Navigating the influence of professional abstinence on pharmacy students: Observations and solutions from their perspective

Lake J.D., Barnsley J., Lofters A., Austin Z.

Professional identity and its development is a focus of research, education, and practice. But, there is a lack of how professional identity impacts changes in pharmacists' roles in practice, which are particularly prevalent in primary care teams. This research uses Goffmanian theory, micro-sociologic interactional theory, to describe the outcomes of role negotiation in integrated primary care teams. This is a multiple case study done per Yin, which used interviews and documents to collect data. Interviews used a storytelling format to gather information on the pharmacist's role and negotiation with their team. Four to six interviews were done in each case. Data was analysed in an iterative manner using the Qualitative approach by Leuven including narrative reports being created for each case. Five cases were recruited but three cases were completed. In each case, the pharmacist was passive in role negotiation and allowed other actors to decide what tasks were of value. Likely due this passivity was due to their professional identities: supportive and "not a physician". These led to a focus on pharmacists' need to develop. This multi-case study demonstrated that pharmacists' professional identity led to passivity being valued and expected. Whether pharmacists self-limited, which has been previously seen, needs to be better defined. But unclear archetypes reduced tasks identified as unique to the pharmacist. Goffmanian theory highlighted a key success for future pharmacist role negotiation as clear professional identity by both pharmacists and society, including team members. Until that occurs, there is a risk of underuse in primary care team settings.

Rodwell L., Faisal S.

Charrois T.L., Sewell H.D.

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. 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. 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. 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.

Li K., Frumkin A., Bi W.G., Magrill J., Newton C.

Family physicians provide comprehensive care for the community and are an integral part of the healthcare system. Canada is experiencing a shortage of family physicians, driven in part by overbearing expectations of family physicians, limited support and resources, antiquated physician compensation, and high clinic operating costs. An additional factor contributing to this scarcity is the shortage of medical school and family medicine residency spots, which have not kept pace with population demand. We analysed and compared data on provincial populations and numbers of physicians, residency spots and medical school seats across Canada. Family physician shortages are the highest in the territories (>55%), Quebec (21.5%) and British Columbia (17.7%). Among the provinces, Ontario, Manitoba, Saskatchewan and British Columbia have the fewest family physicians per 100 000 persons in the population. Among the provinces that offer medical education, British Columbia and Ontario have the fewest medical school seats per population, while Quebec has the most. British Columbia has the smallest medical class size and the least number of family medicine residency spots as a function of population, and one of the highest percentages of provincial residents without family doctors. Paradoxically, Quebec has a relatively large medical class size and a high number of family medicine residency spots as a function of population, but also one of the highest percentages of provincial residents without family doctors. Possible strategies to improve the current shortage include encouraging Canadian medical students and international medical graduates to consider family medicine, and reducing administrative burdens for current physicians. Other steps include creating a national data framework, understanding physician needs to guide effective policy changes, increasing seats in medical schools and family residency programmes, providing financial incentives and facilitating entry into family medicine for international medical graduates.

Johnson J.L., Arif S., Bloom T.J., Isaacs A.N., Moseley L.E., Janke K.K.

Objective. To provide an educator-friendly travel guide for supporting professional identity formation (PIF) for pharmacy students. Findings. In contrast to professionalism, which has emphasized externally visible behaviors, professional identity focuses on the internalization of the attitudes, standards, and behavioral norms of a profession, such that one “thinks, acts, and feels” like a member of that profession. Identity, whether personal or professional, is continuously developed in part during interactions with others and in response to internal and external feedback on those interactions. Educators play a critical role in helping students navigate the “provocative moments” (eg, transitions, dissonance) that accompany identity formation. To help educators travel with purpose, several identity formation theories suggest means of creating learning experiences and supporting the development of a professional identity. Additionally, guidebooks for the trip (ie, published literature) provide examples of didactic and experiential teaching approaches that can be used to promote PIF. While further exploration and research are necessary, traveling this journey with colleagues can help members of the Academy succeed in sustainably and effectively infusing intentional PIF within pharmacy education and training. Summary. There are myriad ways for educators to develop and support PIF, which can present a challenge when defining the role that educators play in this complex, dynamic process. Educators must understand the reasoning behind various approaches and the common dialogue used, in order to engage and support learners as their expedition guides on the lifelong journey to professional identity formation.

Janke K.K., Bloom T.J., Boyce E.G., Johnson J.L., Kopacek K., O’Sullivan T.A., Petrelli H.M., Steeb D.R., Ross L.J.

Kellar J., Singh L., Bradley-Ridout G., Martimianakis M.A., van der Vleuten C.P., oude Egbrink M.G., Austin Z.

Abstract Objectives The objectives of this scoping review were to (a) explore how pharmacists perceive their professional roles and identities and (b) describe factors impacting which professional roles or identities pharmacists embody in different pharmacy practice settings. Methods A scoping review using a deductive approach was undertaken for this study. Systematic searches were conducted in five databases: Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, EBSCO Cumulative Index to Nursing and Allied Health and Scopus (Elsevier). Key words searched included pharmacist, identity, professional role and one variations of these. Results were double-blind screened for relevance by two authors. Data extraction was facilitated by the web-based software platform COVIDENCE. Foucauldian critical discourse analysis was used to deconstruct how pharmacists perceive their professional roles and identities. Key findings In total, 21 701 articles were retrieved in the search. Following de-duplication and screening, 23 studies from 11 different countries were included. Five major identity themes were identified: Clinician, Dispenser, Business Person, Patient Counsellor and Physician Supporter. The dispenser identity was the most widespread, but it was viewed by many pharmacists as undesirable. The clinician identity also had a strong presence but was viewed as an identity that pharmacists aspire to embody. Conclusions This scoping review illustrates that pharmacists do not uniformly perceive themselves to be clinicians. A significant gap exists between the profession’s desired identity and that embodied by practicing pharmacists. The resulting dissonance may be a contributing factor to the lack of wide-scale practice change that the profession has been seeking for decades.

Raiche T., Pammett R., Dattani S., Dolovich L., Hamilton K., Kennie-Kaulbach N., McCarthy L., Jorgenson D.

Canada’s universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada’s 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists’ skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

Wolcott M.D., McLaughlin J.E., Hann A., Miklavec A., Beck Dallaghan G.L., Rhoney D.H., Zomorodi M.

Introduction Growth mindset is a motivation theory proposed by Carol Dweck that posits our beliefs about intelligence, and the ability to change mindsets can have impacts on how we approach challenges, respond to criticism challenges and orient our goals. This study characterised articles on growth mindset theory in health professions education to: summarise the aspects of growth mindset being researched, describe the discussed benefits of growth mindset theory and outline strategies discussed that may promote a growth mindset. Methods A systematic review of the literature yielded 4927 articles-articles were reviewed and excluded if they were outside of health professions education and did not discuss Dweck's growth mindset theory. The final review yielded 14 research articles and 13 commentaries, which were characterised and analysed using content analysis. Results The included articles were published in 2016 and beyond; the articles represented a diverse context, participant type and approach. Most research studies measured participant mindsets and evaluated the correlation with other variables (eg grit, well-being, anxiety). Articles often highlighted benefits and strategies to promote a growth mindset at the learner, educator and organisation level. The most common learner benefits were to help them be more receptive to feedback as well as increased resiliency and perseverance, educator benefits focused on supporting collaborative relationships and safe learning environments. The most prevalent strategies discussed were teaching learners about growth mindset theory, shifting faculty feedback to emphasise effort and to prioritise feedback across the organisation. Conclusion The growth mindset framework has been shown in other fields to help others manage educational challenges and enhance learning environments. Researchers are encouraged to explore how interventions such as teaching about and prioritising a growth mindset can support learners, health care professionals, educators and organisations.

Wu Q., Tsuyuki R.T., Hall J., Biggs C., Charrois T.

Haase K.K.

Biggs C., Hall J., Charrois T.L.

Noble C., McKauge L., Clavarino A.

Transitioning from being pharmacy students to pharmacists is challenging. Students need to reconcile their professional aspirations and what they have learnt with the realities of practice. A smooth transition can be hampered when they are unable to enact the role they have envisaged or if their expectations are not met. These challenges relate to professional identity. A key challenge for pharmacy educators is how best to support the professional identity formation (PIF) of pharmacy students. To assist with this challenge, we conducted a scoping review to identify factors influencing pharmacy students' PIF and pedagogical strategies to support PIF.In September 2018, we undertook a scoping review of all contemporary research investigating pharmacy student PIF including all relevant qualitative, quantitative, theoretical, and gray literature. We searched eight databases for the review: MEDLINE, CINAHL, PsycINFO, Embase, Australian Education Index, PubMed, Scopus, and Web of Science. Literature published between January 2008 and September 2018 was reviewed and screened using inclusion/exclusion criteria. The selected articles were charted and thematically analyzed.We included 22 articles in the review. Studies generally concurred about the importance of attending to PIF throughout the whole pharmacy curriculum. Yet, those studies reporting on pharmacy students' professional identities found that students experienced challenges forming their identities. While several curriculum interventions supporting PIF have been implemented, these tended to be one-offs and there was an absence of interventions engaging key stakeholders including placement preceptors, other health professionals, and patients/consumers.Supporting the formation of pharmacy students' professional identity, while recognized as an important goal for pharmacy education, requires further empirical inquiry. Pedagogical practices focused on identity formation including adopting an integrative curricular approach are required.

Beahm N.P., Smyth D.J., Tsuyuki R.T.

Background: Pharmacists have the authorization to prescribe medications for the treatment of uncomplicated urinary tract infections (UTI) in some provinces. However, there are limited data on the outcomes of this care by pharmacists. Our objective was to evaluate the effectiveness, safety and patient satisfaction with pharmacist prescribing and care in patients with uncomplicated UTI. Methods: We conducted a prospective registry trial in 39 community pharmacies in the Canadian province of New Brunswick. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (Pharmacist-Initial Arm) or if they presented with a prescription for an antibacterial to treat UTI from another health care provider (Physician-Initial Arm). Pharmacists assessed patients and if they had complicating factors or red flags for systemic illness or pyelonephritis, they were excluded from the study. Pharmacists either prescribed antibacterial therapy, modified antibacterial therapy, provided education only or referred to physician, as appropriate. The primary outcome was clinical cure at 2 weeks and the secondary outcomes included adverse events and patient satisfaction. Results: A total of 750 patients were enrolled (87.4% in the Pharmacist-Initial Arm), average age was 40.9 (SD 16.0) years. Clinical cure was achieved in 88.9% of patients. Of those that did not have sustained symptom resolution, most (5.5% overall) had symptom recurrence after completion of therapy. Adverse events were reported by 7.2% of patients and 88.9% of those continued their medication. Most adverse events were gastrointestinal-related and transient. The patient satisfaction survey reflected very high levels of satisfaction for the care they received, as well as for trust and accessibility of the pharmacist. Conclusion: Pharmacist management of uncomplicated UTI is effective, safe, and patient satisfaction appears very high.

Tsuyuki R.T., Rosenthal M., Pearson G.J.

Background: Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed. Pharmacists are accessible primary care professionals and with expanded scopes of practice (including prescribing), could identify and manage patients with dyslipidemia. We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol (LDL-c) levels. Methods: We conducted a randomized controlled trial in 14 community pharmacies in Alberta, Canada. We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines. Intervention was pharmacist-directed dyslipidemia care, including assessment of cardiovascular risk, review of LDL-c, prescribing of medications, health behaviour interventions and follow-up every 6 weeks for 6 months. Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist. Primary outcome was the proportion of participants achieving their target LDL-c (<2 mmol/L or ≥50% reduction) at 6 months between groups. Results: We enrolled 99 patients with a mean (SD) age of 63 (13) years, 49% male and baseline LDL-c of 3.37 mmol/L (0.98). Proportion of patients achieving LDL-c target was 43% intervention versus 18% control ( p = 0.007). Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group ( p = 0.031), who also achieved greater reduction in LDL-c (1.12 mmol/L, SE = 0.112) versus control (0.42 mmol/L, SE = 0.109), for an adjusted mean difference of 0.546 mmol/L (SE = 0.157), p < 0.001. Conclusion: Pharmacist prescribing resulted in >3-fold more patients achieving target LDL-c levels. This could have major public health implications.