Across Canada, the provincial colleges of pharmacy issue licences to those meeting the registration requirements to practise pharmacy. But does one licence fit all? At a minimum, all pharmacists have an undergraduate degree, and many have additional formal training through a Canadian pharmacy residency program or a Doctor of Pharmacy program. All practising pharmacists are registered under the same licence category, even though they work in a wide variety of settings and provide vastly different services, including drug dispensing, patient counselling, adaptation of prescriptions, chronic disease clinics, therapeutic drug monitoring, delegated drug therapy management, medication reconciliation, participation in patient care rounds, interpretation of laboratory test results, and collaborative prescribing, all intended to achieve better patient outcomes. Not knowing what to expect from a pharmacist must be confusing for patients, physicians, and the rest of the health care team, not to mention the general public, health administrators, and ministries of health.
When a health care profession proposes a change to its scope of practice and the corresponding legislation, broad consultation must take place with stakeholder groups such as other health care professionals and the public. Given our duty to protect the public, we must be able to demonstrate that our training provides adequate skills and competence to perform these new functions, and that our profession has a process for ongoing assessment of these competencies. Do I feel that our undergraduate training provides adequate skills and competence for advanced clinical practice? I’m afraid I don’t—if it did, we wouldn’t need advanced training programs such as residencies and graduate degrees. So I am not surprised when proposed legislative changes related to the scope of pharmacists’ practice meet resistance from physician groups across the country.1 On the other hand, do I feel that there are many excellent clinical pharmacists being held back by our single licence category? Absolutely.
I believe the following are essential elements in defining an advanced practice pharmacist: graduation from an accredited experiential pharmacy training program such as a residency, clinical master’s program, or Doctor of Pharmacy program; ability to collaborate with the health care team in their clinical practice; ability to access and interpret comprehensive health information relevant to the patient’s care; ability to assess and monitor a patient’s signs, symptoms, and response to therapy; expectation to practice within the person’s scope of expertise; recognition of duty to incorporate evidence-based decisions and the patient’s goals and preferences into the care plan; recognition of duty to communicate interventions and plans to the rest of the care team; ability to monitor the outcomes of interventions; accountability to ensure appropriate follow-up; and responsibility for the patient’s care (Ensom RJ, Bachand R, Carr R, Corrigan S, de Lemos J, de Lemos M, et al. Advanced practice pharmacist overview. Unpublished discussion paper, prepared July 2009).
Advanced practice pharmacists would have greater flexibility and authority granted under their scope of practice to be able to care for patients and help them achieve desirable health outcomes. Such outcomes might include relief of symptoms, reduction in short- or long-term risk, resolution of an acute medical condition, or stabilization of a chronic disease. To meet these goals, the advanced practice pharmacist would be involved in assessing the condition, monitoring the patient’s progress, and prescribing drug therapy if deemed appropriate for the patient’s care. He or she would help to improve the safety, effectiveness, efficiency, and timeliness of drug therapy and would need to practise under a model of clinical services going well beyond the usual Monday to Friday routine. The new practice model would incorporate direct hand-over of patient care from one clinician to another, and provision of services 7 days a week in acute care settings, similar to the physician model.
We already have evidence supporting the need to go beyond patient counselling, provision of drug information, and provision of pharmacokinetic services, activities that do not affect patient mortality. By contrast, activities such as monitoring adverse drug reactions, obtaining histories on admission, managing drug protocols, and participating in medical rounds do correlate with reductions in mortality.2 In a recent Canadian comparison of advanced pharmacy practice with usual pharmacy care, indicators of quality of care were better and the frequency of re-admissions was lower at 3 months for patients receiving advanced practice care.3
Creating a separate licence category for advanced practice pharmacists would help by setting out clear expectations and accountability for qualifications, competencies, and patient care activities, both internally for our profession and externally for the teams with which we work and for the health care system more broadly. It is a necessary step of added quality assurance to satisfy stakeholder groups that the expanded scope of practice is being adopted with both the best interests and the safety of patients in mind. Pharmacists in Alberta are the first in North America to be granted independent prescribing privileges. Their regulatory model includes different categories of licensure and authorization for this privilege, which will ensure that the required competencies and quality assurances are met.4
Many clinical pharmacists in hospitals, ambulatory care, and long-term care settings are already doing the work of advanced practice pharmacists under established relationships with the team, hospital protocols, or delegated authority. We need to take the next step and give them full responsibility and accountability for their practice.
The new regulatory model should include a process whereby experienced clinicians who meet all the criteria for advanced practice except formal training beyond their undergraduate degree can undertake a competency assessment for the credential. Conversely, if pharmacists without residency training choose not to obtain an advanced practice license, the excellent care that they provide for their patients will not be affected. We are not defined by the licence category to which we belong, but rather by our own clinical practice. The licence category simply sets a minimum threshold of expectations.
About 35 to 40 years ago, trailblazers in our profession left the dispensary and began to provide clinical pharmacy services, such as pharmacokinetic interpretations. Those pharmacists raised the bar of clinical practice, and eventually other hospital pharmacists followed. It is now time for a new set of trailblazers to once again raise the level of clinical practice in our profession and move us to a higher standard of care. “Some pharmacists have not yet identified patient-care responsibilities commensurate with their extended functions, and the profession as a whole has made no clear social commitment that reflects its clinical functions. Some pharmacists will remain mired in the transitional period of professional adolescence until this step is taken”.5 This summary of the situation, by Hepler and Strand, was written in 1990, but unfortunately it still applies 19 years later. The time for action and professional growth is now.
Acknowledgments
I would like to acknowledge the members of the BC Health Authorities Advanced Practice Pharmacist Working Group, led by Dr Robin Ensom. In developing this article, I drew on our discussions and debate on this topic.
References
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