Impacts on practice
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In Qatar, pharmacy practice is rapidly advancing and several extended clinical pharmacy services are now available in institutionalised healthcare settings.
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However, limited evidence is available to explore how key health-related stakeholders perceive these services including the potential development and implementation of new patient-centred pharmacist’s roles.
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Findings of this research could facilitate cognitive pharmaceutical service development and better provision of patient-centered care, which could be transferrable to other countries, especially from the context of the Middle East.
Introduction
Aim of the study
Ethics approval
Methods
Study design
Setting
Inclusion and exclusion criteria
Sampling and sampling approach
Development of interview guide
Data generation
Data analysis
Results
Stakeholders recruitment
Stakeholders’ category | Setting: number of participants* |
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Academic leaders | Medicine: 2 Pharmacy and Pharmacy technician: 5 Nursing: 2 |
Healthcare policy developers | Primary care/Community: 1 Secondary care: 1 Tertiary care: 2 Corporate/Ministry: 2 |
Medical practice leaders | Primary care/Community: 1 Secondary care: 3 Tertiary care: 5 Corporate/Ministry: 1 |
Pharmacy practice leaders | Primary care/Community: 3 Secondary care: 1 Tertiary care: 3 Corporate/Ministry: 1 |
Nursing practice leaders | Secondary care: 1 Tertiary care: 5 Corporate/Ministry: 3 |
Patient safety advocates | Primary care/Community: 1 Secondary care: 1 Tertiary care: 4 |
Key themes that emerged from the interviews
CFIR domain | CFIR constructs | Key themes | Illustrative quotes | |
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Innovation characteristics of the intervention being implemented into a particular organisation | Evidence strength and quality Perceptions on quality and validity of evidence supporting the innovation | The expansion of the numbers of clinical pharmacist within HMC was considered to be an indication of effectiveness, efficiency and acceptability | I don’t really have the statistics but the number of clinical pharmacists now in Hamad [Hamad General Hospital] is really big. We started only with 10. Today maybe we are talking about 60–70 pharmacists. So why did we have this expansion if the role is not really important? Academic Leader 3 | |
Outer setting i.e. economical, political, and social context within which an organisation resides | Needs and resources Extent to which patient needs are known and prioritised | There was a feeling that the general public was not aware of the skillset and roles of pharmacists and that this could act as a barrier to expanding scope of practice | Patients are barriers because they don’t really value the role of the pharmacist… Anytime you speak about pharmacist, shop keeper image pops to their mind. Academic Leader 1 | |
Inner setting i.e. structural, political, and cultural context through which implementation process will proceed | Networks and Communications Nature and quality of networks and communications within the organisation | There were mixed views on the degree of integration of the pharmacist within the multidisciplinary team and therefore the communication networks in operation | I have really good relationship here with my pharmacist as well. We have dialogue with regard to if there is any issue with nurses and administration for instances as well. Nursing Practice Leader 3 In the psychiatric hospital, the pharmacist was always in a little back room. And not on the floor at all. Academic Leader 8 | |
Trust, relationships and communication were thought key to the anticoagulation clinic | From the beginning we had very strong and very positive relationship with the medical directors…They are trusting me a lot. Building the trust and having good relationships with the team will facilitate everything. Pharmacy Practice Leader 6 | |||
Culture Norms, values and basic assumptions of the organisation | Despite the positive developments in clinical practice in HMC, there was still the view that pharmacists were generally undervalued | I suspect that there is a traditional view about the dispensing type pharmacist rather than that understanding of them having the kind of clinical background knowledge as well. Nursing Practice Leader 1 | ||
One factor thought contributing to this lack of awareness and lack of value was the large number of expatriated health professionals | We have physicians from very different backgrounds and parts of the world and all the different cultural heritages and there are sometimes adjustments needed to understand that other professional groups are just as valuable as their professional group is. Medical Practice Leader 1 | |||
Implementation climate Absorptive capacity for change | Tension for change | Almost all acknowledged that while clinical practice had developed, there was potential for further developments | Definitely there is a lot of room for improvement. There has been quite a lot of changes to the pharmacist role but there is a lot of space for further improvement. Academic Leader 1 | |
Relative priority | Developments in clinical practice were felt to align to the Qatar National Vision hence were considered beneficial | …It will relieve the physician time a little bit… I think this is a very important part to be considered in the priorities of the national health over here. Academic Leader 6 | ||
Readiness for implementation Tangible and immediate indicators of organisational commitment to implementation | Leadership engagement | The support of the pharmacy leaders was considered a main influential factor in clinical development | I think the Director of Pharmacy, she is really a pioneer in introducing this programme [clinical pharmacy] into Women’s Hospital. This started I think seven years ago and now we have very good clinical pharmacists who are eager to work and to do further responsibilities. Medical Practice Leader 3 | |
Available resources | There was a perception that the current number of skilled clinical pharmacists was a barrier to further service development | You may have enough [pharmacists] but you need specific skills, you need people with clinical practice, competencies and clinical background. Qatar lacks the number of clinically qualified and skilled professionals. Pharmacy Practice Leader 6 | ||
This was noted to be a particular issue during times of staff absences | If you have only one pharmacist covering the service, it gets difficult sometimes when they need to be on leave for conference or vacation. Academic Leader 6 | |||
Characteristics of individuals Involved in enacting the intervention | Knowledge and beliefs about the innovation Individuals’ attitudes and value placed on innovation | There was general agreement that, given their education and training, pharmacists should be maximising their input to patient care | When I look at the education of pharmacists, I think they should be working to full scope… I think by maximising their scope, it is better for the system and it is better for the patients. Academic Leader 9 | |
Self-efficacy Individual beliefs in their own capabilities | There was recognition that while some pharmacists were motivated to develop their clinical practice, there were many likely to be less so | Pharmacy like any other profession, you will find the group of people who are really motivated to do more work, love the profession, would like to serve more …and other pharmacists who are still [not]. Academic Leader 3 | ||
Notably those involved in establishing the anticoagulation clinic were highly committed despite their existing workload | The people I had on the team were very committed and enthusiastic to the project despite being already overwhelmed with their original work. They were working very hard and they were very proud. Pharmacy Practice Leader 6 | |||
Other personal attributes Broad construct to include other traits such as motivation, value, competence, capacity and learning style | The personal development of the pharmacists in Qatar was appreciated and thought related to their extensive training, and rigid recruitment and licensing standards | I think they improved a lot from maybe 17–18 years ago. There is a lot of improvements in pharmacy practice and we appreciate that there is this change and improvement. Healthcare Policy Leader 6 We have a very tight process for recruiting pharmacists so we are looking for quality first. So we have very good quality pharmacists with us. Pharmacy Practice Leader 2 | ||
There was, however, recognition that practice in community pharmacy centred on dispensing | The role that is played by the community pharmacists in Qatar is still the traditional role in which they just sell medications and maybe provide some recommendations or counselling from time to time. Academic Leader 3 | |||
Process of implementation | Planning Degree to which a scheme or method for implementation are developed in advance | When developing and implementing clinical pharmacy services, there were several key factors for successful implementation such as the need for communication with other health professionals | From the beginning, before we started anything, we communicated in a very nice way with the physicians… So none of the physicians felt threatened… We were very scientific, very friendly with them. Pharmacy Practice Leader 6 | |
Establishing clear guidelines during the development of the anticoagulation clinic and continuous monitoring after implementation were cited as being important | We developed the guidelines for all of the anticoagulants and antiplatelets and we decided on and approved the workflow as well… And then we started and we continued monitoring the work, take feedback from physicians and from patients to improve the process. Pharmacy Practice Leader 6 | |||
Engaging (Key stakeholders) Attracting and involving appropriate individuals in implementation and use of innovation | The need to engage the right key stakeholders as part of implementation was highlighted | And the consultant here was very happy about this idea and he supported it especially since he came from Canada and he knew how the system was running and he supported this. Otherwise it wouldn’t have worked. Patient Safety Advocate 4 |
Innovation characteristics
The clinical pharmacists’ role has developed quite significantly in recent years like, for example, in [Name] Hospital there is the anticoagulation clinic that is run by pharmacists.Academic Leader 1
We call it the anticoagulation clinic where the clinical pharmacists are on the front line, meeting the patients…checking the INR and then adjusting the dose, so they make the decision.Medical Practice Leader 5
Also in clozapine clinic in mental health, there is a direct contact with the patient for monitoring the side effects and recording if require changing the dose…Pharmacy Practice Leader 4
… it will give you more confidence in what you are doing, your clinical skills, would help increase the trust that is given to the pharmacists and maybe help them gain more roles in the future.Academic Leader 6
Generally our feedback with like warfarin clinics and such that we have is very positive… patients don’t wait for months to get an appointment.Healthcare Policy Leader 2
The most important advantage I see from the side of physicians is that it will free their time to do more skilled work.Academic Leader 6
We can see definitely that the anticoagulation outcomes have been better with those monitored by pharmacists.Academic Leader 6
I think they are efficient. They keep continuous education so they have weekly sessions so they are updating themselves.Healthcare Policy Leader 1
It is a condensed course that focuses on anticoagulation, how to dose, what are the guidelines available and the pathophysiology.Pharmacy Practice Leader 3
They don’t have it in primary healthcare, the warfarin clinic. But if the volume of patients increase, it can be in primary healthcare, why not?Medical Practice Leader 5
Inner setting
The public sector I think it is more structured because they are accredited… but in private, nothing. They don’t have the policies, they don’t have guidelines, they are more or less looking for money.Healthcare Policy Leader 3
It is still completely physician driven. There is still a hierarchy.Academic Leader 8
In the cancer centre they have a very intimate collaboration with them [physicians] and communication and they really are valued [as an] equivalent member of the team. There is no hierarchy.Medical Practice Leader 1
As for practice, hospitals are better than community since community is not well developed because it lacks assessment and clinical practice.Pharmacy Practice Leader 6
In primary healthcare centres, they are developing now, they are in a better position if you compare them to the community pharmacists. But I have to say that still they need to work more on themselves.Academic Leader 3
I left the UK thinking that I had a very good pharmacy service. I have come to Qatar and there is a better pharmacy service here in my view.Healthcare Policy Leader 5
The level of automation that goes into packages like Cerner is clearly already demonstrating that pharmacists can take on a more assertive role on behalf of the patients to protect their safety…Healthcare Policy Leader 4
At the beginning, when they don’t have much experience with it, they may be a little bit suspicious… but then after a while, after they saw our abilities and how really the patients have been stable and monitored appropriately, I think they got more and more confident.Academic Leader 6