Abstract
Background
Automatic substitution of biological medicines refers to a dispensing practice in community pharmacies in which a pharmacist substitutes a prescribed biological medicine with an interchangeable biologic product without contacting the prescriber. Automatic substitution of biological medicines in community pharmacies offers one possibility to reduce increased healthcare expenditures through price competition among biological medicines. The implementation of automatic substitution requires active engagement, information and coordination to maintain medication safety. Research on healthcare professionals’ perceptions towards automatic substitution remains limited. This study provides insight into automatic substitution from the perspective of rheumatology nurses, whose role in rheumatology patient care is essential. The Aim of the study was to explore rheumatology nurses’ perceptions of automatic substitution of biological medicines and its safe implementation.
Methods
Data were collected through individual semi-structured interviews in 2025. The participants were rheumatology nurses (n = 10) with clinical experience in patient care, including injection and device guidance for patients. The data were analysed with inductive content analysis. To ensure comprehensive and transparent reporting, the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was utilised.
Results
Four categories were identified: (1) Perceptions of automatic substitution, (2) Factors supporting the implementation of automatic substitution, (3) Concerns related to automatic substitution, and (4) Safe implementation of automatic substitution. All interviewees acknowledged the critical roles of community pharmacies and healthcare personnel in ensuring safe implementation. Perceptions of automatic substitution were positive, although concerns were raised about medication-related issues and work-related challenges such as increased workload in patient counselling. Factors supporting the implementation of automatic substitution were mainly related to the suitability of biological medicines for substitution, and patients’ experience of biological medicines and generic substitution.
Conclusions
Rheumatology nurses’ perceptions of automatic substitution were generally positive, and they considered biological medicines suitable for substitution. However, their concerns regarding work-related challenges and medication-related issues highlight the importance of ensuring sufficient resources to sustain patient safety. Successful and safe implementation of automatic substitution will require comprehensive patient counselling.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12913-026-14848-w.
Keywords: Nurses, Rheumatology, Biological medicines, Automatic substitution, Pharmacy, Interview
Background
Rheumatoid arthritis (RA) is considered the most prevalent chronic autoimmune disease, with an estimated global prevalence of approximately 0.5-1% [1]. The introduction of biological medicines has significantly improved therapeutic outcomes for patients with chronic and inflammatory conditions, including RA [2, 3]. Biological medicines offer an alternative treatment option when conventional medications fail to achieve adequate disease control [4].
In Europe, biological medicines accounted for 41% of pharmaceutical expenditure in 2024 [5]. Biological medicines used in the treatment of RA include various modes of action, such as tumour necrosis factor (TNF) inhibitors (adalimumab, etanercept, infliximab), interleukin inhibitors (anakinra, tocilizumab) and agents targeting B- or T-cells (rituximab, abatacept) [2, 6]. One key distinction compared to conventional therapies is that biological medicines are mainly administered parenterally using an injection device [7].
The role and clinical expertise of rheumatology nurses are essential in achieving effective treatment and managing patients with RA [8]. Their involvement in biologic therapy counselling ensures medication safety, as they routinely educate patients on the correct use and administration of biological medicines. In addition, nurses assess patients’ care needs and offer guidance on treatment effects, potential adverse effects, follow-up care, efficacy, and safety. Nurses occupy a pivotal position within multidisciplinary rheumatology teams nowadays, assuming responsibilities that extend beyond traditional patient care [9].
It is widely recognised that biological medicines are among the most expensive pharmaceutical products, and their growing use has significantly contributed to increasing healthcare expenditures [10]. Biosimilars offer one strategy to mitigate these costs by enhancing price competition, and this potential has been acknowledged by healthcare professionals [11, 12]. The European Medicines Agency (EMA) and Heads of Medicines Agencies (HMA) have stated that reference products and their biosimilars, or biosimilars of the same reference product, are interchangeable [13]. According to the World Health Organization (WHO), legislative and administrative measures should be implemented to support the early market entry of generics and biosimilars [14].
Automatic substitution of biological medicines is a procedure whereby a community pharmacist substitutes a prescribed biological medicine with an interchangeable biologic product during dispensing, without contacting the prescriber [3]. EU member states independently determine their policies regarding interchangeability and automatic substitution, resulting in variation in practices across countries. In Finland, automatic substitution of biological medicines was implemented gradually during 2024—2026, and it is now a standard practice in community pharmacies [15]. The aim is to achieve cost containment by increasing price competition among biological medicines defined as interchangeable by the Finnish Medicines Agency [7, 15]. To ensure the successful and safe implementation of automatic substitution, nurses play a pivotal role, as they are central to patient education, medication counselling, and continuity of care, particularly in chronic disease management [9].
Despite the growing importance of biosimilars and automatic substitution, a previous systematic review indicates that research on healthcare professionals’ perspectives, particularly nurses’, remains limited [16]. Only a few studies have examined healthcare professionals’ perceptions of automatic substitution, and these were conducted in settings where automatic substitution had not yet been implemented [12, 17, 18]. Therefore, this study provides insights into the automatic substitution of biological medicines during its initial implementation phase in Finland. This study aimed to explore rheumatology nurses’ perceptions of automatic substitution of biological medicines and how to ensure its safe implementation in community pharmacies.
Context
In Finland, the treatment of patients with RA is organised through collaboration between specialised and primary healthcare services [6]. Public social and health services are provided by 21 wellbeing services counties, which operate within collaboration areas built around five university hospitals [19]. Rheumatology nurses play an essential role in this care model, contributing not only to patient monitoring and counselling but also to patient education, treatment adherence and functioning as a part of a multidisciplinary team [6]. Rheumatology nurses typically work in specialised healthcare services, i.e., hospitals and provide injection and device guidance for patients initiating biological therapy before they obtain medication from the pharmacy and self-administer the medication.
The costs of biological treatments are shared between the Finnish Social Insurance Institution and the patient [20]. To control reimbursement expenditures, physicians have been required to prescribe the most affordable biological medicine available since 2017. However, this measure alone did not achieve adequate cost containment. Consequently, automatic substitution of biological medicines has been implemented in community pharmacies from spring 2024 onwards, eventually covering all biological medicines except short-acting insulins [21]. For comparison, generic substitution of synthetic medicines has been implemented since 2003 in Finland [22].
Automatic substitution affects patients with RA by allowing their prescribed biological medicine to be substituted with an interchangeable product in the pharmacy. The legal framework regulates automatic substitution, and patients are entitled to continue treatment with the same biological product for six months, even if prices change during that period [21]. The substitution is mandatory for all individuals over 18 years, unless prohibited by a physician. In cases where a patient declines substitution, they are required to pay the price difference exceeding that of the lower-cost alternative [20]. Since 1 January 2025, automatic substitution has applied to all biological medicines used in the treatment of RA [21]. Ministry of Social Affairs and Health has published an official guideline for the automatic substitution procedure after the interviews for this study were conducted [7].
Methods
Aim
The aim of the study was to explore rheumatology nurses’ perceptions of automatic substitution of biological medicines and how to ensure its safe implementation in community pharmacies.
Study design
This study employed a qualitative research design, and the data were collected via individual semi-structured interviews. The data were analysed using inductive content analysis. Additionally, the reporting of the findings was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [23].
Study setting and recruitment
This study was conducted within a hospital setting. Hospital organisations were selected through purposive sampling and included all five university hospitals in Finland, along with five central hospitals representing diverse wellbeing services counties. The inclusion criteria for participating nurses were current clinical practice in rheumatology and experience in providing injection and device guidance for patients. Recruitment was facilitated by a contact person within each hospital organisation. The contact person either directly recommended a suitable nurse, who then contacted the interviewer, or provided the interviewer with the nurses’ contact details for an email-based invitation. Before data collection, research permissions were obtained from each participating hospital organisation. To ensure saturation, the sample size was predetermined at ten interviews. This decision was grounded in prior research demonstrating that most concepts (80–92%) were captured within the first ten qualitative interviews [24].
Data collection
An interview guide (Supplementary Material 1) was developed by the research group which consisted of three researchers (having PhD in pharmacy) with expertise in qualitative research, pharmaceutical policy and nursing, and a master’s student in pharmacy. The guide included three main themes: (1) Injection and device guidance of biological medicines, (2) Perceptions of automatic substitution, and (3) Safe implementation of automatic substitution of biological medicines. The interview guide was pilot tested in two interviews. As no modifications were deemed necessary following the pilot, the data from these interviews were included in the analysis.
Individual semi-structured interviews were conducted remotely via Microsoft Teams between January and April 2025 by the first author (female master’s student in pharmacy). With participants’ informed consent, all the interviews were recorded and transcribed verbatim using Microsoft Teams transcription function. The cumulative duration of the interviews was approximately five hours, with individual interviews lasting an average of 30 min (range: 20–45 min). Repeat interviews were not conducted, nor were the transcripts returned to participants. Since the interviews were recorded, no field notes were taken. The first author compared each transcript against the original recording to ensure accuracy and made corrections where needed.
Data analysis
Data were analysed by the first author using inductive content analysis [25]. Initially, transcripts were reread multiple times to achieve a comprehensive understanding of the data. The unit of analysis was defined as sentences or phrases relevant to the study aims. Meaningful units were systematically identified and initial codes assigned. Subsequently, these codes were then compared and organised into subcategories and further into main categories that captured the core content of the data. Recurring subcategories occurred across multiple interviews, and in the findings, n-values indicate the number of nurses who referenced each subcategory. Data management was performed using Microsoft Word and Microsoft Excel. Throughout the analysis process, research group contributed regularly to the development of the coding framework until consensus was reached. Data saturation was assessed by constructing a coding framework based on the first eight interviews and validating it with the final two interviews, confirming that no new themes emerged. The most illustrative quotations are presented in the findings, where “R” denotes a rheumatology nurse and interviewees are coded from R1 to R10.
Ethical considerations
This study followed the Finnish National Board of Research Integrity guidelines [26]. In accordance with the guidelines, prior ethical assessment was not required for this study design. All interviewees received detailed study information, and informed consent to participate and permission for recording were obtained. Data security and privacy were ensured in compliance with the European General Data Protection Regulation (GDPR) [27]. To protect the interviewees’ privacy and confidentiality, all personal identification data were removed from the transcripts. Furthermore, to secure anonymity, the study findings are reported in a manner that prevents the identification of individual participants.
Rigour and trustworthiness
This study followed established criteria for qualitative research to ensure rigour and trustworthiness through multiple strategies [28, 29]. To support dependability, the first author who conducted the interviews (including pilot interviews) and analysis, maintained reflexive notes and documented all stages of the analysis process. The other members of the research group possess extensive experience in qualitative research and credibility was reinforced through regular peer debriefing. These discussions enabled critical reflection, supported analytical consistency, and helped mitigate individual researcher bias. All interviews were recorded with participant consent to reduce recall bias and transcribed to ensure accuracy and confirmability. Transferability was ensured by providing a detailed description of the research context and methodological approach.
Results
Characteristics of the participants
All interviewed nurses (n = 10) possessed extensive professional experience, with a minimum of 10 years as a registered nurse. Additionally, seven had completed advanced training in rheumatology. The average work experience as a registered nurse was 27 years (range: 11–40 years), while their average work experience specifically in rheumatology nursing was 11 years (range: 3–28 years).
Categories
Four main categories were identified: (1) Perceptions of automatic substitution, (2) Factors supporting the implementation of automatic substitution, (3) Concerns related to automatic substitution, and (4) Safe implementation of automatic substitution. Figure 1 presents the identified main categories and subcategories.
Fig. 1.
The identified main categories and subcategories (n-value presents the number of interviewed nurses who referred to the subcategory)
Perceptions of automatic substitution
Nurses’ perceptions of automatic substitution were categorised as positive, negative, or neutral. Positive perceptions included that automatic substitution is considered to have minor risks, and that it is a beneficial reform.
In my opinion it is a positive reform, especially since other medicines have been substituted for a long time in pharmacies and patients have had the option to change medicine if they want, so yes I see it as a positive reform
- R2.
From the nurses’ perspective, a positive was that the initial phase of implementation had proceeded smoothly. Another positive aspect was that patients have the right to influence substitution decisions. Furthermore, they anticipated that patients would adapt well to the reform, and automatic substitution might help to reduce physicians’ workload.
From a neutral standpoint, nurses emphasised the need for longer-term practical experience to evaluate the impact of automatic substitution, or stated they had no personal stance on the subject. Negative perceptions included that differences among biological medicine devices may complicate substitution, and that the potential impact of supply disruptions had not been considered. All in all, nurses’ attitudes seemed to be cautious, and automatic substitution was also seen as challenging.
And this is quite a complex issue to explain to patients, it’s complex for us too and probably something that still needs to be worked on at the pharmacies as well. So somehow, this whole process of informing has been really complicated and difficult.
-R6.
Factors supporting the implementation of automatic substitution
The implementation of automatic substitution was perceived to be supported by several factors, including the suitability of biological medicines for substitution, patients’ experience, cost impacts, pharmaceutical services, and the legal framework governing automatic substitution. Biological medicines used in the treatment of RA were considered suitable for substitution, with the similarity of administration devices further enhancing their suitability.
Since the administration devices are fairly similar, patients are usually able to manage with them
-R9.
Patients’ prior experience with biological therapies and familiarity with generic substitution of synthetic medicines were also seen to facilitate the implementation. From the nurses’ perspective, cost impacts, for instance, lower costs for patients and improved access to biological therapies, were seen to promote successful implementation.
Of course, the financial aspect is also important, and it is always the patients’ best interest to receive the medication at the lowest possible cost, especially since these are expensive products.
-R8.
The professional expertise and counselling provided by pharmacy staff were also identified as supportive factors. Additionally, the legal framework ensuring a six-month substitution interval for the same product was perceived as a supporting factor.
Concerns related to automatic substitution
The implementation of automatic substitution raised several concerns among nurses, and all interviewees highlighted potential work-related challenges. Anticipated challenges in rheumatology nursing included an increased need for patient counselling. Nurses observed that some patients might resist substitution, struggle to understand the interchangeability of biological medicines, or lack trust in the substitution process.
It will make my work more challenging, as patients who are used to original biological medicines are often unwilling to substitute for biosimilars. We’ll need to have conversations about it, and many of these patients don’t understand why substitution is necessary
-R7.
Nurses also expressed concerns about medication-related issues, including difficulties with self-injection, reduced treatment adherence, adverse effects, and changes in treatment effectiveness. Substitution may also be confusing, leading patients to inadvertently use two versions of the same active substance simultaneously. Particular concerns were expressed regarding the adaptability of specific patient groups, including those newly initiating treatment, younger patients, non-native speakers, and older adults.
We also have elderly patients, and their situation is particularly concerning
-R6.
It was acknowledged that if someone is going to the pharmacy to get the medicine on behalf of the patient, this may lead to misunderstandings. Nurses had several concerns related to the pharmacy setting including the lack of injection guidance, inadequate counselling, patient unawareness of automatic substitution, and insufficient protection of patient privacy.
I wonder whether there’s any kind of private space reserved for that in pharmacies, it’s something that’s been on my mind.
-R5.
Furthermore, one nurse considered that the national preparation for the implementation of automatic substitution had been insufficient, including limited information, minimal time to adapt, and inadequate collaboration among healthcare professionals.
Safe implementation of automatic substitution
All interviewed nurses acknowledged the critical role of both healthcare and community pharmacies’ personnel in ensuring the safe implementation of automatic substitution of biological medicines. They emphasised the importance of informing patients about substitution within the healthcare setting prior to their encounter with it in a pharmacy. Counselling by the name of the active substance rather than the brand name was considered beneficial for promoting patients’ familiarity with treatment and improving medication safety. Nurses highlighted that well-informed patients are better able to adapt to substitution. Comprehensive patient counselling by healthcare personnel, including injection guidance, enhances safety by improving patients’ competence in managing different biological products.
I hope that every patient receives comprehensive patient counselling in healthcare, as it will certainly support the work of pharmacies and ensure patients’ capabilities for substitution
-R8.
Nurses identified several key components of patient counselling to improve the safety of automatic substitution practices in the community pharmacies. Device counselling was considered the most important factor in ensuring patients’ understanding of the differences between interchangeable devices. Medication counselling should be individualised and tailored to each patient’s needs. The use of educational materials, such as demonstration pens, was considered helpful in improving device guidance in pharmacies. Moreover, patients should be advised to contact healthcare services when necessary. To further improve safety, pharmacists were seen as having a key role in reminding patients about proper storage conditions of the medicine and enhancing their understanding of automatic substitution.
Now when automatic substitution of biological medicines is starting in pharmacies, and there are patients who have used the same product for several years, although the active substance remains, but the name of the product will be different, substitution needs to be clearly explained to patients and it must be ensured that the patient is capable of self-injection with the new device
-R9.
Finally, interviewed nurses highlighted the importance of interprofessional expertise and collaboration. Enhanced communication and information sharing between healthcare services and community pharmacies is needed. Additionally, all healthcare professionals involved should receive training and be adequately prepared to ensure safe implementation of automatic substitution.
Healthcare professionals involved in automatic substitution need to know what they are doing and to have adequate knowledge about biosimilars
-R3.
Discussion
To our knowledge, this is the first study to explore rheumatology nurses’ perceptions of automatic substitution of biological medicines and strategies to ensure its safe implementation in community pharmacies. Nurses acknowledged the important roles of both pharmacy and healthcare personnel in ensuring safety. While concerns were raised regarding potential challenges in rheumatology nursing and patients’ medication-related issues, biological medicines were considered suitable for substitution. The results indicate that Finnish rheumatology nurses, as well as Finnish pharmaceutical sector stakeholders in the previous study [12], have overall positive perceptions of automatic substitution of biological medicines. Controversially, more cautious or negative views have been reported in other countries among healthcare professionals [17, 18].
These findings may partly reflect the national pharmaceutical policy context, professional training, and familiarity with biosimilars. Nurses’ positive perceptions may be influenced by the fact that in Finland, switching between biological therapies has commonly occurred in hospital settings [30]. Moreover, prior research indicates that greater knowledge of biosimilars by healthcare professionals is associated with more positive attitudes towards the interchangeability of biological medicines [31]. Rheumatology nurses’ positive views may facilitate the safe and effective implementation of automatic substitution of biological medicines. Their support can enhance patient motivation and improve medication adherence [32]. Patients’ trust in the substitution process can be fostered when nurses monitor treatment outcomes and provide guidance. Conversely, negative perceptions among nurses may contribute to a nocebo effect for patients, potentially compromising treatment outcomes [33].
Despite overall positive perceptions, nurses expressed concerns for workload implications which need to be considered. To contain healthcare expenditures, automatic substitution should not increase the workload in healthcare, as nurses were especially concerned about the growing number of patient contacts. Limited resources and increased patient counselling may generate operational costs in healthcare, potentially offsetting anticipated savings. Increased workload can contribute to stress, further exacerbating the nursing workforce shortage, which is a global issue [34].
Our study indicates that more attention should be paid to enhancing medication safety in automatic substitution to avoid possible medication-related issues. Medication-related issues, including difficulties in self-injection, reduced treatment adherence, patient confusion, and adverse effects, can be exacerbated during automatic substitution if adequate resources are lacking. To address these concerns, clear protocols, sufficient resources, and comprehensive patient support are essential to safeguard therapeutic continuity and the economic and clinical benefits of biologic interchangeability. Nurses emphasised the similarity of devices, although some noted that differences in devices might confuse patients and increase medication-related issues, such as difficulties with injection. Differences between biological medicine devices have been described as a potential barrier to automatic substitution, highlighting the importance of comprehensive patient counselling to reduce confusion [17].
Concerns among healthcare professionals related to physician-led switching and automatic substitution of biological medicines are common [35]. Maintaining medication adherence with automatic substitution is essential to achieve the intended cost containment, especially as adherence has already been noted as a major challenge in healthcare [32]. Potential barriers to medication adherence for patients include distrust, insufficient resources, and lack of time or support. Nurses were concerned that potential automatic substitution would increase medication-related issues and reduce patients’ medication adherence.
Based on the findings of this study, the safe implementation of automatic substitution requires a multifaceted approach, including comprehensive medication counselling and continuous monitoring of medication-related issues. Nurses identified strategies to enhance safety, and the identified roles of both healthcare and pharmacy personnel align with national guidelines, which emphasise the importance of providing information to patients both in healthcare and pharmacies [7]. Information provided in healthcare settings ensures that patients are familiar with automatic substitution when collecting their medication at the pharmacy. In pharmacies, individualised medication counselling, including device guidance, ensures that patients can administer medications safely. A previous Finnish study similarly recognised the important role of pharmacy personnel and patient counselling in the implementation of automatic substitution [12].
Strengths and limitations
This study has several strengths and limitations that should be considered when interpreting the findings. Interviewing is a suitable research method for an unexplored topic when the aim is to understand participants’ views, opinions, and experiences [36]. Although the interviewer had no prior experience in qualitative interviewing or analysis, the rigour of the study was supported by academic training in research methods, careful planning of the study process, and continuous guidance from supervisors, who possess strong experience in qualitative research. While coding was performed by a single researcher, regular discussions with other researchers helped maintain analytical reliability.
The possible limitations of the current study include the relatively small number of participants, as is typical for qualitative studies. As the required research permissions had to be obtained in advance and the process was extensive and time-consuming, the sample size was predetermined at ten. Although this decision was informed by prior qualitative research suggesting that data saturation is often achieved within the first ten interviews, saturation is inherently context-dependent and cannot be guaranteed based solely on numerical thresholds [24, 37]. The complexity of the research topic, as well as potential variability among participants, means that additional interviews may have yielded further themes or nuanced insights. While ten interviews provided sufficient depth for detailed analysis, it is possible that extending data collection beyond this number could have strengthened the robustness of the findings. Future research could address this limitation by adopting a more explicitly iterative approach to sampling, in which data collection continues until saturation is demonstrably reached rather than assumed. Nevertheless, data saturation was achieved, as no new themes emerged during the testing of the coded framework with the final two interviews. Moreover, the study’s aim was focused, and interview data were rich and informative indicating that sufficient information power was achieved [37]. Selection bias is possible, as participants may have been particularly interested in the topic. The number of individuals who declined to participate remains unknown. An important consideration for the transferability of the findings across different settings is that this study was conducted at the beginning of the implementation of automatic substitution and there was only a limited amount of prior research.
Recommendations for further research
Automatic substitution of biological medicines remains an under-researched area, and further studies are needed to evaluate its safe implementation and its impact on both healthcare professionals’ workload and patients’ medication safety. In this study, nurses also highlighted the importance of gaining long-term practical experience, emphasising the need for follow-up studies to evaluate the impact of the reform. It is important to investigate whether nurses’ concerns of the impact of automatic substitution on medication-related issues and nursing workload are realised to evaluate the potential need for changes in practice. For future research, qualitative studies including multiple professional groups and patients’ perspectives may help build a comprehensive understanding of how automatic substitution affects healthcare systems and medication safety. In addition, further studies are needed to evaluate the economic impact of automatic substitution, including potential cost savings in healthcare expenditures.
Implications for policy and practice
Exploring and understanding automatic substitution of biological medicines is essential for ensuring safe and effective patient care. This study highlights the need to enhance safety by paying close attention to comprehensive patient counselling to manage potential medication-related risks. This study also provides insight from the perspective of rheumatology nurses, whose expertise and experiences are highly valuable in improving the safety of automatic substitution practices. Their views can be directly utilised for the development of guidelines, training for healthcare professionals, and patient counselling. Furthermore, the findings may have relevance beyond the national context, offering policymakers a knowledge base when considering the implementation of automatic substitution of biological medicines and potential implications for patients and healthcare systems in other countries.
Conclusions
Rheumatology nurses recognised the important role of both community pharmacies and healthcare personnel in ensuring the safe implementation of automatic substitution. In the community pharmacy setting, individualised medication counselling and device guidance were considered essential, while in the healthcare setting, informing patients about automatic substitution was seen as a key responsibility. Overall, rheumatology nurses’ perceptions of automatic substitution were positive, which may enhance patient safety and medication adherence with automatic substitution. However, their concerns regarding work-related challenges and patients’ medication-related issues need to be addressed, and adequate resources must be ensured. Despite these concerns, biological medicines were considered suitable for automatic substitution.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to thank all collaborating hospital organisations and nurses who generously contributed their time to the interviews.
Abbreviations
- EMA
European Medicines Agency
- COREQ
Consolidated Criteria for Reporting Qualitative Research
- GDPR
General Data Protection Regulation
- HMA
Heads of Medicines Agencies
- RA
Rheumatoid arthritis
- WHO
World Health Organization
Author contributions
Corresponding author, Roosa Oikarinen, M. Sc. in Pharmacy: Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualization Writing – original draft; Emma Aarnio, Senior Researcher: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. Hanna M. Tolonen, HUS Pharmacy quality manager: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. Marja Härkänen, Academy Research Fellow: Methodology, Validation, Writing – review & editing. Katri Hämeen-Anttila, PhD, Professor: Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – review & editing.
Funding
This study received no funding.
Data availability
The datasets generated and analysed during the current study are not publicly available due to privacy restrictions.
Declarations
Ethics approval and consent to participate
According to the Finnish National Board of Research Integrity guidelines followed in this study, prior ethical assessment was not required for this study design [26]. This study was not medical research involving human participants; thus, Helsinki Declaration does not apply for this study. Participation in the interviews was voluntary and informed consent to participate and permission for recording were obtained. Data management procedures and privacy adhered to the requirements of the European General Data Protection Regulation (GDPR) [27].
Consent for publication
Not applicable.
Competing interests
Author Emma Aarnio is an Editorial Board Member of this journal. The other authors declare that they have no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and analysed during the current study are not publicly available due to privacy restrictions.