Lillian Cao, Karen Dahri, and Michael LegalTo cite: Cao L, Dahri K, Legal M. Characterizing the perceived need for advanced clinical pharmacy training in British Columbia. Can J Hosp Pharm. 2024;77(3):e3562. doi: 10.4212/cjhp.3562
ABSTRACT
Background
Currently in Canada there are limited opportunities for advanced clinical pharmacy training after a year 1 residency. Advanced training programs currently in existence are year 2 residencies, clinical Master’s degrees, and Fellowships.
Objectives
To characterize the perceived need for advanced clinical pharmacy training in British Columbia and to determine the desired educational competencies to be gained through advanced training.
Methods
Current pharmacy residents (academic year 2021/22) and residency graduates of the past 5 years (2017–2021), together referred to as early career pharmacists or ECPs, were surveyed. Provincial health authority pharmacy leaders who hire clinical pharmacists were also surveyed and invited to participate in key informant interviews.
Results
Eighty-four ECPs and 22 pharmacy leaders participated in the surveys (estimated response rates 26% and 35%, respectively). Eleven (13%) of the ECPs had already completed advanced clinical training, and an additional 24 (29%) planned to pursue such training within 5 years. Sixteen (73%) of the pharmacy leaders had experienced difficulties in filling advanced practice positions over the previous 3 years due to a lack of qualified applicants, and 21 (95%) believed that more advanced training positions should be offered. The majority of ECPs interested in advanced training (39/60, 65%) chose year 2 residency as their preferred program, and 20 (91%) of the pharmacy leaders agreed that British Columbia should offer year 2 residencies. Both ECPs and leaders rated clinical skills and knowledge as the most important educational competencies.
Conclusions
Pharmacy leaders expressed a need for more pharmacists with advanced clinical pharmacy training, and many ECPs were interested in pursuing such advanced training. Most respondents preferred the year 2 residency, with the most common goal being to improve clinical competencies.
KEYWORDS: advanced pharmacy training, needs assessment, year 2 residency, clinical Master’s degree, Fellowship, educational competencies
RÉSUMÉ
Contexte
Actuellement au Canada, les possibilités de formation avancée en pharmacie clinique après une première année de résidence sont limitées. Les programmes de formation avancée qui existent actuellement sont les résidences de deuxième année, les maîtrises cliniques et les programmes de bourses.
Objectifs
Caractériser le besoin perçu de formation avancée en pharmacie clinique en Colombie-Britannique et déterminer les compétences pédagogiques souhaitées qui doivent être acquises grâce à la formation avancée.
Méthodologie
Les résidents actuels en pharmacie (année universitaire 2021–2022) et les diplômés en résidence des 5 dernières années (2017–2021), appelés ensemble « pharmaciens en début de carrière » (« PDC »), ont été interrogés. Les responsables de pharmacie des autorités sanitaires provinciales qui embauchent des pharmaciens cliniciens ont également été interrogés et invités à participer à des entrevues à titre d’informateurs clés.
Résultats
Quatre-vingt-quatre PDC et 22 responsables de pharmacie ont participé aux sondages (taux de réponse estimés à 26 % et 35 %, respectivement). Onze PDC (13 %) avaient déjà suivi une formation clinique avancée et 24 autres (29 %) prévoyaient de le faire dans les cinq ans. Seize responsables de pharmacie (73 %) ont éprouvé des difficultés à pourvoir des postes de pratique avancée au cours des trois années précédentes en raison d’un manque de candidats qualifiés, et 21 (95 %) d’entre eux étaient d’avis que des postes de formation plus avancée devraient être offerts. La majorité des PDC intéressés par une formation avancée (39/60, 65 %) ont choisi la résidence de deuxième année comme programme de premier choix, et 20 responsables de pharmacie (91 %) convenaient que la Colombie-Britannique devrait offrir des résidences de deuxième année. Les PDC et les responsables ont évalué les compétences et les connaissances cliniques comme étant les compétences théoriques les plus importantes.
Conclusions
Les chefs de file des pharmacies ont exprimé le besoin de disposer d’un plus grand nombre de pharmaciens ayant une formation avancée en pharmacie clinique, et de nombreux PDC souhaitaient poursuivre une telle formation. La plupart des répondants préféraient la résidence de deuxième année, l’objectif le plus couramment cité étant l’amélioration des compétences cliniques.
Mots-clés: formation avancée en pharmacie, évaluation des besoins, résidence de deuxième année, maîtrise clinique, bourse, compétences théoriques
With the introduction of entry-level PharmD programs in Canada over the past decade, traditional postgraduate PharmD programs have been mostly eliminated across the country,1 leaving a gap in advanced clinical training opportunities after the completion of a year 1 (Y1) residency. Currently, the few advanced clinical pharmacy training programs in Canada consist of a limited number of year 2 (Y2) residencies (13 seats across 9 programs for the 2023/24 academic year),2 Fellowship programs, and 2 Ontario-based Master’s programs for advanced clinical pharmacy practice. These 2 clinical Master’s programs are mostly intended for graduates of a Y1 residency, in contrast to the Master’s programs in Quebec, which are considered equivalent to a Y1 residency. The number of seats for Fellowship and advanced clinical Master’s programs are not publicly available, as they depend on the availability of supervisors at any particular time.
Pharmacists with advanced training have a unique role to fill in the health care system. Advanced practice has been associated with high-quality patient care (which may include prescribing and physical examination), teaching, research, and leadership.3 Advanced practitioners may also be involved in consulting for health care providers inside and outside their facility, as well as planning and assessing treatment policies.4 Given that pharmacists with advanced training are essential in the health care system, it is important to assess pharmacists’ training needs in the era of entry-level PharmD programs.
In studies conducted in the United States over the past decade, pharmacy residents have reported various motivators for pursuing postgraduate training, including gaining knowledge, experience, and confidence5,6; gaining research skills6; preparing for the evolving role of pharmacists5; and meeting job requirements.7 Studies of pharmacy students in Canada and the United States over the same period have found similar results. Gaining knowledge and experience8,9 and the belief that residency would help the students achieve their career goals10 were common motivators. Conversely, financial constraints,5–9,11 jobs available without further training,5–8 family obligations,11 and concerns about succeeding in a challenging program8,11 were commonly cited as barriers or demotivating factors for residents and students. There is a lack of Canadian research related to post-Y1 advanced clinical pharmacy training, particularly since the shift to entry-level PharmD programs. Such information may inform the further development of advanced clinical pharmacy training programs.
The primary objective of this study was to characterize the perceived need for advanced pharmacy training in British Columbia, including the demand for such training and the desired types of training, among recent graduates of Y1 pharmacy residency programs and pharmacy leaders. The secondary objective was to determine the desired educational competencies arising from advanced pharmacy training and perceived barriers to pursuing advanced training.
This mixed-methods study, using surveys and semistructured key informant interviews, involved 2 groups of participants. The first group consisted of early career pharmacists (ECPs), who were defined as current pharmacy residents (i.e., in the 2021/22 academic year) or pharmacists who had graduated from a hospital residency or similar Quebec Master’s program within the previous 5 years (2017 to 2021 inclusive) and were working within one of British Columbia’s health authorities. The cut-off of 5 years was selected as it was felt that this group was most likely to be interested in pursuing additional clinical pharmacy training. The second study group consisted of pharmacy leaders working within British Columbia health authorities, whose responsibilities included the hiring of clinical pharmacists. Pharmacy leaders were included in the study to offer the perspective of stakeholders who would be evaluating the qualifications of pharmacist applicants when hiring for advanced positions in their workplace.
ECPs and pharmacy leaders who declined to provide informed consent or were unable to do so, for whatever reason, were excluded from participation.
A literature search was conducted, and the research objectives and results of the studies found were used to inform the development of the survey questions.5–11 Members of the study team created an initial draft of 2 surveys, 1 for ECPs and 1 for pharmacy leaders. Pilot testing of the surveys was conducted by 4 ECPs and 2 pharmacy leaders, respectively, to assess the face validity and clarity of the survey questions, and the surveys were revised according to their feedback. The survey for ECPs (Appendix 1) included questions about their awareness of and level of interest in advanced pharmacy training programs, the program types desired, the educational competencies desired, and the motivators and barriers for pursuing advanced training. The survey for pharmacy leaders (Appendix 2) asked for their perspectives on the demand for pharmacists with advanced training, appropriate educational competencies and program goals, and types of training programs that should exist in British Columbia. Both surveys included descriptions of the various types of training programs, as well as questions about participants’ work settings and prior training. Most questions were multiple choice, with some opportunities for free-text responses. Both surveys were hosted on the online platform Qualtrics (version February 2022).
Before the surveys were launched, the study team used the topics from the pharmacy leader questionnaire to create questions for the 30-minute semistructured interviews involving pharmacy leaders. These interviews were intended to allow for more detailed exploration of perspectives about the current job market for pharmacists with advanced training. The interviews were conducted by one of the investigators (L.C.) via Zoom video conferencing software (version 5.10.0).
An invitation to participate in the study was sent by email to residency coordinators and health authority pharmacy directors in British Columbia, who were asked to forward the invitation to their residents, staff pharmacists, and leadership teams. The contact information for residency coordinators and health authority directors is readily available, and we received permission from the research ethics board to contact them with this request. Because the surveys were anonymous, multiple leaders from a single site were allowed to participate. Pharmacy leaders were asked at the end of the survey to indicate their interest in participating in an interview.
The surveys were deployed in February 2022, and participants were given 1 month to complete the surveys, with a reminder email sent 1 week before the deadline. Signed informed consent was obtained for participation in the interviews but was waived for the surveys, as consent was implied by survey completion. The study was approved by the University of British Columbia Behavioural Research Ethics Board.
Descriptive statistics were calculated using Microsoft Excel spreadsheet software (version 16.59). Audio recordings of the interviews were transcribed verbatim for qualitative thematic analysis by a study team member. The transcriptions were verified by a second study team member (L.C.), then coded independently by these 2 team members using the software program NVivo (version 12.7.0; QSR International [now Lumivero]). Field notes were also reviewed. Coding differences were discussed until a consensus was reached, and a third study team member (K.D. or M.L.) was to be consulted if the 2 original members could not reach an agreement. Codes were then grouped to create themes, which were discussed among the entire study team.
Twenty-two pharmacy leaders and 84 early career pharmacists participated in the surveys (Table 1). The estimated response rates were 26% and 35%, respectively. We could not determine the number of people who received the study invitation, so the estimated response rates are based on estimates of the numbers of pharmacy leaders and ECPs in British Columbia. Most participants worked in the Lower Mainland region (which includes the Greater Vancouver area), but there was also representation from other parts of the province.
TABLE 1 Participant Characteristics
Among the ECPs, 75% (63/84) had completed a Y1 residency, and 13% (11/84) had completed some form of advanced clinical pharmacy training, specifically a post-professional PharmD for 9 individuals and a Y2 residency for 2 individuals.
Among the pharmacy leaders, most (86%) were from the Lower Mainland. In terms of practice setting, 59% were responsible for community hospitals and 50% for tertiary/academic hospitals, with 32% overseeing ambulatory care settings. A total of 6 leaders participated in 5 interviews; one of the interviews involved 2 participants from the same site, who chose to be interviewed together. Four of these participants worked in the Lower Mainland, and 2 participants worked in other regions of the province.
In early 2022, when this study was conducted, there were 4 Y2 residency positions available each year across 3 different programs in British Columbia.12 Of the ECPs who participated in our study, 13% (11/84) had already completed an advanced training program, 29% (24/84) had plans to pursue advanced training within the next 5 years, 43% (36/84) were undecided, and 15% (13/84) had no plans. Interest was similar between current Y1 residents and recent residency graduates, with 38% of residents (8/21) and 25% of recent graduates (16/63) planning for advanced training within 5 years.
Pharmacy leaders expressed demand for pharmacists with advanced clinical training to fill Clinical Pharmacy Specialist (CPS) positions. Most leaders (77%, 17/22) indicated that over the previous 3 years, they had found it difficult to fill vacant CPS positions, for which pharmacists with advanced clinical training are required.13 A similar proportion (73%, 16/22) reported having vacant CPS positions at some time in the past 3 years and needing to withdraw the position, downgrade the position, or leave it vacant for 3 months or longer, due to a lack of qualified applicants. More than half of the pharmacy leaders (64%, 14/22) were very or extremely concerned about the supply of pharmacists with advanced training in British Columbia, and 95% (21/22) believed that British Columbia needed more pharmacists with advanced training than were being trained each year. Just over half of the leaders (55%, 12/22) believed that British Columbia should produce 6 to 10 pharmacists with advanced training per year, and 32% (7/22) wanted 11 to 15 such graduates per year.
All of the ECPs who responded to our survey were aware of Y2 residencies, and 96% (81/84) were aware of post-professional PharmD programs, whereas 45% (38/84) and 49% (41/84) were aware of clinical Master’s and Fellowship programs, respectively.
When ranking different advanced pharmacy training programs by interest and desired educational outcomes, ECPs who were interested in or undecided about pursuing their first advanced training program (n = 60) were most interested in Y2 residencies, with 65% (39/60) selecting it as their first choice. The next most desired programs were specific clinical certifications (e.g., Board of Pharmacy Specialties [BPS] certification), clinical Master of Pharmacy programs, pharmacy Fellowships, post-professional PharmD programs, and others (e.g., specific continuing education opportunities, Master of Health Administration, Master of Business Administration). Eighty-two percent (27/33) of entry-to-practice PharmD graduates and 46% (12/26) of Bachelor of Pharmacy graduates selected the Y2 residency as their first choice. Many Bachelor of Pharmacy graduates selected the post-professional PharmD (19%, 5/26) or BPS certification (31%, 8/26) as their first choice.
Among pharmacy leaders, 68% (15/22) strongly agreed that the Y2 residency should be offered in British Columbia, whereas 23% (5/22) agreed with this statement, and only 9% (2/22) disagreed. The pharmacy leaders were also interested in clinical Master’s programs and Fellowships, with 73% (16/22) and 77% (17/22), respectively, agreeing that these programs should be offered in British Columbia. Almost half of the leaders (41%, 9/22) agreed that advanced practice pharmacists should pursue BPS certification, and 36% (8/22) agreed that there should be a Canadian equivalent to BPS certification. Three respondents commented that BPS certification does not include the practical experience or mentorship offered by other training programs.
Of ECPs who were interested in or undecided about pursuing their first or second advanced training program, 62% (40/65) were most interested in specialized training in a specific clinical area or setting; an additional 26% (17/65) were most interested in general training, and 12% (8/65) had no preference. Among pharmacy leaders, 73% (16/22) supported the expansion of both specialized and general training programs in British Columbia, 18% (4/22) supported only the expansion of general programs, 1 person supported only the expansion of specialized programs, and 1 person believed that neither type of program needed further expansion in British Columbia. Three leaders commented that general training would confer generalizable skills and allow graduates to work in various practice settings, which would increase flexibility for hiring.
ECPs who were interested in or undecided about pursuing advanced training were asked to select up to 5 specialty areas in which they would be interested in training, and pharmacy leaders were asked to choose specialty areas according to the current and future needs of their departments and patients. Internal medicine and critical care were highly desired among both groups (Figure 1), and ECPs also favoured infectious diseases/antimicrobial stewardship and cardiology.
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FIGURE 1 Specialty areas desired for advanced training, based on top 5 specialties selected by each participant. AMS = antimicrobial stewardship, HIV = human immunodeficiency virus. “Other” choices by early career pharmacists were nephrology, palliative care, informatics, and surgery. “Other” choices by leaders were neonatal intensive care/perinatal care, combination of mental health/addictions/opioid stewardship. | ||
Pharmacy leaders and ECPs somewhat agreed or strongly agreed that various clinical skills and knowledge were desired educational competencies and motivators for pursuing advanced training. Specifically, these skills included increasing or improving pharmacotherapeutic knowledge, skills in patient assessment, critical appraisal and evidence-based decision-making, and management of complex patients (Figure 2). Acquiring specific job qualifications was also a major motivator for ECPs. Leaders also valued research skills, teaching skills, navigating team dynamics within the health care team, and developing as a leader in pharmacy practice.
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FIGURE 2 Desired educational competencies and motivators for pursuing advanced pharmacy training. ACPR2 = Accredited Canadian Pharmacy Resident year 2, ECPs = early career pharmacists who had completed any advanced clinical pharmacy training or were interested in or undecided about pursuing advanced training within the next 5 years. | ||
“Financial considerations” was the most agreed-upon barrier to pursuing advanced clinical pharmacy training among ECPs (81%, 68/84). In addition, 74% of ECPs (62/84) agreed that the time taken from other life priorities was a barrier. Seventy-six percent (16/21) of the ECPs who lived outside of the Lower Mainland agreed that a specific program of interest not being offered locally was a barrier, compared with 43% (27/63) of pharmacists living within the Lower Mainland. Of note, all currently available advanced training programs in British Columbia operate only within the Lower Mainland.
Through thematic analysis, 68 codes were created, and 8 themes were derived. These themes and representative quotes are presented in Table 2. The third reviewer did not need to be consulted in the development of codes and themes, as there was full agreement in the initial coding.
TABLE 2 Thematic Analysis of Key Informant Interviews
All 6 interview participants expressed that pharmacists with advanced training have qualities and responsibilities that make them valuable members of the health care team. Although 1 participant had not experienced any difficulty in hiring advanced practice pharmacists in recent years, all participants recognized that there is now an increased demand for and a lack of supply of pharmacists with advanced training in British Columbia. Three leaders expressed confusion about the various training programs currently available in Canada, and all 6 cited the variable quality and outcomes produced by these programs as a consideration when hiring for advanced practice positions. Four participants expressed an interest in exploring different training models, and 5 preferred general training programs over specialized programs because they provide transferable skills and flexibility for hiring purposes. Two leaders suggested that specialized programs could be pursued after completion of a general program. All participants agreed that advanced patient care skills and research were key educational competencies for advanced training programs, whereas they did not consistently agree upon the value of teaching and leadership skills in such programs. Two leaders commented that although it is important to develop leadership skills, they should be secondary to clinical competencies. One mentioned that pharmacists who wish to work as administrators or managers could also consider specific leadership training programs.
The results of this study demonstrate that pharmacy leaders in British Columbia were concerned about a lack of pharmacists with advanced training. Many ECPs were interested in pursuing advanced training, which suggests that the lack of supply is not due to a lack of interest among pharmacists. Year 2 residency programs were viewed favourably by leaders and pharmacists alike, but there were differences in the preference for general versus specialized training, and the specialty areas that were prioritized. Skills and knowledge in research, teaching, leadership, and, in particular, clinical practice, were seen as important educational competencies and motivators for pursuing advanced clinical training.
As described in the interviews with pharmacy leaders and reflected in the desired educational competencies, graduates of advanced clinical pharmacy training can make significant contributions to patient care, as well as to pharmacy departments and health care systems. Pharmacy leaders most often suggested increasing the number of advanced training graduates in British Columbia to 6–10 per year, but as the demands on health care systems continue to increase, the need for pharmacists with advanced clinical pharmacy training will likely increase further. Canada will need to develop strategies to accommodate the enrolment of more learners in advanced clinical training.
Compared with pharmacy leaders, ECPs were most interested in Y2 residencies and had a lower interest in clinical Master’s and Fellowship programs. Clinical Master’s and Fellowship programs do not currently exist in British Columbia, and although the various program models were explained in the survey itself, the lack of awareness of these programs among ECPs may have affected these results. It is also possible that Fellowships would be more relevant for pharmacists who have already done some advanced training, or that Y2 residencies were more favoured because of their shorter duration (1 year vs 2 years) and lesser financial impact (receiving a stipend vs paying tuition), given that pharmacists considered both time and money to be important barriers to pursuing advanced training.
The barriers and motivators for pursuing advanced training were similar to those reported in studies of pharmacy residents in the United States5–7 and pharmacy students in Quebec8 and the United States.9–11 However, ECPs placed a slightly lower value on competencies relating to research, teaching, and leadership than did pharmacy leaders. It may be that ECPs are more focused on achieving the advanced clinical practice outcomes and may not be familiar with the full extent of an advanced practitioner’s nonclinical duties. It would be interesting to further explore the reasons for this difference, as it may relate to the professional identities of ECPs and their understanding of the expectations of advanced practitioners.
The reasons for ECPs’ preference for specialized over general advanced training should also be further explored and considered during the development of advanced training programs. The direction of Y2 residency training in Canada has previously been debated,14 but the current Y2 residency accreditation standards focus on advanced pharmacy practice in a specific area of practice rather than general practice.15 Many of the high-priority specialty areas selected by pharmacy leaders in this study, such as psychiatry, addiction medicine, emergency medicine, and ambulatory care, reflect areas of expansion and current mandates set by the government.16 Advanced pharmacy training programs will need to consider balancing current health care priorities and pharmacists’ interests, while offering enough flexibility and transferable skills to allow pharmacists to work in other areas if needed.
This study may have been limited by volunteer bias, in that respondents may have been more interested in advanced training than were nonrespondents. In addition, the response rates were low, and could only be estimated. The majority of pharmacy leaders who participated had some form of advanced training beyond Y1 residency, and therefore may have been more inclined to support advanced pharmacy training. The 2 leaders who were interviewed together could have influenced each other’s responses, but we believe that their combined input was still valuable. Pharmacy practice and job requirements vary across Canada, so the results may not be directly applicable to other provinces. Despite these differences, the need for advanced pharmacy practitioners across Canada will continue to grow, so further study about the reasons for ECPs’ preference for specialized or general training and their understanding of the nonclinical roles of advanced practitioners is warranted.
In this study, pharmacy leaders reported a need for more pharmacists with advanced clinical training after a Y1 residency, and many ECPs described an interest in pursuing such training. Most leaders and ECPs favoured a Y2 residency as the method for advanced training, although there was limited awareness and understanding of the other types of advanced training programs. Study participants agreed that developing competencies in clinical practice, research, teaching, and leadership were important outcomes of advanced training. These findings may help inform the development of additional advanced clinical training opportunities in British Columbia and in the rest of Canada.
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16 Ministry of Health 2022/23 – 2024/25 service plan. Government of British Columbia, Ministry of Health; 2022 Feb [cited 22 Jul 17]. Available from: https://www.bcbudget.gov.bc.ca/2022/sp/pdf/ministry/hlth.pdf
Address correspondence to: Dr Michael Legal, Lower Mainland Pharmacy Services, 1081 Burrard Street, Vancouver BC V6Z 1Y6, email: mlegal@providencehealth.bc.ca
Competing interests: For activities unrelated to the study reported here, Karen Dahri has received a Health Innovation Funding Investment Award from the Canadian Institutes of Health Research, a grant from the UBC Students as Partners Fund, and a Seed Grant from the BC Ministry of Health; consulting fees from TRC Healthcare (for contract writing); honoraria from Pear Tree Healthcare, the Association of Faculties of Pharmacy of Canada, the University of British Columbia CPPD, and BC Primary Care Pharmacists; and travel support from the Canadian Society of Hospital Pharmacists to attend the National AGM. No other competing interests were declared.
Funding: None received.
Acknowledgements: The authors thank Armita Shadgan for her help in transcribing and coding the interviews.
Submitted: November 16, 2023
Accepted: March 7, 2024
Published: August 14, 2024
© 2024 Canadian Society of Hospital Pharmacists | Société canadienne des pharmaciens d’hôpitaux
Canadian Journal of Hospital Pharmacy, VOLUME 77, NUMBER 3, 2024
