Abstract
Background: Pharmacists in Alberta can apply to the Alberta College of Pharmacists in order to obtain the designation of additional prescriber. This designation uniquely allows them to initiate therapy, in addition to other medication-related activities. Our objective was to examine specific experiences of pharmacists regarding the decision to apply and the application itself, and use this information to help inform other pharmacists who are considering additional prescribing.
Methods: All pharmacists involved in a randomized, controlled trial being conducted in rural Alberta who had received their additional prescribing authorization (APA) were invited to participate. Pharmacists were contacted via e-mail and asked to respond to questions regarding their experiences in applying for APA. Responses were analyzed using content analysis and the identites of all respondents were kept anonymous.
Results: Fourteen pharmacists were invited to participate. Review and examination of the responses revealed 3 main themes: motivation, hurdles and outcomes. Motivation can be understood as the reasons why they applied for their APA. Hurdles include any problems encountered of a personal, environmental or professional nature. Outcomes refer to how this designation has changed their practice.
Discussion: Pharmacists had to address many factors that were unexpected during the application process; however, the eventual outcome of obtaining APA was deemed beneficial, both professionally and with regard to patient care.
Conclusion: The information shared from these pharmacists will help other pharmacists, regardless of jurisdiction, overcome some of the challenges associated with obtaining advanced prescribing privileges.
Background
Prescribing by pharmacists is the next frontier of pharmacy practice. In the United Kingdom, pharmacists have been able to prescribe since 2003,1 with the designation of supplementary prescriber. Independent pharmacist prescribing in the UK started in 2006.2,3 As of 2008, there are 1500 registered pharmacist prescribers in the UK, most of whom fall under the supplementary prescriber category.3 Other jurisdictions across Canada and around the world are following suit.4,5
Key points.
Pharmacists in Alberta can apply for additional prescribing authorization (APA).
As of December 2011, 144 pharmacists have received the APA designation.
The motivation for applying was centred around being better able to help their patients.
The time it took to complete the application was the most commonly cited hurdle, though self-confidence and documentation procedures were also mentioned.
Identifying hurdles can help other pharmacists consider what they need to change in their practice before considering practice advancement.
Points clés.
Les pharmaciens de l'Alberta peuvent demander une autorisation de prescription additionnelle.
Jusqu'à maintenant, 144 pharmaciens ont obtenu cette autorisation.
La motivation à l'origine de ces demandes reposait principalement sur la possibilité d'aider davantage leurs patients.
Le temps nécessaire pour remplir la demande était l'obstacle le plus fréquemment cité. La confiance en soi et les procédures de documentation ont également été mentionnées.
La mise en lumière des obstacles peut aider les autres pharmaciens à savoir qu'elles modifications ils doivent apporter avant d'envisager d'étendre leurs activités.
In Alberta, all pharmacists can adapt prescriptions and prescribe in an emergency. Adaptation includes altering a dose, formulation or regimen; therapeutic substitution; or renewal of a prescription. In addition to this, pharmacists can apply to the Alberta College of Pharmacists in order to obtain the additional prescribing authority (APA). This designation uniquely allows them to initiate therapy for any condition, as long as it is within their area of expertise and act as an independent prescriber.6
The application process for APA can present a real or perceived stumbling block for many pharmacists. It requires self-assessment; completion of a comprehensive form detailing current practice environment; obtaining letters of collaboration from other prescribers; and completion of 3 care plans that must meet a number of key activities and indicators.7 The following link describes the APA process: https://pharmacists.ab.ca/Content_Files/Files/APA_guide_final.pdf.
The College does have a system to gather feedback from applicants; however, the focus is related to the utility of the application form itself, not the application process overall.
Although there has been research conducted regarding how pharmacists feel about expanding their scope of practice in general, there has been little work regarding the actual process of obtaining prescribing status.2,3,8,9 With pharmacist prescribing on the horizon in many jurisdictions, we need to understand pharmacists' uncertainties with this new practice opportunity. Our objective was to examine specific experiences of Alberta pharmacists regarding the decision to apply and use this information to help inform other pharmacists who are considering obtaining their APA.
Methods
All pharmacists invited to participate were part of the Rural Alberta Clinical Trial in Optimizing Hypertension (rural RxACTION study), a randomized, controlled trial of pharmacist prescribing for patients with poorly controlled hypertension.10 This study is ongoing in rural sites in Alberta, Canada. In order to deliver the intervention, pharmacists were required to obtain APA before starting the study.
Pharmacists were contacted via e-mail and asked to respond to questions regarding their experiences in applying for APA. All questions were open-ended and were intended to prompt the pharmacist to relate the story behind the application process.
The questions posed to pharmacists were:
What prompted you to apply for your APA?
What were some of the hurdles you faced in applying? (e.g., obtaining references, changing your practice to adhere to key indicators, convincing yourself of your abilities…)
What about this process has surprised you most?
How has obtaining this ability impacted your practice? (in general terms and/or illustrated by a specific example)
What do you like best about having this new ability?
Given what you know of the process, is there anything you would change?
No restrictions were placed on the length of responses. Responses were analyzed using content analysis, by 2 independent reviewers. All respondents were kept anonymous.
Results
Fourteen pharmacists were invited to participate and all pharmacists responded. Demographics were not collected, in order to maintain the anonymity of the participants, however, all the pharmacists have a bachelor of science degree in pharmacy (i.e., none had advanced pharmacy degrees). All pharmacists were currently involved in the Rural RxACTION study and hold an APA designation with the Alberta College of Pharmacists. Review and examination of the responses revealed 3 main themes: motivation, hurdles and outcomes. Motivation can be understood as the reasons why pharmacists applied for their APA. Hurdles include any problems encountered of a personal, environmental or professional nature. Outcomes refer to how this designation has changed their practice. These changes could include patient care, working relationships (both inter- and intraprofessional) and personal views.
Motivation
Pharmacists identified several factors that influenced their decision to apply for APA. These included a desire to improve overall patient health; being at the leading edge of pharmacy practice and change; improving collaborative relationships with other health care professionals; increasing continuity of care; validating some of the responsibilities they were already undertaking; and ensuring timely care is provided to patients through a collaborative process. One pharmacist stated: “I am passionate about providing direct patient care, helping patients achieve their health goals and being able to work collaboratively and efficiently with physicians/nurses and other health care providers as part of the interprofessional team.” Another pharmacist described the desire to be able to help patients who “…are unable to see a physician.”
Hurdles
A variety of hurdles to completing the application were discussed by the pharmacists. We further categorized the hurdles theme into personal, environmental and professional. Time was the most common personal hurdle that pharmacists cited. This not only included finding time at work and at home to dedicate to the writing of the application itself, but also reworking processes within their practice to assist in their application (i.e., changing documentation procedures). Another personal hurdle was a lack of confidence in current levels of knowledge and skills. One pharmacist stated, “…My greatest challenge was having the confidence to start the application.”
The act of self-reflection on their current practice environment, something most pharmacists had never had occasion to do, was another hurdle to overcome. Two questions in particular, asking the pharmacists under what circumstances they would and would not use their prescribing authority, were quite difficult and upon reflection led to surprising thoughts about the prescribing process. One pharmacist noted that realizing she could actually harm a patient with her decisions was a hard concept for her to process, but also important in the completion of her application, as she stated, “I had never stopped to think that I could bring harm to someone, let alone cause them to end up in emergency!”
Environmental hurdles primarily related to uncertainty surrounding expectations and content for the application. Pharmacists repeatedly expressed frustration over uncertainty about the types of documents they should include, the level of detail needed in patient cases and the lack of examples available from the application package and the College. Pharmacists also noted that upon receipt of their nonsuccessful adjudicated applications, there were often contrary comments regarding their patient cases, making resubmission difficult. One pharmacist stated:
I found the process a bit unnerving. My first application failed. Two of the assessors were kind in their comments and constructive. One actually lambasted me and I really felt incompetent. It took me a bit of time to regain some confidence and try again.
One of the most challenging professional hurdles for the pharmacists to overcome was the need to improve their documentation. For example, one pharmacist said,
My documentation/implementation/follow-up wasn't concise and an easy-to-follow patient profile... most of my documentation was on prescription hard copies, and notes on file. I didn't typically write up formal care plans, I simply suggested most therapy changes or initiated medications by faxing the patient's prescriptions back to the doctor, so it was a challenge for me to improve my documentation process.
Pharmacists also experienced skepticism and obstruction from other pharmacists. One pharmacist relayed a story where she “had pharmacists phone [her] at home to say it's not fair that [she is] doing this prescribing.” She also had pharmacists refuse to accept prescriptions from her. This attitude and suspicion from other pharmacists in their communities was noted as being a surprising result of the process.
Outcomes
Pharmacists gave us inspiring examples of ways in which obtaining their APA has changed their practice and, more importantly, the health of their patients. Timely patient care was repeatedly highlighted as being the best part of having APA. Pharmacists related instances of patients having difficulty getting in to see their physicians, and said that having APA helped reduce this problem.
Often we (pharmacists) are making recommendations and suggestions that are accepted but, due to process and time, are not followed through in a timely fashion. [APA] allows for continuity and [prompt] addressing of the patients' health needs….
Respondents also felt that they were able to become more functional collaborators within the health care team by having their APA. They felt it strengthened relationships and improved processes related to care. One pharmacist stated that she felt the best outcome was the additional respect from medical staff. This, however, was not a commonly reported beneficial outcome. Another pharmacist summarized her thoughts regarding how APA has changed her practice:
We test patients' blood for INR, check labs, monitor anticoagulation, provide diabetes services, do blood pressures, heights, weights, consult for lifestyle changes, help quit smoking, provide home parenteral therapy for palliative care, anti-infectives, provide injections, give travel advice, recommend and provide vaccinations and oh, did I mention, we dispense too.
Discussion
Three primary themes were identified from the responses of pharmacists participating in the Rural RxACTION study regarding the application process for obtaining APA. These themes included motivation, hurdles and outcomes. We found that pharmacists had to address many factors that were unexpected during the application process; however, the eventual outcome of obtaining APA was deemed beneficial, professionally and with regard to patient care.
The motivation for these pharmacists to prescribe was primarily their desire to help their patients. This altruistic notion is sometimes forgotten in the business of pharmacy and the everyday tasks involved in dispensing medications. Unfortunately, the risks involved in prescribing often become the sole focus of attention.11 Whether or not this feeling of helping the patient is maintained as they continue to prescribe is unknown. Many of the respondents also felt the process made them re-evaluate how they practised and led them to improve processes within their practice, namely documentation. As documentation is an integral component to patient assessment and therapeutic planning, it is critical that independent prescribers develop strategies to meet not only the legal requirements, but the practical requirements as well.12 Furthermore, if the profession of pharmacy as a whole is going to move more seriously towards providing pharmaceutical care to all patients, developing educational programs to assist pharmacists to improve their documentation would be prudent.
Another notable finding is the lack of confidence pharmacists had regarding their abilities to even undertake the prescribing application in the first place. It has been postulated that culturally, pharmacists have a general lack of confidence, but there has been limited work done in this area.13 The pharmacist responses regarding the outcomes they achieved after obtaining their APA suggest that this lack of confidence has somewhat abated with the designation. Again, whether or not this is sustained for any length of time is unknown.
The animosity and skepticism from pharmacy colleagues towards those pharmacists who have obtained their APA was an interesting finding in this study. Hesitation from other health professionals, namely physicians, has been identified previously and with the expansion of pharmacist prescribing is a growing reality for the profession.14,15 Some pharmacists believe that prescribing, and most notably independent prescribing, should be a task left to physicians.16 Even pharmacists with additional prescribing functions (i.e., supplementary prescribing in the UK) feel that independent prescribing is not a necessary advancement for the profession, leading to encroachment on physician, and in some cases nursing, territory.11,14
In a survey of Scottish pharmacists' views on supplementary prescribing, a quarter of the respondents said they would not wish to take on this role.9 In an Australian survey, only half the pharmacists surveyed actually thought they should be granted independent prescribing authority.17 With uncertainty and division within our own profession, as shown by some of the experiences within our pharmacist population, it is somewhat less appealing for “fence-sitters” to jump to the side of prescribing. The independent prescribers in our project found it even more difficult to manage professional relationships once practising in this way.
There are limitations with our work. First, we had a small sample of pharmacists who were involved in a research project. These pharmacists were definitely “hand-picked” and this may bias the results. We would argue, however, that any pharmacist who applies for and obtains APA is actually in the upper echelon of their profession and practice. Second, all of the pharmacists were from a rural setting. Rural pharmacy practice models are different than urban, given the small size of the community and the physical proximity to physicians. This may mean that these results are not as applicable to pharmacists in urban settings.
Our objective was to examine specific experiences of Alberta pharmacists regarding the decision to apply for APA, as well as the application process itself. From this, we have come up with a list of considerations for pharmacists interested in obtaining an advanced prescribing status, independent of jurisdiction (Box 1).
BOX 1 Interested in obtaining advanced prescribing status?
Conclusion
Pharmacists in Alberta who apply for their APA are challenged by many aspects of the application process, but also invigorated by the outcomes. The information shared from these pharmacists will help other eligible pharmacists overcome some of the challenges of the APA process. It can also serve as a basis for self-reflection in pharmacists who are considering advancing their practice, whether to supplementary prescribing, independent prescribing or enriching programs within their current work environment.
Footnotes
A poster of this work was presented at the Canadian Pharmacists Association Conference, May 2010, Calgary, Alberta.
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