Canadian Pharmacists Journal - May/June 2019 - 149

COMMENTARY
EDITORIAL
advanced patient care activities. Research has demonstrated
that payment for services does not consistently lead to
improved uptake of advanced patient care activities.13
At what point do some practitioners lose their enthusiasm
for providing optimal care? Lack of time due to workload and
lack of confidence have been foremost in pharmacists' defense of
maintaining practice status quo.1,9 It may also be a culmination
of damaging experiences causing a loss of confidence and/or an
uninspiring work environment. In a recent publication, employer
support to offer advanced services and perceived utilization of
clinical skills was linked with professional satisfaction.14 Barriers
shown to impede job satisfaction were regulatory changes and
reduced autonomy in practice.14 Nationally, regulatory barriers
are being broken down, though they remain variable across the
country. Pharmacists have the ability to ensure continuity of care
and prescribe for ambulatory conditions ("minor ailments")
and/or chronic disease management, increasing their autonomy
in practice. We acknowledge that major steps have been made
in the right direction through legislation and payment models;
however, we know that there is still work to be done.
While some pharmacists are influenced by positive role
models and mentors in practice, others have negative experiences. There may be a disconnect between the idealized model
of pharmacy and actual practice, where pharmacists see a
mismatch between what they have been taught and what they
see and experience in practice. This may lead to confusion
over their identity as professionals.9,15 An apathetic colleague
or manager can also have a negative effect on whether a pharmacist considers evolving roles as his or her career progresses.
To move forward, pharmacists need to be confident in making decisions; however, the literature reveals that they are often
hesitant to make any clinical decisions.11,12 When pharmacists
defer clinical decision making due to a perceived lack of information, they often refer the patient to a physician. Not making
a clinical decision in this case is still a decision, a decision to
avoid responsibility for care and potentially put the patient at
risk.11 This behaviour has been called "buck-passing." We are not
encouraging pharmacists to practise outside of their knowledge,
skills and abilities, as this poses a risk to the patient. We assert
that situations where pharmacists have access to information
and the competence to make a decision but do not engage in
providing the necessary care are cases of professional abstinence.
Recent work has shown that there are 9 facilitators for practice change ("the 9 Ps"), 3 of which are pertinent to professional abstinence: peer referencing, practice and professional
identity.16 Pharmacists who reference their practice with a peer
can shape and redirect behaviours promoting practice change.

The opportunity to practise new skills in a safe environment
and the selection of a simple initial case to apply the skills can
help build confidence and reinforce positive behaviour. Having the opportunity to construct responsible and accountable
aspects of professional identity early in practice through experience and mentoring can also help foster and model development of an advanced patient care practice.
What can individual pharmacists do? Find peers and
shadow them. Find mentors who have grown their knowledge,
skills and abilities through varying experiences. Precept students and reciprocally learn from them. Reconstruct the narrative that we do not know enough or have enough information.
Make and influence simple care decisions that positively affect
patients and be accountable for the outcomes. Amass competence and confidence through repetition. There are many system and policy impediments, but by slowly changing what we
do, how we think and how we engage in patient care, pharmacists will continue to evolve along with practice.
If we do not disrupt what we have defined as professional
abstinence, pharmacists will be deprived of the opportunities provided through education, experience and legislation.
Our professional identity will be at risk of being dismantled.
Instead, focus on growth and adapting together so all Canadians can experience exceptional care from every pharmacist
they encounter.

Alternate vignette
Patient: I'm here to pick up my methotrexate and
hydroxychloroquine.
Assistant: Here they are, but can you just wait a couple of
minutes? The pharmacist wanted to talk to you quickly.
Patient: Okay.
Pharmacist: Hi. I just wanted to let you know you were
out of folic acid refills, but I extended the prescription
so it matched up with your refills for methotrexate. I
checked your blood work and it all looks good. The next
time you are in to see your rheumatologist, you'll need to
get some more refills for that.
Patient: Oh, that is great. I feel just terrible if I don't
take the folic acid, so this is perfect. I'll be seeing
my rheumatologist in 3 months, so will get refills of
everything then. Thank you! ■

From Alberta Health Services (Biggs) and the Faculty of Pharmacy and Pharmaceutical Sciences (Hall, Charrois), University of Alberta, Edmonton, Alberta. Contact
Theresa.charrois@ualberta.ca
ORCID iD: Theresa L. Charrois

https://orcid.org/0000-0002-6691-6295

C P J / R P C * M ay / J u n e 2 0 1 9 * V O L 1 5 2 , N O 3

149

https://www.orcid.org/0000-0002-6691-6295

Canadian Pharmacists Journal - May/June 2019

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