Clinical pharmacists’ services, role and acceptance: a national Swedish survey

Abstract

Aim

Describe, and between regions, compare the services provided, and the pharmacists’ perceptions of their role and its importance.

Method

Online survey involving active clinical pharmacists in Sweden.

Result

The survey was completed by 118 pharmacists (66%), half of whom had at least 1 year’s formal training in clinical pharmacy, and work experience in excess of 5 years. Admission medication reconciliation and medication review are provided in most regions and often on a daily basis. The most important services were: making suggestions to physicians regarding drug changes, medication review, medication reconciliation, and patient communication. On a five-point Likert-scale (where 1 = negative and 5 = positive) very few respondents scored less than 4 on the role, acceptance and skills questions.

Discussion

Our study confirms the strong position of clinical pharmacy and clinical pharmacists in Sweden. There were some differences regarding the services provided between regions but clinical pharmacists’ patient-centred work in the clinical setting as part of the care team is well established, accepted and important. Respondents believed they could take on additional responsibilities for prescription changes without the need for further education.

Conclusion

Patient-centred clinical pharmacy work in a clinical setting as part of the care team is well established, accepted and important.

Introduction

In recent decades, hospital pharmacy has shifted from a focus on the product itself (the medication) to a greater focus on the patient (pharmaceutical care).¹ The European Society of Clinical Pharmacy (ESCP) defines clinical pharmacy as a health specialty, which describes the activities and services of the clinical pharmacist in developing and promoting the rational and appropriate use of medicinal products and devices.² The European Association of Hospital Pharmacists’ (EAHP) Common Training Framework (CTF) group has recently developed a competency framework for hospital pharmacy in order to enhance the quality, safety and equity of access to patient care in every European country.³ This framework contains competencies, knowledge items, behaviour competencies and clusters with individual outcomes for the practice.

Some clinical pharmacy models with activities ranging from admission to discharge and further in the continuum of care have been developed and have shown significant clinical and economic benefits.^4–6 However, a recent systematic review and meta-analysis concluded that evidence of effectiveness and cost-effectiveness of regular, ward-based pharmacists’ input was of very low to moderate quality due to risk of bias, imprecision and inconsistency.⁷

EAHP has developed statements and regularly produces surveys on hospital pharmacy activities in individual European countries.⁸ Additionally, some national surveys and comparisons between countries have been published.^{9 10}

In 2012, the Swedish National Board of Health and Welfare introduced a new regulation on drug reviews.¹¹ This coincided with an increase in the number of clinical pharmacists from approximately 25 in 2011, to 120 in 2015, and 190 in 2019.¹² There is no detailed information available on the services provided by clinical pharmacists and the importance of these services.

The aim of this study was to describe, and between regions compare, what services are provided and how often, and assess the pharmacists’ perception of their role, importance and acceptance within the healthcare team.

Methods

A survey was conducted targeting Swedish clinical pharmacists working with patients in hospitals and in primary/community care. The survey was web-based and employed the Google Forms tool. Questions focused on the clinical pharmacists’ services in the different regions of Sweden and examined the pharmacists’ view of their professional role.

We found no existing study or questionnaire that fully met our needs, and so we developed a questionnaire based on our requirements and earlier experiences, previous studies and reports,3 8–10 12 the two Swedish systematic models^{4 6} and the drug review regulation from the Swedish National Board of Health and Welfare.¹¹ We also studied several sources on how to write survey questions and answers¹³ and discussed the survey with experienced colleges. Finally we produced a questionnaire comprising 23 questions that were divided into three sections: basic demographic data about the pharmacist, the services provided, and the pharmacist’s view of their professional role (see online supplemental appendix). Most questions had a five-point Likert scale. Participants had to answer all the questions to complete the survey.

Persons responsible for clinical pharmacy services in all regions were contacted via email contacts found on Sweden’s municipalities’ and regions’ websites. They were asked to share the names and email lists of clinical pharmacists in each region. Of the 21 regions, 14 provided email lists, and six forwarded the questionnaire and cover letter themselves to the pharmacists concerned.

The questionnaire was sent electronically via email in March 2020. The email included a brief description of what the survey was about with a link to enter the survey. A cover letter containing more information about participation and work was also attached. After 2 weeks, a reminder was sent out. Inclusion criteria were that the pharmacist should work closely with patients and perform services such as medication reconciliations, medication reviews and patient interviews for at least 20% of their employment. We wanted to compare regions, but without unblinding individual responses. Regions with fewer than four responses were therefore grouped together.

Results sheets were transferred from Google Forms to Microsoft Excel for analysis and processing. This was a descriptive study and no statistical comparisons are provided. Data are presented as percentage of responses, and mean and median values for acceptance, role and importance. Respondents volunteered to participate in the survey. As questionnaire used the tool Google Forms no personal data were saved or processed during the survey, and therefore there were no General Data Protection Regulation (GDPR) requirements for the study and no ethical approval was needed.

Results

Respondents

The survey was sent to 180 pharmacists and completed by 118 (66%). Four participants were excluded because less than 20% of their work was of a clinical nature and/ or they did not work closely with patients.

Of the participants, 42 worked in hospital settings only, eight worked in primary/community care only, and the remainder worked in both settings. The majority (91%) of the respondents were female, and the mean age was 39 years. Approximately half the pharmacists had at least 1 year’s formal training in clinical pharmacy (table 1) and in excess of 5 years of experience (mean 7.5 years), and 22% had only in-house training. As shown in table 1, respondents from regions with a small number of respondents (and by population) appeared to have a high level of experience but a low level of formal education.

Table 1.

Description of pharmacists’ education, experience, services and participation

Region (number of responses)	Training at least 40 weeks/MSc in Clinical Pharmacy (%)	Experience >5 years (%)	Admission medication reconciliation, every day (%)	Medication review, every day (%)	Make suggestions to physicians, every day (%)	Discharge medication reconciliation, always or often (%)	Participation in medical rounds, always or regular (%)	Have a specific model for performance (%)
Total (114)	51	49	63	48	66	6	43	51
Skåne (18)	56	67	72	100	89	0	17	72
Uppsala (16)	50	44	81	44	100	25	50	44
Sörmland (15)	63	56	69	44	44	0	88	44
Stockholm (9)	78	56	89	33	78	0	56	67
Gävleborg (8)	38	38	63	50	75	0	13	75
Kalmar (8)	38	63	13	13	25	0	38	38
Västra Götaland (7)	13	25	25	0	38	13	50	63
Dalarna (6)	67	33	100	67	67	0	33	0
Västmanland (5)	60	60	60	80	80	20	40	60
Jönköping (4)	0	100	50	50	50	0	25	100
Kronoberg (4)	0	75	0	25	25	0	25	100
Örebro (4)	0	75	50	0	50	25	50	50
Other (10)	40	60	40	40	50	0	60	70

Services provided

Table 1 describes the clinical pharmacy services provided. There appear to be large differences between regions for every service. Admission medication reconciliation and medication review are provided in most regions and often on a daily basis. This leads to pharmacists making suggestions regarding medication therapy. All regions have at least regular participation in medical rounds. Discharge medication reconciliation seems not to be the focus of clinical pharmacy services since only 6% of respondents perform it and 79% never do it. The discrepancies between and within regions are large. The most important service components were making suggestions to physicians regarding dose adjustments or change of drugs (77%), medication review (76%), medication reconciliation (57%) and patient information (48%). Only 51% of respondents stated that they worked according to a specific and systematic clinical pharmacy model, despite the development of two models in Sweden, in Skåne and in Uppsala.^{4 6}

Acceptance, role and importance

Table 2 describes the important features of the clinical pharmacist’s acceptance, role and importance from the clinical pharmacists’ point of view. The results are very positive and very few respondents scored less than 4 on the role and skills questions.

Table 2.

Acceptance, role and importance of the clinical pharmacist

Question	Likert scale score		Median value	Mean value
	1	5
Treatment from others in the care team	Very negative	Very positive	5	4.6
Collaboration with others in the care team	Very bad	Very good	4	4.4
Treatment from physicians when making suggestions regarding drug therapy	Very negative	Very positiv	4	4.4
Clinical pharmacist role in the care team	Not important	Very important	5	4.6
Skills of the clinical pharmacist are utilised in the care team	Do not agree	Completely agree	4	3.9
Need more clinical pharmacists regionally	Do not agree	Completely agree	5	4.7
Possibility of clinical pharmacists making minor changes to prescriptions	Do not agree	Completely agree	4	3.8
Need further education in order to make minor changes to prescriptions	Do not agree	Completely agree	3	3.0

Discussion

Our study confirms the strong position of clinical pharmacy and clinical pharmacists in Sweden. Clinical pharmacists perform admission medication reconciliation, medication review, take part in medical rounds, and make suggestions to physicians, on a daily basis. Their services and role are perceived by themselves as important and are almost fully accepted. In Sweden, pharmacists can not make any prescription changes. It seems that most clinical pharmacists are ready to expand their role by taking responsibility for minor changes to prescriptions.

There have not been many surveys conducted on clinical pharmacy services and comparisons, nor on the perceived acceptance, role and importance of clinical pharmacists. In a Canadian emergency department study the most commonly provided services were order clarification, troubleshooting, medication reconciliation, and assessment of renal dosing.⁹ A survey of 52 directors of pharmacy and neonatal pharmacists in hospitals in Poland and Australia showed significant differences in the types of pharmaceutical care services provided by the two countries.¹⁰ More than 93% of Australian pharmacists performed medication recommendations, interventions to resolve drug therapy problems, and medication chart reviews. Among Polish pharmacists the comparable figures were below 13%. Sweden appears similar to Australia in this regard.

In the latest EAHP survey from 2018, 58% of the 12 responding Swedish hospitals stated that “The pharmacists in our hospital reconcile medicines on admission”.⁸ The majority (92%) stated that “The pharmacists in our hospital assess the appropriateness of all patients’ medicines, including herbal and dietary supplements” and “The pharmacists in our hospital work routinely as part of a multidisciplinary team”. These findings align with the results of our study. Sweden seems to have a high activity compared with most other European countries, and with a marked increase since 2016.⁸

This study had shortcomings as regards its validity as no qualitative tests and formal pilot studies were conducted; however, as described, the survey was piloted and discussed with three experienced colleges. We did not have full control of how many clinical pharmacists were approached via email since some regions sent these out themselves. Also one region did not respond at all. The coronavirus situation might have had some impact, as well as the short response time (3 weeks). Nevertheless, we believe that the response rate was high enough for us to be able to draw some conclusions.

Conclusions

There were some differences between regions in Sweden regarding the clinical pharmacy services provided but patient-centred work in a clinical setting as part of the care team is well established, accepted and important. The most important services are making suggestions to physicians regarding drug changes, medication review, medication reconciliation, and patient information. Respondents believed that they could take on some more responsibility for prescription changes without the need for further education.

Key messages.

What is already known on this subject

• A framework for hospital pharmacy has been developed in order to enhance the quality, safety and equity of access to patient care in every European country.

• Direct patient-centered clinical pharmacy services are important and are an expanding part of hospital pharmacy.

What this study adds

• Pharmacists and clinical pharmacy services are well established in most regions and are also well accepted and important within the care team.

• The most important services are making suggestions to physicians regarding drug changes, medication review, medication reconciliation, and patient information.

• Clinical pharmacists can assume greater responsibility for prescription changes without the need for further education.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Not required.