Jonathan Penm
The COVID-19 pandemic has stretched health care systems and exacerbated problems in areas that were already under pressure. To relieve this pressure, health care systems are looking for ways to expand pharmacists’ scope of practice. One approach would be to increase both the utilization of pharmacist prescribing and the number of independent clinical pharmacist practitioners. Although pharmacist prescribing has been commonplace in some provinces for more than a decade,1 only recently has it been implemented in others, such as Ontario.2 Internationally, Australia has also recently adopted pharmacist prescribing for minor ailments (e.g., urinary tract infections).3 Utilizing these skills is more common among pharmacists in community and outpatient settings. However, such roles have had less uptake in the hospital pharmacy setting. Correspondingly, expansion of the scope of pharmacist practice appears less clear in the inpatient hospital setting than in the community or outpatient setting.4
In this issue, Almawed and others5 report on the proportion of patients for whom inpatient pharmacists with additional prescribing authorization (APA) prescribe at discharge. Prescribing at discharge by hospital pharmacists is a fairly novel concept. A recent randomized trial in an Australian geriatric medical ward showed that pharmacists who prescribed using handwritten prescriptions had fewer patients experiencing at least one medication error at discharge relative to conventional handwritten discharge prescribing (29% versus 95%, p < 0.0002).6 A similar though smaller benefit was seen with digital prescriptions (62% versus 100%, p = 0.005).6 Given these benefits, Almawed and others conducted a cross-sectional web-based survey of APA inpatient pharmacists, specifically asking about their activities at discharge. The authors found that fewer than half of APA pharmacists prescribed at discharge. They also identified the top three enabling factors for pharmacists who did prescribe at discharge: a supportive care team (71.4%), competence in the particular area of practice (54.9%), and desire to deliver more efficient care (51.6%).5 From these results, it appears that the external environment, including availability of support, is perceived as having a greater influence on pharmacist prescribing at discharge than internal motivators.
Pharmacists’ comfort with prescribing and the pathway to becoming independent clinical pharmacist practitioners are also explored in this issue by Parmar and others.7 These authors define a clinical pharmacist practitioner as “a pharmacotherapy expert who practises independently at their full scope, conducts thorough patient assessments, responds to consultations, monitors and adjusts drug therapy, provides education to patients and colleagues, and may prescribe independently or in collaboration with other health care professionals.” During 13 interviews with Canadian clinical pharmacist practitioners (mainly hospital pharmacists; n = 8), strong mentorship, internal motivation, and endorsement of diverse professional pathways were identified as important factors that led interview participants to become clinical pharmacist practitioners. In particular, they identified mentorship as a critical factor that helped shape their practice. Similar to the previously mentioned study,5 the external environment and appropriate support were seen as the most crucial factors in the development of a clinical pharmacist practitioner.7
One possible way to develop supportive external environments is through a unified national credentialling system that signifies high-level pharmacy practice in Canada. Such a process has been explored in Australia and the United Kingdom, where frameworks for advanced pharmacy practice have been developed.8,9 In Australia, such frameworks have been supported by the Society of Hospital Pharmacists of Australia’s Advanced Training Residencies.10 These residencies offer an accredited pathway for specialty development in a specific practice area or specialty in accordance with Stage 2 (the “Consolidation” level) of the National Competency Standards Framework for Pharmacists in Australia.11 Such residencies have been available since 2020 and are ideal for practitioners with 3 to 7 years of foundational hospital pharmacy experience.10 Similar structured pathways could be considered for Canada to ensure that pharmacists wishing to develop as clinical pharmacist practitioners are supported on their journey.
Parmar and others7 also identified role uncertainty within the pharmacy profession itself as a major barrier for the advancement of the profession. They highlighted that the future vision for pharmacists was unclear or even lacking in Canada.7 This concern is not new and indeed has been expressed by pharmacists around the world for many years. For example, in response to this concern, the Hospital Pharmacy section of the International Pharmaceutical Federation (FIP) hosted the Global Conference on the Future of Hospital Pharmacy back in 2008 in Basel, Switzerland.12 The FIP is the global body representing over 4 million pharmacists, pharmaceutical scientists, and pharmaceutical educators through its more than 150 national pharmacy organization members.13 At the 2008 conference, the FIP’s Hospital Pharmacy section developed the Basel Statements, a set of consensus statements reflecting a unified global vision of hospital pharmacy practice.12 The statements have a strong focus on medication safety and describe hospital pharmacists’ involvement in procurement; their influences on prescribing, preparation and delivery, administration, and monitoring of medicine use; and the role of human resources, training, and development.12,14 The Basel Statements have been updated regularly to reflect current practice,14 with the latest revision under discussion in September 2023 at the FIP Brisbane Congress.15 I encourage all hospital pharmacists to contribute to these updates and to ensure that learnings from your country are heard and recognized around the world.15 Although the Canadian Society of Hospital Pharmacists is not an organizational member of the FIP, it has already contributed toward revision of the Basel Statements. From this work, I believe pharmacists around the world have more commonalities than differences, and constant reflection on international practices will ensure that our patients receive the best care that pharmacists can provide.
1 Yuksel N, Eberhart G, Bungard TJ. Prescribing by pharmacists in Alberta. Am J Health Syst Pharm. 2008;65(22):2126–32.
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2 Expanded scope of practice: Minor ailments 2023. Ontario College of Pharmacists; [cited 2023 Aug 4]. Available from: https://www.ocpinfo.com/practice-education/expanded-scope-of-practice/minor-ailment/
3 UTI program now permanent in Qld [news release]. Pharmacy Guild of Australia; 2022 Oct 12 [ cited 2023 Jul 1]. Available from: https://www.guild.org.au/news-events/news/forefront/v12n10/uti-program-now-permanent-in-qld
4 Poh EW, McArthur A, Stephenson M, Roughead EE. Effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review. JBI Database System Rev Implement Rep. 2018;16(9):1823–73.
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5 Almawed R, Shiu J, Bungard T, Charrois T, Gill P. Pharmacist prescribing at inpatient discharge in Alberta. Can J Hosp Pharm. 2023;76(4):275–81.
6 Finn S, D’arcy E, Donovan P, Kanagarajah S, Barras M. A randomised trial of pharmacist-led discharge prescribing in an Australian geriatric evaluation and management service. Int J Clin Pharm. 2021; 43(4):847–57.
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7 Parmar R, Legal M, Dahri K, Wilbur K, Shalansky S, Partovi N. Pathways to developing clinical pharmacist practitioners: is there a better way forward? (Path-CPP). Can J Hosp Pharm. 2023;76(4):302–8.
8 The RPS advanced pharmacy framework (APF). Royal Pharmaceutical Society; 2013 [cited 2023 Aug 4]. Available from: https://www.rpharms.com/resources/frameworks/advanced-pharmacy-framework-apf
9 Jackson S, Martin G, Bergin J, Clark B, Stupans I, Yeates G, et al. An advanced pharmacy practice framework for Australia. Pharmacy (Basel) 2015;3(2):13–26.
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10 Advanced training residencies. Society of Hospital Pharmacists of Australia; 2023 [cited 2023 Aug 4]. Available from: https://www.shpa.org.au/workforce-research/residency/advanced-training
11 National competency standards framework for pharmacists in Australia. Pharmaceutical Society of Australia Ltd; 2016 [cited 2023 Aug 4]. Available from: https://www.psa.org.au/wp-content/uploads/2018/06/National-Competency-Standards-Framework-for-Pharmacists-in-Australia-2016-PDF-2mb.pdf
12 International Pharmaceutical Federation. The Basel Statements on the future of hospital pharmacy. Am J Health Syst Pharm. 2009;66 (5 Suppl 3):S61–6.
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13 Who we are [webpage]. International Pharmaceutical Federation; 2023 [cited 2023 Jul 1]. Available from: https://www.fip.org/about
14 Vermeulen LC, Moles RJ, Collins JC, Gray A, Sheikh AL, Surugue J, et al. Revision of the International Pharmaceutical Federation’s Basel Statements on the future of hospital pharmacy: from Basel to Bangkok. Am J Health Syst Pharm. 2016;73(14):1077–86.
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15 Basel Statements: the future of hospital pharmacy practice. International Pharmaceutical Federation; 2023 [cited 2023 Jul 1]. Available from: https://www.fip.org/basel-statements
Competing interests: For activities unrelated to this editorial, Jonathan Penm has received a grant from the Medical Research Future Fund (Australian Government). He has also received consulting fees (paid to the University of Sydney) from the Hospital Pharmacy Section of the International Pharmaceutical Federation. No other competing interests were declared.
Canadian Journal of Hospital Pharmacy, VOLUME 76, NUMBER 4, Fall 2023