Full scope of practice is vital for rural health care: Student experience in Peace River

About a year ago, we set off on a 41-hour-long car ride from Ottawa to a rural town in northern Alberta called Peace River to start our final cooperative education term. This would be the beginning of an unforgettable and life-changing adventure, where our eyes were opened to the true potential of the pharmacy profession.

For many years, rural health care has been facing an ongoing crisis. Doctor shortages, emergency room closures, lack of funding and scarce resources threaten the health of community members. With the addition of a global pandemic, burnout and overworked health care providers, the crisis has been rapidly exacerbated. Although pharmacy can often be overlooked, pharmacists play a vital role in improving patient outcomes and have the potential to be a part of the solution for this crisis.

As pharmacy students, we read about these issues in our textbooks and listen to our professors tell us stories about the current challenges. However, in order to fully understand the disparities that affect rural communities, we felt that there was no better way to learn than by living it first-hand. We made the decision to move to Peace River, to work in a community pharmacy under a pharmacist with advanced prescribing authority (APA) during our final work-term placement. Our 4 short months in Peace River were extremely eye-opening, challenging and yet one of the most rewarding opportunities we’ve experienced. It confirmed for us that rural pharmacy professionals are key to increasing accessibility and equity within rural communities and that interprofessional collaboration and being able to work to a full scope of practice are crucial to the health care system. It also showed us that advocacy is a powerful tool that all pharmacists must engage in to better patient outcomes, the pharmacy profession and the Canadian health care system.

Accessibility and health equity

Access to health protection systems that enable equal opportunities to achieve the highest attainable level of health is known as health equity. ¹ Despite the World Health Organization deeming healthy equity as a fundamental right, people living in rural communities lack access to health care facilities and often suffer from poorer health outcomes. ²

Residents of rural communities often face barriers accessing health care. Health care facilities are few and far between compared to urban settings, meaning patients need to travel further distances to receive care. Lack of transportation infrastructure, like public transit, forces patients to drive or rely on a driver to access the facilities. When facilities are available, the extreme shortage of health care providers further limits care. Locums come and go, leaving patients without family physicians and continuity of care.

What about telehealth? Although virtual visits do increase accessibility and have been a great solution for many, especially during the COVID-19 pandemic, it may not necessarily be all-encompassing. Many remote locations lack access to broadband Internet and fast network connections, which make video conferencing difficult.

In addition to geographical barriers, financial barriers and lower health literacy are disparities that greatly impact rural health care. In urban settings, a large number of patients present with private insurance(s). However, in smaller and more remote communities, many residents are self-employed or work for small businesses that do not provide any health insurance. Despite medications and services like physiotherapy, counselling, gym memberships and healthy food being available, affordability can be a different ballgame. Lower health literacy rates can mean that patients may not completely understand the importance of health interventions and how to carry them out. They may not implement recommended lifestyle changes, monitor their health effectively, or take the prescribed medications as directed, which further jeopardizes their well-being.

Did you know that 80% of rural Canadian residents live within one kilometer of a pharmacy? ³ This makes pharmacists among the most accessible health care providers, giving them a vital role in diminishing the rural health care crisis. Not only are pharmacists in an ideal position to help make health care more physically accessible, but they implement practices that contribute to health equity.

While working in Peace River, we were often told that the pharmacy was like a walk-in clinic and that we were the initial point of triage. Patients who had any sort of health-related problem would come to the pharmacy before making an appointment with their physician or going to the hospital. One hot summer day, a patient who was experiencing shortness of breath came to the pharmacy for help. They had been outside all day doing yard work and realized their asthma inhalers were completely empty. Instead of sending the patient to the emergency room (ER) for a new prescription, we were able to renew their prescription with a quick yet thorough assessment. From patients with runny noses to chronic conditions, arthritis pain, mental health disorders and everything in between, the pharmacy team would do an initial assessment and provide patients with pharmacotherapy or an appropriate referral. Patients were not only able to access health care more easily, but this led to a decrease in the burden on family physicians and ER health care providers.

Above all, pharmacists have a duty to educate patients. During our time practising in Alberta, we spent time with many patients teaching them how to properly measure their blood pressure and blood sugars. We discussed new medications and expected side effects. But more importantly, we had real conversations with our patients to help find tangible solutions when recommended interventions were not affordable or attainable.

Full scope of practice

Alberta has a remarkable full (also known as expanded) scope of practice for pharmacists. That is one of the reasons we wanted to work there for one of our placements, as we felt that working in a full scope pharmacy practice was the ultimate way to challenge our clinical knowledge and gain confidence in our ability to deliver exceptional patient care. Working under a pharmacist with APA was conducive to learning and challenged us to step outside of our comfort zones and use the knowledge we acquired in pharmacy school to positively impact patients’ health. Our preceptor, Monique Lavoie, obtained her APA in 2012 and was therefore very established in the community and heavily relied upon by many patients and other health care professionals to provide care.

Full scope is a vital component to rural health care in order to productively and effectively use each health care professional to their full capacity. Pharmacists in rural areas have the ability to exercise their clinical knowledge entirely and are given opportunities to acquire a wider range of skills than in urban settings. Pharmacists in cities may often be consumed with drug dispensing and may rarely encounter clinical assessment opportunities. However, the opposite is true for remote locations. Working in the community pharmacy in Peace River provided us with innumerable clinical experiences. From simple questions about over-the-counter products and ambulatory conditions, to vaccine inquiries and complex health problems, we were often the first point of contact. We reviewed patients’ medications with them, developed care plans, ordered lab work, administered vaccinations, prescribed or deprescribed medications, renewed long-standing prescriptions, measured blood pressures, blood sugar and more. Working to our full scope of practice, we were able to help many patients, freeing up valuable time and resources for family physicians and ER doctors to dedicate to patients with more serious health issues. Working this way is a powerful tool in improving accessibility to health care.

Interprofessional collaboration

Have you ever worked in a community pharmacy, faxed a physician a renewal request or a note about a drug therapy problem and never heard back? That is the reality in many community pharmacies, where health care appears segregated rather than unified. Working in Peace River allowed us to gain a deeper understanding of interprofessional collaboration and communication with all members of the team in a responsive and respectful manner. There were challenges and barriers to collaborating with physicians, especially since most physicians were only working in Peace River for a few weeks or months at a time, leaving residents with limited continuity of care. On the other hand, physicians relied on pharmacists in Peace River to provide health care to patients, as there was and still is a shortage of physicians and simply not enough time to care for all members of the community. The pharmacy we worked at was instrumental in picking up the pieces and providing patients with the health care they deserve. Physicians and pharmacists have a mutual understanding that in order to keep members of their community safe and healthy, they must collaborate and work together.

For example, physicians would write messages on prescriptions such as, “Pharmacist to dose adjust as needed,” “Pharmacist to follow up with this patient about diabetes control” or “Can the pharmacist please educate this patient about their new blood pressure machine for home use?” We collaborated with other health care professionals in the community as well, such as calling a nurse at the hospital to confirm which medications a patient was taking while admitted or speaking with a social worker about a little boy living with schizophrenia who needed regular counselling and medication.

There is value in understanding our role in the health care system as well as the roles of those in other professions in order to establish and achieve patient and community goals. Mutual respect is of utmost importance and is often a barrier to interprofessional collaboration.

Indigenous health care

Developing cultural safety and humility is a vital component of being a patient-centred, empathetic pharmacist. As Canadians, we have heard about the inequities that exist in the health care system for Indigenous patients. We have been dedicated to ensuring that we thoroughly understand how to work in collaboration with Indigenous patients to achieve optimal health outcomes, such as respecting and integrating traditional medicine practices into treatment plans.

In Peace River, we were involved in a project to ameliorate access to health care in surrounding Indigenous communities. We were asked by a physician to perform medication reviews at the Woodland Cree Health Centre, located in Cadotte Lake, Alberta, which services the reserves of the Woodland Cree First Nation. The physician travels there annually but understands this is not enough to care for all members of the community. This was an extremely eye-opening and powerful experience for us, as it was our first time providing care in an Indigenous community. Patients brought all their medications to the appointment and we discussed each medication with them. We then developed a care plan with the patient, ensured they understood the plan and subsequently faxed our recommendations to the physician.

One memorable patient at the Woodland Cree Health Centre, who had had a myocardial infarction (MI) 6 months before, had been prescribed several new medications. Prior to his MI, the patient did not take any regular medications, so he felt over-whelmed when he was instructed to start 5 new medications. He admitted to self-discontinuing 2 of his medications because he “didn’t feel any different after taking them.” We educated him about the importance of these 2 medications and how they benefit his health despite him not “feeling” different. He agreed to restart his medications, and his comment, “I appreciate you taking the time to explain everything to me—I have learned more today about my health than I ever have from a doctor,” has remained with us ever since. The patient struggled with understanding complex medical terms, highlighting the importance of communicating with patients in ways that they understand.

This experience allowed us to learn more about the Indigenous population and their relationship with the health care system, reflect on our own biases and preconceived notions and make tangible steps to developing diversity competency and humility. Our journey has only just begun and we look forward to continuing to grow into the empathetic pharmacists that we strive to be.

Advocacy

Pharmacy students are the future of the profession and we have a vital responsibility to use our voices to advocate for changes that we wish to see within our profession and within health care. However, advocating for equitable access to health care starts with first-hand experiences. As students who have recently had a formative experiential opportunity, we are using our voices to highlight how a career in rural pharmacy practice can not only benefit patients in the community but can also allow pharmacists and pharmacy students to continually challenge themselves and achieve a fulfilling career.

Throughout our time in Peace River, we gained soft skills through real-world experiences. We saw how stigma regarding Indigenous people can be detrimental to their health care. We lived the realities of the barriers associated with rural health, but also appreciated the open interprofessional communication and trust, a pharmacist’s full scope and the ability to help patients to our utmost capacity.

Most of all, we are advocating for pharmacists to be able to practise to their full scope. The number of patients that we were able to help while working under a pharmacist with APA was astronomical. If all pharmacists across Canada could do this, imagine the relief there would be in our health care system.

Conclusion

Being given this opportunity to practise in an environment where pharmacists have a full scope has allowed us to gain a deeper understanding of the importance of patient-centred care and truly integrating and valuing the input and the engagement of the patient in their health care. Practising in rural pharmacy allowed us the opportunity to build trusting relationships not only with our patients, but other health care professionals in the community.

Overall, rural pharmacy practice nourishes professional and personal growth, while simultaneously promoting career satisfaction. The ability to practise to our full clinical scope alongside interprofessional team members and make a difference in patients’ lives is a distant aspiration for many, but a reality in rural practice.

Biography

Randilynne has worked at numerous pharmacies and completed unique cooperative education placements at the Canadian Pharmacists Association, The Ottawa Hospital and a rural community pharmacy in Northern Alberta. She is actively involved in research alongside 2 faculty members at the School of Pharmacy about peripartum mental illness in women and the role of the pharmacist. Randilynne is graduating in August 2023 and will begin a pharmacy residency at The Ottawa Hospital after this. In the future, Randilynne hopes to be a hospital pharmacist while also pursuing other areas of pharmacy that she finds fulfilling—including advocacy, research and teaching. She is extremely proud to be joining the profession of pharmacy and looks forward to continuing to learn and advocate for her patients and this profession that is so close to her heart.

Thao has worked in a variety of diverse settings, completing her previous cooperative education placements at the Ontario Ministry of Health Exceptional Access Program, Shoppers Cannabis Care and in a community pharmacy in rural Northern Alberta. Being passionate about equitable access and Indigenous health care, she is currently completing her 4th-year patient care rotation placement in the remote town of Mindemoya on Manitoulin Island. She is looking forward to gaining cultural competency by integrating herself into numerous cultural events and practices. In the future, Thao hopes to pursue a career where she can continue to push the boundaries of the pharmacy profession in hopes of attaining more equitable access to health care for all.