Abstract
Objective:
The principal aim of this study was to explore the self-perception of community pharmacists of their professional identity and roles and how they think patients and doctors perceive them. The study also aimed at exploring their opinions regarding role expansion and how they assess their capabilities.
Methods:
This is an exploratory study that employed qualitative method. Individual, in-depth interviews were conducted with a purposive sample of 50 community pharmacists working in Khartoum State, Sudan, from October to November 2015. Each interview was recorded, transcribed, and coded into themes. Thematic analysis was carried out.
Findings:
The study revealed nine different identities of community pharmacists including supplier of medicines, medicines maker, dispenser, patient counselor, medicines expert, clinical practitioner, health promoter, monitor of medicines use, and family practice identity. Participants described that most of the patients value their professional role while doctors perceive them as merely dispensers. Most of participants believe that they are capable to fulfill their roles; however, they identified the need for continuous education. The study revealed that community pharmacists are thirst to role expansion.
Conclusion:
The study concluded that community pharmacists are aware of the different identities of their profession. The good recognition of their role by patients reflects good service provided while lack of integrated primary health care system that join doctors and pharmacists resulted in lack of pharmacists’ recognition by doctors. Continuous educational program is needed for community pharmacists, and role expansion will allow for better self-perception and better profession contribution in healthcare.
Keywords: Community pharmacists, professional identity, role expansion, self-perception
INTRODUCTION
WHO defined that community pharmacists are the health care professionals that are most accessible to the public. They supply medicines, counsel patients, provide drug information to healthcare professionals, patients, and general public, and participate in health-promotion programs.[1]
They have been an on-going debate regarding the professional identity of pharmacists and their contribution to healthcare. Professional boundaries between pharmacists and other healthcare professionals are sometimes described as blurred. Pharmacists have been perceived with different identities including medicines makers, medicines experts, health advisers, clinicians, pill pushers, bottle labelers, and as substitutes for general practitioners (GPs).[2,3,4,5,6,7,8,9,10] Accordingly, some researchers called for more empirical research to find out just what kind of occupation pharmacy is and what is its impact on healthcare. In the UK, for example, it was found that pharmacy profession place and contribution to the UK National Health Service (NHS) are ambiguous and unpredictable.[11,12]
Pharmacists perceive themselves in different ways. In one study, they rated their own profession as more empathic but less powerful than medical specialists.[13] Another study showed that pharmacists rated themselves similarly to medical specialists on academic ability.[14] On the other hand, there are researches that investigated how pharmacists believe others such as doctors and patients perceive them. Some studies showed that pharmacists feel valued by their professional colleagues and patients, but they think doctors undervalue them.[9,15]
There has been a growing need for community pharmacists around the world to have a greater professional contribution in the delivery of health care for patients.[16] In England, there is evidence that there are insufficient GPs to meet the escalating demand for accessible health services. One of the approaches to overcome the problem is the skill mix initiative that involve role enhancement of pharmacists that were found to be under-utilized.[16]
Considering the ambiguity in the professional identity of pharmacists that augmented by the changes in pharmacy profession in recent years and the lack of researches that investigated pharmacists’ self-perception in Sudan, it was considered timely to conduct this study. The objective of the study was to define the identities and roles of community pharmacists from their own perspectives and to examine how they think patients and doctors perceive them and how they assess their capabilities. The study also aimed at exploring pharmacists’ opinions regarding role expansion.
METHODS
This is a qualitative study that used face-to-face in-depth interviews with community pharmacists in Khartoum State, Sudan. The study was conducted from October to November 2015.
The study used a sample of 50 community pharmacists with different demographic variables [Table 1]; it was designed to gain insight and to give the analyst different views rather than to assume representativeness.
Table 1.
Participants’ demographic data
The sampling technique used was purposive sampling; those whom the researchers believe that they have good insight and can contribute significantly to the results were selected. Potential participants were contacted initially by telephone, interviews arrangements were made with those who agreed, and interviews took place at their place of work.
Participants were given information of the aims of the study. A covering letter containing this information were given to them.
A simple checklist of topics (main questions) was used to begin and guide the conversations [Appendix 1]. Probing and follow-up question were developed during the interview depending on participants’ answers. Interviewer appeared and spoke in a neutral, nonjudgmental manner. He asked questions in nonbiasing and nonleading way.
Audiotape recording was used to collect the data after taking permission from interviewees. Notepapers were also used to keep tracking of the topics that have been covered, as well as backup to failed recordings.
Thematic analysis was carried out. Data were transcribed and coded into different categories (themes) using coding up technique. Manual categorization was used and categorization continued until the identification of all themes. To satisfy criteria of reliability and to allow for different perspectives, the field data were listened, viewed, and coded first by the chief investigator to ensure consistency in coding. The secondary investigator independently assessed all coding. The two categorizations were then compared and any discrepancies were discussed and final categorization agreed.
The faculty of Pharmacy, University of Khartoum, Ethics Committee, approved this study in September 2015.
RESULTS
The paper revealed different themes regarding how community pharmacists perceived their identity and professional roles and highlighted how they think others perceive them, which mainly includes patients’ counselor, supplier of medicines, medicines maker, dispenser, medicines expert, clinical practitioner, health promoter, monitor of medicines use, and family practice identity. The paper also identified community pharmacists’ capabilities from their point of view and examined their opinions regarding role expansion. Participants are coded using the letter P followed by a number (e.g., P1, P2, P3).
Nine different identities of community pharmacist in Khartoum State were described in this study including supplier of medicines, medicines maker, medicines dispenser, patient counselor, medicines expert, clinical practitioner, health promoter, monitor of medicines use, and family practice identity. The patient counselor was the strongest identity identified as it was described repetitively in the interviews:
“The major role of community pharmacist is to counsel the patient about drug use, drug interaction with other drugs, food, or disease state, and about adverse drugs effects …” - P5.
The dispenser of medicines is one of the most common identities, and it was described by most of participants:
“The main role of community pharmacist is to dispense the prescribed drugs and to check if there are any medications errors.” - P12.
Many pharmacists described that it was part of their role to be clinical practitioners and to respond to patients’ symptoms. Moreover, some participants expressed that community pharmacist should even substitute doctors in certain circumstances:
“Patients expect from us to fulfill doctors’ role as most of them cannot afford consultation fees.” - P26.
One of the primary roles of community pharmacists is to make medicines available, which was highlighted by many participants. This identity is crucial in countries that suffer from medicines shortage such as Sudan:
“I think one of the important and basic roles is to make medicines available in our pharmacies. In Sudan, supply of medicines is irregular due to economic setback.” - P22.
Some pharmacists perceived themselves as medicines experts. They explored that it is part of their role to provide patients and doctors with knowledge about medicines:
“Community pharmacists have an integral role in any healthcare system that includes providing information to other healthcare professionals.” - P1.
Few pharmacists showed awareness regarding participation in health promotion campaigns to the community:
“It is part of our responsibility to provide health promotion programs to the public such as smoking cessation, family planning, and diseases awareness.” - P49.
Only one interviewee described that community pharmacists should monitor pharmacovigilance issues:
“Pharmacist should monitor medicines use after being dispensed to detect any drug-related problems.” - P50.
As most of medicines are currently manufactured by pharmaceutical industry, a few participants described medicines maker as an identity:
“Pharmacists usually prepare small-scale medicines in pharmacies.” - P23.
Some pharmacists described some sort of family practice identity:
“Pharmacist should provide follow-up with the patients who have chronic illnesses to assess medicines effectiveness or adverse effects.” - P3.
Most of the participants described that community pharmacists in Sudan are capable of fulfilling their professional roles in terms of knowledge. However, they think that pharmacists should keep improving their knowledge by continuous education programs and reading:
“Pharmacists are competent enough to do their job, because they have comprehensive knowledge about medicines, but they must keep their knowledge up to date.” - P28.
One participant questioned the academic curriculums at some faculties of pharmacy in Sudan:
“Some pharmacists have weak knowledge because of the weak curriculums at some faculties of pharmacies.” - P6.
Pharmacists believe that most of the doctors perceive them as dispensers or shopkeepers while patients value their roles. However, some participants described that this depends on how the pharmacist presents himself:
“Doctors perceive us as dispensers or shopkeepers. Some patients trust pharmacists more than doctors.” - P41.
“This depends on my knowledge and attitude …” - P35.
Most of participants supported the idea of role expansion of community pharmacists but with the condition of receiving proper training:
“Role expansion will change pharmacists’ perceptions about themselves as mere dispensers.” - P28.
“This is a very good idea but requires extensive training …” - P3.
DISCUSSION
This paper revealed that community pharmacists in Khartoum State differ in their self-perception. Nine identities were identified; patient counselor was found to be the strongest one as it was described by most of participants. The paper identified that most of community pharmacists consider their academic capabilities as sufficient; however, they are looking for continuous educational programs. Pharmacists consider themselves valued by patients while they believe doctors perceive them as mere dispensers, and they welcomed role expansion idea.
The professional identity of pharmacists has been a topic for many researchers since the 1960s. Some studies found that pharmacists construct identities differently depending on the context in which their role is situated. Consequently, identity construction is influenced by personal identity, role identity, and work and family contexts, as well as professional values. Another study concluded that professional identity formation needs to be in the foreground from commencement of the pharmacy degree and throughout the curriculum.[17,18]
The multiple identities of community pharmacists identified in this study are similar to those identified in other studies. In England, Elvey identified the presence of nine identities for pharmacists: scientist, medicines advisor, clinical practitioner, social carer, medicines maker, medicines supplier, manager, businessperson, and unremarkable character. Unlike our study, the scientist was the strongest identity identified.[19] NØrgaard et al. also described that Danish community pharmacists have different perceptions of their profession that include community pharmacist as a provider of technical and standardized advice, pharmacist as a drug expert, pharmacist as a leader, and pharmacist as a provider of individualized advice.[8]
The patient counselor was the strongest identity identified in our study, which might be due to the fact that many patients in Sudan, especially poor ones used to seek consultation from community pharmacists rather than going to doctors due to lack of consultation fees.[20]
Medicines making is a minimal task of community pharmacists nowadays as pharmaceutical industry has been providing pharmacies with readymade medicines. However, participants described medicines making as one of their identities. The reason might be that medicines making provides pharmacists with better self-esteem compared with dispensing.[12]
Some important roles were not described in this study such as checking the patient medications record before dispensing the prescription. In Sudan, the healthcare system is not developed to the level of sharing patients’ records with community pharmacies.
Our study revealed that some community pharmacists believe that they are capable of fulfilling their current professional roles. However, most of participants described that pharmacists should continue updating their knowledge. One participant criticized the academic curriculums of some faculties of pharmacy. These findings shed light on the need for continuous educational program for community pharmacists and to revise the curriculums at the different faculties of pharmacy. In UK, due to expansion of the types of services offered by pharmacies within the NHS, the UK General Pharmaceutical Council is redefining educational standards to meet the changing needs of the pharmacy workforce as it was described that pharmacy students have almost no exposure to practice in the early years, and the undergraduate training needs are not centered on patients.[16]
Our study showed that pharmacists think that patients value their professional role while doctors perceive them as dispensers. This might be due to the lack of integrated primary health care team. Such underestimation of pharmacist's role is prevalent in other places including developed countries. In Northern Ireland, the shopkeeper image of community pharmacy emerged as the superordinate theme described by GPs.[21] Some courtiers showed better recognition of pharmacists’ role. In a study conducted in Malaysia, 52.5% of GPs surveyed agreed that pharmacists are the best healthcare professionals to educate patients about safe and appropriate use of medications; 61.3% of them acknowledged that the pharmacy profession had undergone a major metamorphosis from a product-oriented profession to a more patient-centered and outcome-oriented one.[22]
This paper identified that community pharmacists are thirst to role expansion. They believe that this will lead to better self-perception and professional recognition among patients and other healthcare professionals. They described that role expansion requires specific training programs. This desire for more expanded role was described by other researches in Canada and South Africa.[9,23]
This study is the first one in Sudan that explored self-perception of community pharmacists of their professional identity. The study used a qualitative approach with a purposive sample size. Research of this type is not designed to be statistically generalizable. The curriculums at the faculties of pharmacies in Sudan and how to expand community pharmacists’ role are a potential area for future researches.
The paper revealed that community pharmacy profession involves different identities. Pharmacists in Khartoum State are aware of these identities with strong perception of the counselor role. Patients have high recognition of the contribution of community pharmacists while doctors lack such awareness possibly because of the lack of integrated healthcare team that involves pharmacists and doctors at community level. Role expansion will improve self-perception of pharmacists and continuous pharmacy education is needed.
AUTHORS’ CONTRIBUTION
All authors’ contribution adheres to the international committee of medical journals editors’ definition of authorship. Anas Mustafa Salim developed the concept, designed the study, and drafted the article. Bashir Elgizoli collected the data and participated in the analysis and re-drafting of the article. All authors gave final approval of the version to be published. All authors had full access to the data that support the publication.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
APPENDIX: Appendix 1: Checklist of topics to be covered in the interviews (main questions):
How do you perceive professional identity?
How do you think patients and other healthcare professionals perceive you?
What are the main roles of community pharmacists?
How do you assess community pharmacists’ capabilities to fulfill their job roles?
What is your opinion regarding role expansion of community pharmacists?
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