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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 292–299
Integrating pharmacists into primary care teams: barriers and facilitators Derek Jorgensona, Tessa Laubscherb, Barry Lyonsc and Rebecca Palmerd a
College of Pharmacy and Nutrition, bDepartment of Family Medicine, University of Saskatchewan, cSaskatoon Cancer Centre, Saskatoon, SK and Health Services, Canadian Forces, Greenwood, NS, Canada
d
Keywords clinical pharmacy; clinical practice; delivery of care; primary care; professional practice Correspondence Dr Derek Jorgenson, College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place S7N 5E5, Saskatoon, SK, Canada. E-mail: [email protected] Received August 6, 2013 Accepted October 11, 2013 doi: 10.1111/ijpp.12080
Abstract Objectives This study evaluated the barriers and facilitators that were experienced as pharmacists were integrated into 23 existing primary care teams located in urban and rural communities in Saskatchewan, Canada. Methods Qualitative design using data from one-on-one telephone interviews with pharmacists, physicians and nurse practitioners from the 23 teams that integrated a new pharmacist role. Four researchers from varied backgrounds used thematic analysis of the interview transcripts to determine key themes. The research team met on multiple occasions to agree on the key themes and received written feedback from an external auditor and two of the original interviewees. Key findings Seven key themes emerged describing the barriers and facilitators that the teams experienced during the pharmacist integration: (1) relationships, trust and respect; (2) pharmacist role definition; (3) orientation and support; (4) pharmacist personality and professional experience; (5) pharmacist presence and visibility; (6) resources and funding; and (7) value of the pharmacist role. Teams from urban and rural communities experienced some of these challenges in unique ways. Conclusions Primary care teams that integrated a pharmacist experienced several common barriers and facilitators. The negative impact of these barriers can be mitigated with effective planning and support that is individualized for the type of community where the team is located.
Introduction Primary healthcare systems are beginning to utilize a teambased approach to care delivery. Pharmacists are increasingly being integrated as co-located members of interprofessional primary care teams in many countries, such as the UK, Canada and the USA.[1–4] Pharmacists contribute to patient care in these teams by providing individual patient assessments, provision of comprehensive medication management (often taking responsibility for prescribing), educating other team members regarding medication management, answering drug information questions and educating patients.[3] Studies have shown that including pharmacists as integrated members of primary care teams results in significant benefits including enhanced detection of drug therapy problems and improvements in various chronic disease indicators.[3,4] Despite the expansion of pharmacists into primary care teams, few studies have evaluated the barriers that pharmacists experience when attempting to integrate into © 2013 Royal Pharmaceutical Society
this new role. Understanding these barriers is key to developing strategies to ensure pharmacists integrate successfully into these teams. The most robust study identified in the literature (the IMPACT trial) examined seven pharmacists who integrated into primary care teams in Ontario, Canada, from 2004 to 2006.[3] This study evaluated the barriers and facilitators experienced during the integration process, from both the physician and pharmacist perspectives. The limited data available in the literature, including results from the IMPACT trial, suggest that pharmacists struggle with several barriers when attempting to integrate into these teams. These include: lack of role definition, absence of an established relationship of trust and respect with existing team members, inadequate pharmacist training, need for mentorship or peer support and a lack of adequate space.[3,5–9] Unfortunately, these studies evaluated small numbers of pharmacists practising exclusively in urban settings. International Journal of Pharmacy Practice 2014, 22, pp. 292–299
Derek Jorgenson et al.
In 2009, the province of Saskatchewan, Canada (which has a population of approximately 1 million people who are distributed across a large geographical area of more than 650 000 km2), integrated pharmacists into 23 existing primary care teams. Prior to 2009 only one primary care team in the province employed a co-located pharmacist. These 23 teams were located in every region of the province and most (87.0%, n = 20/23) were situated in rural communities. All 23 teams included an existing collaborative practice between one or more physician and one or more nurse practitioner. However, the smaller rural teams were managed primarily by nurse practitioners and the larger urban teams by physicians. This was the largest simultaneous integration of pharmacists into primary care teams in Canadian history and the only one to involve a significant number of rural communities. The purpose of this study was to evaluate the barriers and facilitators to team integration that were experienced as pharmacists were integrated into these 23 existing primary care teams in Saskatchewan, Canada. The overall aim was to better understand the experiences of pharmacists who attempt to integrate into primary care teams.
Methods This qualitative study used one-on-one telephone interviews and thematic analysis of interview transcripts to explore the barriers and facilitators experienced by the teams as the pharmacist role was integrated. Research ethics approval was obtained from the Behavioural Research Ethics Board at the University of Saskatchewan.
Participants In May 2010, each of the 23 primary care teams that integrated a pharmacist in the previous year was sent an invitation to have their pharmacist participate in a one-on-one telephone interview. Teams were also asked to self-identify one physician or nurse practitioner who worked closely with the pharmacist and who would be willing to take part in an interview.
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with the pharmacist integration, but the interviewer was also encouraged to ask additional prompting questions when necessary to either expand on a discussion topic or to better clarify an individual’s responses. The interview guide was piloted (on one pharmacist and one physician) and revised prior to implementation. We endeavored to continue interviewing until saturation of data was observed in both groups. Data saturation was defined as the point in the data collection when data from subsequent interviews no longer brought additional insights to the research question. Two members of the research team (DJ, RP) met regularly after completion of every five interviews to review the transcripts and assess if data saturation had been achieved.
Data analysis Four research team members with varied backgrounds [family physician (TL), primary care team pharmacist (DJ), hospital pharmacist (BL), pharmacy student (RP)] independently read and coded all of the interview transcripts. The research team immersed themselves in the data over multiple readings and using thematic analysis, formulated codes and themes.[10] Team members met on two separate occasions to discuss and agree on the emerging themes. As an auditing measure, the final themes were shared with an academic pharmacist previously uninvolved in the project, who was asked to read through the transcripts and confirm that the themes identified were valid and accurate. As a memberchecking exercise, the final themes were also shared with two of the pharmacist interviewees to provide written feedback to ensure the results were accurate and that no important themes were missed. Triangulation was used to confirm the themes identified in the analysis. The aim was to select triangulation sources (four researchers with varied backgrounds, two different data sources, one auditor external to the research team and a member-checking exercise) that had different biases and strengths, thus improving the validity and credibility of the results when convergence is observed across these multiple sources.[10]
Data collection One-on-one telephone interviews performed (by a research assistant who had previous experience performing semistructured interviews) between June and August 2010 were anonymized and transcribed verbatim. An interview guide was created to facilitate a standardized, semi-structured interview process (Figure 1). Since a pre-existing interview guide was not identified in the literature, two authors (DJ, RP) took the lead in developing the interview guide and all authors agreed to the final version. Specific questions were included in the interview guide to elicit the interviewees’ experiences © 2013 Royal Pharmaceutical Society
Results Interviews were completed with 14 pharmacists, three family physicians and eight nurse practitioners. Saturation of data was observed in all groups. The majority of interviewees (68.0%, n = 17/25) practised in primary care teams located in rural communities with fewer than 5000 people and an even larger proportion (80.0%, n = 20/25) practised in rural communities under 50 000 (Table 1). The majority of pharmacists (85.7%, n = 12/14) worked 1 day per week on the primary care team, while the remaining pharmacists worked International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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Primary care team pharmacist integration
Pharmacist Interviews 1. Can you start off by telling me about your educational background? 2. Please describe your previous work experience as a pharmacist prior to working with the primary care team. 3. Can you tell me how many days per week you work directly with the primary care team and how long have you worked there? Do you work elsewhere on the other days of the week (if so where)? 4. Can you list the different health professionals that work directly within your primary health centre? 5. Please describe your role and responsibilities on the primary health care team at the present time. 6. Can you describe your collaborative working relationship with the other team members prior to your integrating onto the team? 7. Can you describe your experience as you integrated onto this primary health care team? 8. What surprised you most about your integration process into this team? 9. Please describe any factors that you feel made it easier or that were helpful to you in attempting to integrating into this team. 10. Please describe any factors that you feel made it difficult for you or that were barriers to integrating into this team. 11. Do you remember what was done just prior to, or soon after, you started working with your team to assist in making your integration more successful? 12. What would you do differently if you could go back and attempt integrating into the team again? 13. Do you have anything else that you would like to add that you think is relevant to this topic that I have not already asked? Physician / Nurse Practitioner Interviews 1. Can you describe your job title, role and responsibilities in the primary care team at the present time? 2. Approximately when did your team integrate a pharmacist and how many days per week is the pharmacist now working directly with the team? 3. Can you briefly describe the pharmacists’ role and responsibilities on your team? 4. Can you describe your collaborative working relationship with the pharmacist prior to him/her integrating onto the team? 5. Can you list the other different (non-pharmacist) health professionals that work directly with your team? 6. Can you describe your experience as you integrated the pharmacist onto your existing team? 7. What surprised you the most about the process of integrating the pharmacist onto your team? 8. Please describe any factors that you feel made it easier or that were helpful in attempting to integrate the pharmacist into your team. 9. Please describe any factors that you feel made it difficult or that were barriers to integrating the pharmacist into your team. 10. Do you remember what was done just prior to, or soon after, the pharmacist started working with your team to assist in making his/her integration onto the team more successful? 11. What would you do differently if you could go back and attempt integrating the pharmacist onto the team again? 12. Do you have anything else that you would like to add that you think is relevant to this topic that I have not already asked? Figure 1
Interview guides.
© 2013 Royal Pharmaceutical Society
International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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Table 1
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Distribution of interviewees based on size of community
Population 50 000
Pharmacists
Nurse practitioners
Physicians
9 2 3
7 1 0
1 0 2
2.5 days per week (14.3%, n = 2/14). All physicians and nurse practitioners worked full time.
Theme 1: relationships, trust and respect The presence of a pre-existing professional relationship between the pharmacist and the other team members, in which a certain degree of mutual trust and respect had been previously attained, was a significant facilitating factor in the success of the integration. If these relationships did not exist prior to the arrival of the pharmacist, it resulted in a delay in the development of a collaborative role, while the team members learned to trust and respect the pharmacist’s abilities. We are in a relationship business. We manage relationships, whether that’s with patients, nurses or physicians. (Pharmacist 3) This is one area where significant divergence was identified between the rural and urban teams. None of the pharmacists who had integrated into urban teams had a previous collaborative relationship with any of the other team members. However, all of the pharmacists in the rural communities described a pre-existing professional relationship with one or more of the other team members, and interviewees commented that this was a major facilitating factor to the integration. The pharmacy in town is attached to our clinic and because of this close proximity . . . it feels like we have already worked together. (Nurse practitioner 1) The informal relationship was there from the start and this was instrumental to the success of the new role. (Physician 2) Teams with previous experience integrating other allied health professionals (e.g. social worker, diabetes educator) identified this experience as an additional facilitating factor. Interviewees reflected on how the process to integrate the pharmacist was similar to integrating other professionals. This theme was only observed in the interviews of the urban team members, as most rural teams had little or no experience with integrating professionals other than physicians and nurse practitioners. © 2013 Royal Pharmaceutical Society
Theme 2: role definition Interviewees from both urban and rural teams consistently reported frustration and delays in integrating the pharmacist because of a lack of understanding regarding the roles and responsibilities of the new co-located clinical pharmacist position on the team. In most cases, none of the team members had experience working with a co-located clinical pharmacist. No teams reported the existence of a detailed pharmacist job description. Many team members admitted that they were ignorant about the pharmacists’ skills and the potential clinical roles within the team, even though most had experience working with pharmacists who practised in a more traditional dispensary setting. Consequently, this lack of role definition clarity was a major barrier to successful pharmacist integration. The pharmacists’ expectations and responsibilities were never formulated. So I had to figure out how I could help her . . . in the midst of running a busy practice . . . so I don’t think that part went smooth[ly] at all. (Nurse practitioner 5) . . . it was difficult, they [the team] didn’t really know what I was supposed to be doing. I didn’t really have a clear direction what the health region expected of me. (Pharmacist 6) Some pharmacists overcame this barrier by taking the initiative to develop a job description collaboratively with the team. One pharmacist met with individual team members several times prior to and soon after arriving in the clinic to achieve this goal. The pharmacist presented each team member with a summary of what a pharmacist could do within a primary care team and then tailored her role based on the unique needs of her primary care team. She eventually created a written job description and had the team approve it at a staff meeting. . . . once I showed them what I could do and they had a few experiences with me, then they were able to figure out what it was that I actually should do. (Pharmacist 8)
Theme 3: orientation and support Most pharmacists (in both urban and rural teams) reported a lack of support from health region managers or supervisors as a significant barrier to their integration into the team. Many interviewees lamented about how they arrived for work on their first day and found that there was no formal orientation planned and no manager to greet them. Some even arrived to a team where not all existing members were aware of the new pharmacist’s role. This created frustration for both the pharmacist and the existing team members, who reported International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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that they were forced to get the pharmacist oriented when they had a busy patient schedule and many other responsibilities. Animosity was expressed towards management from both pharmacists and non-pharmacists for not arranging a proper orientation to prepare the team for the addition of the new role. They [management] didn’t really do anything for me . . . I don’t even know if a lot of the other team members knew I was coming. (Pharmacist 8) There wasn’t a good orientation . . . we should have been able to take some time away from our jobs to work this through. It was like, you just go ahead and form your own team and figure out what you want to do, but we [management] won’t give you time to do it. (Nurse practitioner 2) Although most pharmacists reported a lack of orientation and support from management, it was common for pharmacists to have received mentorship and assistance from clinical pharmacist colleagues outside of the primary care team; this was found to be a major facilitator to successful integration. Pharmacists either developed an individual mentor–mentee relationship with a local ‘expert’ who provided formal and informal assistance, advice and resources during the integration process; or they accessed similar support from a national virtual network of ‘experts’ called the Primary Care Pharmacists Specialty Network. This professional mentorship and support was consistently found to be invaluable to the successful integration of the pharmacist’s role in both urban and rural settings.
Theme 4: pharmacist personality and professional experience Successful integration appeared to be heavily dependent on the individual characteristics of the pharmacists in both urban and rural teams. Pharmacists who were motivated, assertive and confident were much less likely to struggle as they forged a new role in these teams. They were able to alleviate the negative impact of the barriers already noted by taking the initiative to quickly build relationships with the team members, define their responsibilities and teach the team how to utilize their role. She was very proactive . . . and it was useful because we are all busy and it was great just to have her come and plan her own role. I would say that one of our pharmacists is more integrated than the other and that is completely personality dependent. (Physician 1) The professional experience and training of the individual pharmacists was also a factor in the integration. Pharmacists with previous experience working in any sort of collaborative © 2013 Royal Pharmaceutical Society
Primary care team pharmacist integration
setting (even if it was not in primary care) or with advanced training/credentials (Master’s or Doctor of Pharmacy degree, Certified Diabetes Educator, Board-Certified Pharmacotherapy Specialist) found the integration process to be easier.
Theme 5: pharmacist presence and visibility An additional barrier to pharmacist integration, for both urban and rural teams, was the fact that the pharmacists were present and available to the team in the medical clinic on a sporadic basis. Most pharmacists were funded to work with the team on the basis of 1 day per week. This was seen to adversely effect integration since team members often forgot about the pharmacist. However, it was less of a barrier if pharmacists were in the clinic on a consistent day each week, so that team members could expect them to be present on a regular schedule. . . . not being here much and not having a predictable schedule was a barrier to integration because the team did not know if it was even worth asking me for something because I might not be there to do it. (Pharmacist 2) This appeared to be a more significant issue for pharmacists in rural communities. Most rural pharmacists were employed by a local community pharmacy, which had a contract to provide the pharmacist services to the primary care team 1 day per week. Consequently, it was common for these pharmacists to cancel some of their primary care team shifts in the medical clinic when they were required to work extra hours in the community pharmacy when other employees were ill or on vacation. This issue was not observed with the urban pharmacists, who were mostly employed by the local health region or hospital network. Pharmacists who made an effort to be highly visible to the team while at the medical clinic found that their integration was more successful. Some examples included having a workstation within or near a busy area of the clinic such as the nursing station (as opposed to having a private office away from the patient care area), attending team meetings and patient care rounds on a regular basis, and attending social events and eating lunch with other team members. Some pharmacists reported that they utilized a strategy that they called ‘strategic loitering’, where they would regularly spend a few minutes each day in high-traffic areas of the clinic when they were not busy with other tasks, in order to be visible to the team. I think physically being away from them and not seeing them made it difficult. I have my own work space upstairs . . . but it means they can’t physically see me and they forget that I am here. (Pharmacist 8) International Journal of Pharmacy Practice 2014, 22, pp. 292–299
Derek Jorgenson et al.
The first two weeks I had a private office around the corner. After that I asked to move into the students’/ residents’ room where all the action was. It was unbelievable how that changed my integration! (Pharmacist 1)
Theme 6: resources and funding Several physician/nurse practitioner team members reported that they were reluctant to fully integrate the pharmacist’s role during the first year when the service was referred to as a ‘pilot project’ and the funding to support the service was not permanent. Interviewees worried about the implications of relying on a new service that might not be available the following year. Some teams also did not have adequate office space and other physical resources necessary for optimal clinical pharmacist practice (e.g. computer, drug information resources, desk, room for patient consultations). We don’t have a room for her . . . so she has to use a room at the hospital, which is away from the clinic . . . and then she doesn’t have easy access to the patient charts. (Nurse practitioner 3)
Theme 7: value of the pharmacist role Physician/nurse practitioner interviewees consistently reported a high level of satisfaction regarding the new pharmacist role. Despite the barriers and struggles that were experienced, interviewees expressed the positive impact that the pharmacist role had on their practices and on the patient care being delivered. Interestingly, physicians and nurse practitioners were not specifically asked about their personal satisfaction or the potential impact of the pharmacist role on patients. In the final question of the interview, when participants were asked if they would like to add anything that was not previously discussed, many non-pharmacist interviewees spontaneously spoke about their positive experience with the pharmacist role. Consequently, this was seen to be a significant facilitator to the successful integration of the pharmacist. Physicians and nurse practitioners reported that they persevered through the challenges and barriers, at least in part due to the positive impact they felt that the pharmacist was having on the team and their patients. It was just such a wonderful thing. Not only did patients enjoy this wonderful service, but all of the professionals that got to work with her learned a lot too. (physician 1) The clients like the fact that they can talk to someone about their medications – not to mention that I liked it because it took some pressure off of me time wise. I © 2013 Royal Pharmaceutical Society
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didn’t need to spend as much time on the medications. It has been invaluable. Just an awesome, awesome experience. (nurse practitioner 7).
Discussion These results demonstrate that the majority of the 23 primary care teams identified several common barriers and facilitators as they integrated a pharmacist, including relationships, trust and respect; poor pharmacist role definition; lack of orientation and support from management; pharmacist personality and professional experience; pharmacist presence and visibility within the clinic setting; resources and funding; and value of the pharmacist role.
Study strengths and limitations The results of this qualitative study are trustworthy for the following reasons: the perspectives of three different health professions were included as data sources, four researchers with varied backgrounds analysed the data, an external auditor confirmed the findings and a member-checking exercise was included. This is the largest study that we are aware of that has investigated the barriers and facilitators that pharmacists experience when integrating into a primary care team and the only one that included a large number of rural teams. The results are potentially applicable to primary care teams in many countries, particularly those that provide primary health services to people living in both rural and urban communities. Researcher bias is a potential limitation of this study. Three of the four authors had previous experience practising within primary care teams; therefore they may have some degree of pre-existing bias, which could have influenced the data analysis. We attempted to mitigate the impact of this bias by using standardized interview templates, utilizing multiple data sources, de-identifying and transcribing interviews verbatim and involving a student analyst, an external auditor and a member-checking exercise. An additional limitation is that this study did not consider the perspectives of team members other than pharmacists, nurse practitioners and physicians.
Discussion of findings Some of our findings are consistent with the existing literature regarding the barriers that pharmacists face when attempting to integrate into primary care teams. Our study found that pharmacists consistently struggle with: (1) lack of pharmacist role definition, (2) limited support and mentorship (mostly from management) and (3) lack of adequate resources and space. Previous studies have also identified similar themes.[3,5–9] Fortunately these are three barriers that can be mitigated by proper planning and International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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preparation. Health systems that integrate pharmacists into their primary care teams should consider the importance of strong managerial support during the integration phase to assist the pharmacists in developing a role definition and ensuring that adequate resources and space are available. Interestingly, some of our findings are inconsistent with the existing literature on this topic. Previous studies, performed primarily in urban settings, found that pharmacists struggle to develop a relationship of trust and respect with other team members, which is a major barrier to integration into the team.[3,5–9] Pharmacist interviewees in our study, performed primarily in rural settings, found that most pharmacists had a strong pre-existing relationship with other team members, which was a major facilitating factor to successful integration. This is a significant finding; our study appears to identify an integration challenge that is different for urban and rural primary care teams. Our study identified additional differences between the integration experiences of urban and rural primary care teams, which have not been previously identified in the literature. Urban teams were more experienced with interprofessional collaboration than rural teams, as many had previously integrated other (non-pharmacist) team members. However, this finding is difficult to interpret and should be confirmed in a larger study, considering only three of the teams were located in urban settings. Rural pharmacists also experienced greater challenges attending their weekly shifts in the primary care clinic (due to competing responsibilities with their primary community pharmacy employer), which resulted in a more sporadic presence on the team. The importance of individual pharmacist assertiveness and confidence that was identified in both the urban and rural teams in our study cannot be understated and is a key factor in overcoming many of the integration barriers previously noted. Although this theme has not been previously identified in primary care team integration literature, it has been discussed as a general barrier to pharmacist practice change.[11] Pharmacists who possess these personality traits may be better suited than others for working in a multidisciplinary primary care team setting.
Primary care team pharmacist integration
several common barriers and facilitators during the integration process. This is the first study of its kind to include primary care teams located primarily in rural communities and our findings suggest that the integration barriers in this setting are unique. Consequently, efforts to prepare for and support pharmacist integration into primary care teams must be tailored to reflect the type and size of community where the team is located. The findings of this study will be useful to health system managers and pharmacists who are attempting to integrate into a primary care team. The results may also be helpful to policy makers and researchers who may wish to develop practice guidelines or policy and procedure manuals based on these findings to standardize the integration process across an entire health region, province or country.
Declarations Conflict of interest The Authors have no personal or financial conflicts to report.
Funding This work was supported by the Interprofessional Health Collaborative of Saskatchewan, Kelsey Trail Health Region and the College of Pharmacy and Nutrition, University of Saskatchewan.
Authors’ contributions D. Jorgenson initiated the project, took a lead in design, methodology and data analysis, supervised the project, took the lead in writing the manuscript and reviewed the final draft of the manuscript. T. Laubscher and B. Lyons both contributed to the design, methodology and data analysis, assisted in writing the manuscript and reviewed the final draft of the manuscript. R. Palmer contributed to the design, methodology and data analysis and reviewed the final draft of the manuscript. All Authors state that they had complete access to the study data that support the publication.
Conclusion
Ethics information
Pharmacists who were recruited into the 23 primary care teams in Saskatchewan, Canada, were found to experience
This study was approved by the Behavioral Research Ethics Board at the University of Saskatchewan (BEH 10-085).
© 2013 Royal Pharmaceutical Society
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References 1. Silcock J et al. The organisation and development of primary care pharmacy in the United Kingdom. Health Policy 2004; 67: 207–214. 2. Bradley F et al. The challenge of integrating community pharmacists into the primary health care team: a case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration. J Interprof Care 2008; 22: 387–398. 3. Dolovich L et al. Integrating family medicine and pharmacy to advance primary care therapeutics. Clin Pharmacol Ther 2008; 83: 913–917.
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4. Isetts BJ et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc 2003; 48: 203–211. 5. Farrell B et al. Integrating into family practice: the experiences of pharmacists in Ontario. Canada. Interm J Pharm Pract 2008; 16: 309–315. 6. Kolodziejak L et al. Integration of a primary healthcare pharmacist. J Interprof Care 2010; 24: 274–284. 7. Newton PJ et al. Barriers and facilitators to the implementation of the collaborative method: reflections from a single site. Qual Saf Health Care 2007; 16: 409–414.
8. Kozminski M et al. Pharmacist integration into the medical home: qualitative analysis. J Am Pharm Assoc 2003; 51: 173–183. 9. Phillips L et al. Integrating a brief pharmacist intervention into practice: osteoporosis pharmacotherapy assessment. Can Pharm J (Ott) 2012; 145: 218–220. 10. Pope C et al. Qualitative research in health care. Analysing qualitative data. BMJ 2000; 320: 114–116. 11. Frankel GE, Austin Z. Responsibility and confidence: identifying barriers to advanced pharmacy practice. Can Pharm J (Ott) 2013; 146: 155–161.
International Journal of Pharmacy Practice 2014, 22, pp. 292–299
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 292–299
Integrating pharmacists into primary care teams: barriers and facilitators Derek Jorgensona, Tessa Laubscherb, Barry Lyonsc and Rebecca Palmerd a
College of Pharmacy and Nutrition, bDepartment of Family Medicine, University of Saskatchewan, cSaskatoon Cancer Centre, Saskatoon, SK and Health Services, Canadian Forces, Greenwood, NS, Canada
d
Keywords clinical pharmacy; clinical practice; delivery of care; primary care; professional practice Correspondence Dr Derek Jorgenson, College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place S7N 5E5, Saskatoon, SK, Canada. E-mail: [email protected] Received August 6, 2013 Accepted October 11, 2013 doi: 10.1111/ijpp.12080
Abstract Objectives This study evaluated the barriers and facilitators that were experienced as pharmacists were integrated into 23 existing primary care teams located in urban and rural communities in Saskatchewan, Canada. Methods Qualitative design using data from one-on-one telephone interviews with pharmacists, physicians and nurse practitioners from the 23 teams that integrated a new pharmacist role. Four researchers from varied backgrounds used thematic analysis of the interview transcripts to determine key themes. The research team met on multiple occasions to agree on the key themes and received written feedback from an external auditor and two of the original interviewees. Key findings Seven key themes emerged describing the barriers and facilitators that the teams experienced during the pharmacist integration: (1) relationships, trust and respect; (2) pharmacist role definition; (3) orientation and support; (4) pharmacist personality and professional experience; (5) pharmacist presence and visibility; (6) resources and funding; and (7) value of the pharmacist role. Teams from urban and rural communities experienced some of these challenges in unique ways. Conclusions Primary care teams that integrated a pharmacist experienced several common barriers and facilitators. The negative impact of these barriers can be mitigated with effective planning and support that is individualized for the type of community where the team is located.
Introduction Primary healthcare systems are beginning to utilize a teambased approach to care delivery. Pharmacists are increasingly being integrated as co-located members of interprofessional primary care teams in many countries, such as the UK, Canada and the USA.[1–4] Pharmacists contribute to patient care in these teams by providing individual patient assessments, provision of comprehensive medication management (often taking responsibility for prescribing), educating other team members regarding medication management, answering drug information questions and educating patients.[3] Studies have shown that including pharmacists as integrated members of primary care teams results in significant benefits including enhanced detection of drug therapy problems and improvements in various chronic disease indicators.[3,4] Despite the expansion of pharmacists into primary care teams, few studies have evaluated the barriers that pharmacists experience when attempting to integrate into © 2013 Royal Pharmaceutical Society
this new role. Understanding these barriers is key to developing strategies to ensure pharmacists integrate successfully into these teams. The most robust study identified in the literature (the IMPACT trial) examined seven pharmacists who integrated into primary care teams in Ontario, Canada, from 2004 to 2006.[3] This study evaluated the barriers and facilitators experienced during the integration process, from both the physician and pharmacist perspectives. The limited data available in the literature, including results from the IMPACT trial, suggest that pharmacists struggle with several barriers when attempting to integrate into these teams. These include: lack of role definition, absence of an established relationship of trust and respect with existing team members, inadequate pharmacist training, need for mentorship or peer support and a lack of adequate space.[3,5–9] Unfortunately, these studies evaluated small numbers of pharmacists practising exclusively in urban settings. International Journal of Pharmacy Practice 2014, 22, pp. 292–299
Derek Jorgenson et al.
In 2009, the province of Saskatchewan, Canada (which has a population of approximately 1 million people who are distributed across a large geographical area of more than 650 000 km2), integrated pharmacists into 23 existing primary care teams. Prior to 2009 only one primary care team in the province employed a co-located pharmacist. These 23 teams were located in every region of the province and most (87.0%, n = 20/23) were situated in rural communities. All 23 teams included an existing collaborative practice between one or more physician and one or more nurse practitioner. However, the smaller rural teams were managed primarily by nurse practitioners and the larger urban teams by physicians. This was the largest simultaneous integration of pharmacists into primary care teams in Canadian history and the only one to involve a significant number of rural communities. The purpose of this study was to evaluate the barriers and facilitators to team integration that were experienced as pharmacists were integrated into these 23 existing primary care teams in Saskatchewan, Canada. The overall aim was to better understand the experiences of pharmacists who attempt to integrate into primary care teams.
Methods This qualitative study used one-on-one telephone interviews and thematic analysis of interview transcripts to explore the barriers and facilitators experienced by the teams as the pharmacist role was integrated. Research ethics approval was obtained from the Behavioural Research Ethics Board at the University of Saskatchewan.
Participants In May 2010, each of the 23 primary care teams that integrated a pharmacist in the previous year was sent an invitation to have their pharmacist participate in a one-on-one telephone interview. Teams were also asked to self-identify one physician or nurse practitioner who worked closely with the pharmacist and who would be willing to take part in an interview.
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with the pharmacist integration, but the interviewer was also encouraged to ask additional prompting questions when necessary to either expand on a discussion topic or to better clarify an individual’s responses. The interview guide was piloted (on one pharmacist and one physician) and revised prior to implementation. We endeavored to continue interviewing until saturation of data was observed in both groups. Data saturation was defined as the point in the data collection when data from subsequent interviews no longer brought additional insights to the research question. Two members of the research team (DJ, RP) met regularly after completion of every five interviews to review the transcripts and assess if data saturation had been achieved.
Data analysis Four research team members with varied backgrounds [family physician (TL), primary care team pharmacist (DJ), hospital pharmacist (BL), pharmacy student (RP)] independently read and coded all of the interview transcripts. The research team immersed themselves in the data over multiple readings and using thematic analysis, formulated codes and themes.[10] Team members met on two separate occasions to discuss and agree on the emerging themes. As an auditing measure, the final themes were shared with an academic pharmacist previously uninvolved in the project, who was asked to read through the transcripts and confirm that the themes identified were valid and accurate. As a memberchecking exercise, the final themes were also shared with two of the pharmacist interviewees to provide written feedback to ensure the results were accurate and that no important themes were missed. Triangulation was used to confirm the themes identified in the analysis. The aim was to select triangulation sources (four researchers with varied backgrounds, two different data sources, one auditor external to the research team and a member-checking exercise) that had different biases and strengths, thus improving the validity and credibility of the results when convergence is observed across these multiple sources.[10]
Data collection One-on-one telephone interviews performed (by a research assistant who had previous experience performing semistructured interviews) between June and August 2010 were anonymized and transcribed verbatim. An interview guide was created to facilitate a standardized, semi-structured interview process (Figure 1). Since a pre-existing interview guide was not identified in the literature, two authors (DJ, RP) took the lead in developing the interview guide and all authors agreed to the final version. Specific questions were included in the interview guide to elicit the interviewees’ experiences © 2013 Royal Pharmaceutical Society
Results Interviews were completed with 14 pharmacists, three family physicians and eight nurse practitioners. Saturation of data was observed in all groups. The majority of interviewees (68.0%, n = 17/25) practised in primary care teams located in rural communities with fewer than 5000 people and an even larger proportion (80.0%, n = 20/25) practised in rural communities under 50 000 (Table 1). The majority of pharmacists (85.7%, n = 12/14) worked 1 day per week on the primary care team, while the remaining pharmacists worked International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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Pharmacist Interviews 1. Can you start off by telling me about your educational background? 2. Please describe your previous work experience as a pharmacist prior to working with the primary care team. 3. Can you tell me how many days per week you work directly with the primary care team and how long have you worked there? Do you work elsewhere on the other days of the week (if so where)? 4. Can you list the different health professionals that work directly within your primary health centre? 5. Please describe your role and responsibilities on the primary health care team at the present time. 6. Can you describe your collaborative working relationship with the other team members prior to your integrating onto the team? 7. Can you describe your experience as you integrated onto this primary health care team? 8. What surprised you most about your integration process into this team? 9. Please describe any factors that you feel made it easier or that were helpful to you in attempting to integrating into this team. 10. Please describe any factors that you feel made it difficult for you or that were barriers to integrating into this team. 11. Do you remember what was done just prior to, or soon after, you started working with your team to assist in making your integration more successful? 12. What would you do differently if you could go back and attempt integrating into the team again? 13. Do you have anything else that you would like to add that you think is relevant to this topic that I have not already asked? Physician / Nurse Practitioner Interviews 1. Can you describe your job title, role and responsibilities in the primary care team at the present time? 2. Approximately when did your team integrate a pharmacist and how many days per week is the pharmacist now working directly with the team? 3. Can you briefly describe the pharmacists’ role and responsibilities on your team? 4. Can you describe your collaborative working relationship with the pharmacist prior to him/her integrating onto the team? 5. Can you list the other different (non-pharmacist) health professionals that work directly with your team? 6. Can you describe your experience as you integrated the pharmacist onto your existing team? 7. What surprised you the most about the process of integrating the pharmacist onto your team? 8. Please describe any factors that you feel made it easier or that were helpful in attempting to integrate the pharmacist into your team. 9. Please describe any factors that you feel made it difficult or that were barriers to integrating the pharmacist into your team. 10. Do you remember what was done just prior to, or soon after, the pharmacist started working with your team to assist in making his/her integration onto the team more successful? 11. What would you do differently if you could go back and attempt integrating the pharmacist onto the team again? 12. Do you have anything else that you would like to add that you think is relevant to this topic that I have not already asked? Figure 1
Interview guides.
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Table 1
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Distribution of interviewees based on size of community
Population 50 000
Pharmacists
Nurse practitioners
Physicians
9 2 3
7 1 0
1 0 2
2.5 days per week (14.3%, n = 2/14). All physicians and nurse practitioners worked full time.
Theme 1: relationships, trust and respect The presence of a pre-existing professional relationship between the pharmacist and the other team members, in which a certain degree of mutual trust and respect had been previously attained, was a significant facilitating factor in the success of the integration. If these relationships did not exist prior to the arrival of the pharmacist, it resulted in a delay in the development of a collaborative role, while the team members learned to trust and respect the pharmacist’s abilities. We are in a relationship business. We manage relationships, whether that’s with patients, nurses or physicians. (Pharmacist 3) This is one area where significant divergence was identified between the rural and urban teams. None of the pharmacists who had integrated into urban teams had a previous collaborative relationship with any of the other team members. However, all of the pharmacists in the rural communities described a pre-existing professional relationship with one or more of the other team members, and interviewees commented that this was a major facilitating factor to the integration. The pharmacy in town is attached to our clinic and because of this close proximity . . . it feels like we have already worked together. (Nurse practitioner 1) The informal relationship was there from the start and this was instrumental to the success of the new role. (Physician 2) Teams with previous experience integrating other allied health professionals (e.g. social worker, diabetes educator) identified this experience as an additional facilitating factor. Interviewees reflected on how the process to integrate the pharmacist was similar to integrating other professionals. This theme was only observed in the interviews of the urban team members, as most rural teams had little or no experience with integrating professionals other than physicians and nurse practitioners. © 2013 Royal Pharmaceutical Society
Theme 2: role definition Interviewees from both urban and rural teams consistently reported frustration and delays in integrating the pharmacist because of a lack of understanding regarding the roles and responsibilities of the new co-located clinical pharmacist position on the team. In most cases, none of the team members had experience working with a co-located clinical pharmacist. No teams reported the existence of a detailed pharmacist job description. Many team members admitted that they were ignorant about the pharmacists’ skills and the potential clinical roles within the team, even though most had experience working with pharmacists who practised in a more traditional dispensary setting. Consequently, this lack of role definition clarity was a major barrier to successful pharmacist integration. The pharmacists’ expectations and responsibilities were never formulated. So I had to figure out how I could help her . . . in the midst of running a busy practice . . . so I don’t think that part went smooth[ly] at all. (Nurse practitioner 5) . . . it was difficult, they [the team] didn’t really know what I was supposed to be doing. I didn’t really have a clear direction what the health region expected of me. (Pharmacist 6) Some pharmacists overcame this barrier by taking the initiative to develop a job description collaboratively with the team. One pharmacist met with individual team members several times prior to and soon after arriving in the clinic to achieve this goal. The pharmacist presented each team member with a summary of what a pharmacist could do within a primary care team and then tailored her role based on the unique needs of her primary care team. She eventually created a written job description and had the team approve it at a staff meeting. . . . once I showed them what I could do and they had a few experiences with me, then they were able to figure out what it was that I actually should do. (Pharmacist 8)
Theme 3: orientation and support Most pharmacists (in both urban and rural teams) reported a lack of support from health region managers or supervisors as a significant barrier to their integration into the team. Many interviewees lamented about how they arrived for work on their first day and found that there was no formal orientation planned and no manager to greet them. Some even arrived to a team where not all existing members were aware of the new pharmacist’s role. This created frustration for both the pharmacist and the existing team members, who reported International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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that they were forced to get the pharmacist oriented when they had a busy patient schedule and many other responsibilities. Animosity was expressed towards management from both pharmacists and non-pharmacists for not arranging a proper orientation to prepare the team for the addition of the new role. They [management] didn’t really do anything for me . . . I don’t even know if a lot of the other team members knew I was coming. (Pharmacist 8) There wasn’t a good orientation . . . we should have been able to take some time away from our jobs to work this through. It was like, you just go ahead and form your own team and figure out what you want to do, but we [management] won’t give you time to do it. (Nurse practitioner 2) Although most pharmacists reported a lack of orientation and support from management, it was common for pharmacists to have received mentorship and assistance from clinical pharmacist colleagues outside of the primary care team; this was found to be a major facilitator to successful integration. Pharmacists either developed an individual mentor–mentee relationship with a local ‘expert’ who provided formal and informal assistance, advice and resources during the integration process; or they accessed similar support from a national virtual network of ‘experts’ called the Primary Care Pharmacists Specialty Network. This professional mentorship and support was consistently found to be invaluable to the successful integration of the pharmacist’s role in both urban and rural settings.
Theme 4: pharmacist personality and professional experience Successful integration appeared to be heavily dependent on the individual characteristics of the pharmacists in both urban and rural teams. Pharmacists who were motivated, assertive and confident were much less likely to struggle as they forged a new role in these teams. They were able to alleviate the negative impact of the barriers already noted by taking the initiative to quickly build relationships with the team members, define their responsibilities and teach the team how to utilize their role. She was very proactive . . . and it was useful because we are all busy and it was great just to have her come and plan her own role. I would say that one of our pharmacists is more integrated than the other and that is completely personality dependent. (Physician 1) The professional experience and training of the individual pharmacists was also a factor in the integration. Pharmacists with previous experience working in any sort of collaborative © 2013 Royal Pharmaceutical Society
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setting (even if it was not in primary care) or with advanced training/credentials (Master’s or Doctor of Pharmacy degree, Certified Diabetes Educator, Board-Certified Pharmacotherapy Specialist) found the integration process to be easier.
Theme 5: pharmacist presence and visibility An additional barrier to pharmacist integration, for both urban and rural teams, was the fact that the pharmacists were present and available to the team in the medical clinic on a sporadic basis. Most pharmacists were funded to work with the team on the basis of 1 day per week. This was seen to adversely effect integration since team members often forgot about the pharmacist. However, it was less of a barrier if pharmacists were in the clinic on a consistent day each week, so that team members could expect them to be present on a regular schedule. . . . not being here much and not having a predictable schedule was a barrier to integration because the team did not know if it was even worth asking me for something because I might not be there to do it. (Pharmacist 2) This appeared to be a more significant issue for pharmacists in rural communities. Most rural pharmacists were employed by a local community pharmacy, which had a contract to provide the pharmacist services to the primary care team 1 day per week. Consequently, it was common for these pharmacists to cancel some of their primary care team shifts in the medical clinic when they were required to work extra hours in the community pharmacy when other employees were ill or on vacation. This issue was not observed with the urban pharmacists, who were mostly employed by the local health region or hospital network. Pharmacists who made an effort to be highly visible to the team while at the medical clinic found that their integration was more successful. Some examples included having a workstation within or near a busy area of the clinic such as the nursing station (as opposed to having a private office away from the patient care area), attending team meetings and patient care rounds on a regular basis, and attending social events and eating lunch with other team members. Some pharmacists reported that they utilized a strategy that they called ‘strategic loitering’, where they would regularly spend a few minutes each day in high-traffic areas of the clinic when they were not busy with other tasks, in order to be visible to the team. I think physically being away from them and not seeing them made it difficult. I have my own work space upstairs . . . but it means they can’t physically see me and they forget that I am here. (Pharmacist 8) International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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The first two weeks I had a private office around the corner. After that I asked to move into the students’/ residents’ room where all the action was. It was unbelievable how that changed my integration! (Pharmacist 1)
Theme 6: resources and funding Several physician/nurse practitioner team members reported that they were reluctant to fully integrate the pharmacist’s role during the first year when the service was referred to as a ‘pilot project’ and the funding to support the service was not permanent. Interviewees worried about the implications of relying on a new service that might not be available the following year. Some teams also did not have adequate office space and other physical resources necessary for optimal clinical pharmacist practice (e.g. computer, drug information resources, desk, room for patient consultations). We don’t have a room for her . . . so she has to use a room at the hospital, which is away from the clinic . . . and then she doesn’t have easy access to the patient charts. (Nurse practitioner 3)
Theme 7: value of the pharmacist role Physician/nurse practitioner interviewees consistently reported a high level of satisfaction regarding the new pharmacist role. Despite the barriers and struggles that were experienced, interviewees expressed the positive impact that the pharmacist role had on their practices and on the patient care being delivered. Interestingly, physicians and nurse practitioners were not specifically asked about their personal satisfaction or the potential impact of the pharmacist role on patients. In the final question of the interview, when participants were asked if they would like to add anything that was not previously discussed, many non-pharmacist interviewees spontaneously spoke about their positive experience with the pharmacist role. Consequently, this was seen to be a significant facilitator to the successful integration of the pharmacist. Physicians and nurse practitioners reported that they persevered through the challenges and barriers, at least in part due to the positive impact they felt that the pharmacist was having on the team and their patients. It was just such a wonderful thing. Not only did patients enjoy this wonderful service, but all of the professionals that got to work with her learned a lot too. (physician 1) The clients like the fact that they can talk to someone about their medications – not to mention that I liked it because it took some pressure off of me time wise. I © 2013 Royal Pharmaceutical Society
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didn’t need to spend as much time on the medications. It has been invaluable. Just an awesome, awesome experience. (nurse practitioner 7).
Discussion These results demonstrate that the majority of the 23 primary care teams identified several common barriers and facilitators as they integrated a pharmacist, including relationships, trust and respect; poor pharmacist role definition; lack of orientation and support from management; pharmacist personality and professional experience; pharmacist presence and visibility within the clinic setting; resources and funding; and value of the pharmacist role.
Study strengths and limitations The results of this qualitative study are trustworthy for the following reasons: the perspectives of three different health professions were included as data sources, four researchers with varied backgrounds analysed the data, an external auditor confirmed the findings and a member-checking exercise was included. This is the largest study that we are aware of that has investigated the barriers and facilitators that pharmacists experience when integrating into a primary care team and the only one that included a large number of rural teams. The results are potentially applicable to primary care teams in many countries, particularly those that provide primary health services to people living in both rural and urban communities. Researcher bias is a potential limitation of this study. Three of the four authors had previous experience practising within primary care teams; therefore they may have some degree of pre-existing bias, which could have influenced the data analysis. We attempted to mitigate the impact of this bias by using standardized interview templates, utilizing multiple data sources, de-identifying and transcribing interviews verbatim and involving a student analyst, an external auditor and a member-checking exercise. An additional limitation is that this study did not consider the perspectives of team members other than pharmacists, nurse practitioners and physicians.
Discussion of findings Some of our findings are consistent with the existing literature regarding the barriers that pharmacists face when attempting to integrate into primary care teams. Our study found that pharmacists consistently struggle with: (1) lack of pharmacist role definition, (2) limited support and mentorship (mostly from management) and (3) lack of adequate resources and space. Previous studies have also identified similar themes.[3,5–9] Fortunately these are three barriers that can be mitigated by proper planning and International Journal of Pharmacy Practice 2014, 22, pp. 292–299
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preparation. Health systems that integrate pharmacists into their primary care teams should consider the importance of strong managerial support during the integration phase to assist the pharmacists in developing a role definition and ensuring that adequate resources and space are available. Interestingly, some of our findings are inconsistent with the existing literature on this topic. Previous studies, performed primarily in urban settings, found that pharmacists struggle to develop a relationship of trust and respect with other team members, which is a major barrier to integration into the team.[3,5–9] Pharmacist interviewees in our study, performed primarily in rural settings, found that most pharmacists had a strong pre-existing relationship with other team members, which was a major facilitating factor to successful integration. This is a significant finding; our study appears to identify an integration challenge that is different for urban and rural primary care teams. Our study identified additional differences between the integration experiences of urban and rural primary care teams, which have not been previously identified in the literature. Urban teams were more experienced with interprofessional collaboration than rural teams, as many had previously integrated other (non-pharmacist) team members. However, this finding is difficult to interpret and should be confirmed in a larger study, considering only three of the teams were located in urban settings. Rural pharmacists also experienced greater challenges attending their weekly shifts in the primary care clinic (due to competing responsibilities with their primary community pharmacy employer), which resulted in a more sporadic presence on the team. The importance of individual pharmacist assertiveness and confidence that was identified in both the urban and rural teams in our study cannot be understated and is a key factor in overcoming many of the integration barriers previously noted. Although this theme has not been previously identified in primary care team integration literature, it has been discussed as a general barrier to pharmacist practice change.[11] Pharmacists who possess these personality traits may be better suited than others for working in a multidisciplinary primary care team setting.
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several common barriers and facilitators during the integration process. This is the first study of its kind to include primary care teams located primarily in rural communities and our findings suggest that the integration barriers in this setting are unique. Consequently, efforts to prepare for and support pharmacist integration into primary care teams must be tailored to reflect the type and size of community where the team is located. The findings of this study will be useful to health system managers and pharmacists who are attempting to integrate into a primary care team. The results may also be helpful to policy makers and researchers who may wish to develop practice guidelines or policy and procedure manuals based on these findings to standardize the integration process across an entire health region, province or country.
Declarations Conflict of interest The Authors have no personal or financial conflicts to report.
Funding This work was supported by the Interprofessional Health Collaborative of Saskatchewan, Kelsey Trail Health Region and the College of Pharmacy and Nutrition, University of Saskatchewan.
Authors’ contributions D. Jorgenson initiated the project, took a lead in design, methodology and data analysis, supervised the project, took the lead in writing the manuscript and reviewed the final draft of the manuscript. T. Laubscher and B. Lyons both contributed to the design, methodology and data analysis, assisted in writing the manuscript and reviewed the final draft of the manuscript. R. Palmer contributed to the design, methodology and data analysis and reviewed the final draft of the manuscript. All Authors state that they had complete access to the study data that support the publication.
Conclusion
Ethics information
Pharmacists who were recruited into the 23 primary care teams in Saskatchewan, Canada, were found to experience
This study was approved by the Behavioral Research Ethics Board at the University of Saskatchewan (BEH 10-085).
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