95% CI, 0.68-1.17). CONCLUSIONS: Pharmacist care in the treatment of patients with HF greatly reduces the risk of all-cause and HF hospitalizations. Since hospitalizations associated with HF are a major public health problem, the incorporation of pharmacists into HF care teams should be strongly considered.