Millcroft Hospital Pharmacy Leadership Conference - June 1 - 3, 2007

Theme:Scope of Pharmacy Practice - What Will the Future Look Like?

Neil Johnson invited participants to take a forward-looking view of the scope of practice, thinking far into the future as well as one or two years out. The day’s presentations and discussions were structured to present an overview of trends in health care and its various professions. When a nucleus of pharmacy leaders develops a view of the future, it will be possible to begin to develop a plan on how to get there.

Johnson expressed his hope that the meeting would provide some “takeaway ideas” to implement in the shorter term as well as “broader strokes” for the future. “Moving the profession forward is about the leaders in this room and where we move together at the 50,000 foot level, but also from a basic tactical level.”

He stressed the importance of ensuring that the vision is shared with staff and senior organizational leaders. It is crucial not to get “too far out in front of those we lead, in case we start to look like the enemy,” he said. “Tools that keep us all together will be the most effective way of implementing the important changes that we see ahead.”

Scope of Practice–Views of Other Professions

Dr. Andrew Gomori, BSc, MD, FAAN, FRCPC
Associate Professor, Section of Neurology, Department of Medicine
University of Manitoba
Winnipeg, MB

Dr. Andrew Gomori observed that medicine and pharmacy traditionally have been equally involved in managing patient health, but have had little direct interaction with each other. Physicians provide diagnosis and disease management, while pharmacists aid in optimizing drug therapy after diagnosis. Improving communication and strengthening the relationship between the two professions will ultimately lead to improved patient care and outcomes.

Health care is in an era of rapid progress and evolution, Dr. Gomori said. Changes to the pharmacist role parallel changes in the broader health care system and are vitally important. Noting that the role of pharmacy is frequently misunderstood by the public, he presented some historical background. Clinical pharmacy was introduced as far back as the 1960s. Today’s pharmacists, particularly hospital pharmacists, are drug experts who work in collaboration with patients, physicians, and other health care providers to optimize medical management and care.

Today, the scope of practice for pharmacists varies across the country, Dr. Gomori said.

•	In Alberta, pharmacists who have completed a continuing education and orientation program are permitted to prescribe Schedule 1 drugs and administer intra-muscular and subcutaneous injections.
•	In British Columbia, pharmacists may prescribe Schedule 4 medications within approved guidelines.
•	In Quebec, pharmacists with required certification may initiate or adjust medication and provide emergency contraceptives.
•	In Manitoba, Continued Care prescriptions allow pharmacists to renew or refill prescriptions without contacting a physician, and dispense emergency contraceptives.

Those who oppose an expanded role for pharmacists are primarily concerned with a potential conflict of interest, Dr. Gomori noted. It is important to ensure that pharmacists do not receive any financial benefit from the drugs they prescribe.

A 2006 report on consumer perceptions, published in the Canadian Journal of Pharmacy Students and Interns, found that 96% of consumers consider a knowledgeable pharmacist the most important factor in choosing a pharmacy. That is good news for the profession, Dr. Gomori said. However, a more negative aspect is noted in other documents, such as the Romanow Report and The Canadian Medical Association Journal, which essentially claim, “Pharmacists are filling prescriptions, but not their potential.”

The Romanow Report placed strong emphasis on patient-focused teams, which include pharmacists, Dr. Gomori explained. Patient-oriented health care has the capacity to break down traditional barriers and establish pharmacists as integral members of inter-professional practice sites.

Dr. Gomori presented an overview of the inter-professional team at the Multiple Sclerosis Clinic at the Winnipeg Health Sciences Centre. The team is composed of a variety of health disciplines, including dietetics, medicine, nursing, occupational therapy, pharmacy, physiotherapy, psychotherapy, and social services. Manitoba’s College of Physicians and Surgeons Registry recognizes a new professional designation: Multiple Sclerosis Medical Clinical Assistant. The role is analogous to that of a medical resident and requires a broader knowledge of diagnostic testing and the ability to conduct basic physical examinations. The clinical assistant has the authority to order blood work and other tests and write prescriptions. All of this takes place under the auspices of the supervising clinician.

“The whole idea is to work as a team and not in isolation,” Dr. Gomori said. “Every member of the team knows and respects the work of the other members. This way, the pharmacist is not under-utilized.” As part of an inter-professional team, the practice of pharmacy is focused on the patient rather than on the drug. Specific educational guidelines have been developed for pharmacists who work as part of the inter-professional practice team.

Not all patients require inter-professional practice teams, Dr. Gomori said. However, complex diseases and chronic conditions with multiple problems, such as Parkinson’s disease, multiple sclerosis, HIV/AIDS, chronic pain, Alzheimer’s, and palliative care, greatly benefit from inter-professional approaches that include enhanced pharmacy practice.

It is unlikely that all or even most pharmacists are ready for these advanced responsibilities, Dr. Gomori said. Some will want to continue in the traditional role of community pharmacist in the drugstore setting. The complex highly involved hospital role is not for everyone.

Physicians may present another barrier to acceptance of an enhanced role for pharmacists. Some physicians may be reluctant to have their judgment questioned by pharmacists, and may resist sharing patient load or responsibility for care.

Dr. Gomori identified other sensitive issues to work out, such as liability in the event of a team member making a medical mistake. He noted that the success of the Multiple Sclerosis Medical Clinical Assistant has made him confident that the benefits are worth the challenges. An expanded pharmacist role can lead to a reduction in wait times, more patient turnover, the optimization of the use of medications, fewer medication errors, and improved access for patients. Moreover, the model can be expanded to other medical disciplines.

“The future of health care lies in better and more extensive collaboration between all health professionals,” Dr. Gomori concluded. “But this can only begin once a mutual understanding and respect for each care domain is realized.”

Scope of Practice–Views of Other Professions (cont.)

Ann Syme, RN, MSN, PhD Candidate
Provincial Program & Network Director
Pain and Symptom Management/Palliative Care
British Columbia Cancer Agency
Vancouver, BC

Lessons from the expansion of the scope of practice of nursing and other professions can help pharmacy anticipate and face challenges and adversity more successfully, Ann Syme said. Increased clinical-setting interaction between pharmacists and nurses would benefit both professions as pharmacy’s role expands.

Nursing is often referred to as the “glue” that holds health care together, she said. In the recent evolution of nursing roles, the challenge has been to bring in the concepts of caring and cultural competence. These roles are especially important when supporting patients who are transitioning back to their communities.

Syme presented an overview of various nursing roles and the education for each. A diploma is no longer sufficient. Registered Nurses (RNs) have Bachelor degrees; Advanced Practice Nurses (APNs) have Master’s or PhD qualifications. Nurses who have obtained their PhD may also serve as formal nurse leaders or nurse scientists.

Roles are further delineated within these broad categories, Syme said. Clinical Nurse Specialists are APNs who concentrate on a particular area of nursing practice, providing direct care, expert consultation to care providers, and leadership to implement systemic changes designed to improve health care. Nurse Practitioners are APNs who have advanced preparation in diagnostics, and prescriptive practices grounded in the discipline of nursing.

Jurisdictions have begun to develop the specific legislation required to licence Nurse Practitioners, with 900 licensed across the country. In British Columbia, attempts were made to integrate Nurse Practitioners at the community-based level. However, the ground was not well prepared, and many Nurse Practitioners have gravitated to the acute care sector. “There is lots of room for expanded roles, but the structures do not yet exist across the whole spectrum of care to allow them to happen,” Syme cautioned.

Of all the various barriers and facilitators to expanded scope of practice, the most important is how people within the profession see themselves. The process of accreditation will be crucial, as will the smaller details such as job titles. She questioned the appropriateness of the term “assistant” in the title Multiple Sclerosis Medical Clinical Assistant. “Although it’s very political, language is important,” she said. “As soon as you say assistant, you are subordinating one discipline to another, which can have practical implications.”

Successful role enhancement also requires good policies, legislation, and practice models; strong, rational government funding support; education for all team members; and good evaluation and outcome measures. Equally important is the willingness of discipline leaders to identify opportunities for expanded scope, and press ahead where there is most openness to change. The uptake on the Nurse Practitioner role, for example, has been fuelled by the current reality of physician shortages. A similar opportunity has permitted the emergence of Nurse Anaesthetists and Nurse Endoscopists. US studies suggest that the cost of one Certified Registered Nurse Anaesthetist is one-tenth of a Medical Doctor, while clinical outcomes are equal. Such factors make the ground ripe for expansion of the nursing role.

Nurses and pharmacists bring complementary skills, Syme noted. She reviewed several examples of professional teams that integrate the pharmacist role. The cancer-care system has been strengthened by including Nurse Practitioners to help transition patients back into their community and offers a clear role for advance-prepared pharmacists. However, there persists a shortage of research to support these developments. “An exploration of these complementary roles has never been provided in academia,” she said. Education should be seen in conjunction with work force development and management, not just in terms of curriculum development.

Practitioners in inter-professional teams must also understand the limitations of advanced practice. “Not every patient needs every team member every time,” Syme said. “And not all team members can fill all roles all the time.” Relationships must be managed dynamically, due to the continual potential for conflict due to overlapping roles.

The advantages of expanded practice, however, far outweigh the challenges, she said. Expanded practice is more patient-centred and creates more access to patients. Care planning is more competent and comprehensive. Practitioners like pharmacists have more patient contact, which is empowering for both patient and professional. As pharmacokinetics becomes more complicated, advanced practice is needed to ensure that physicians are getting the technical support and knowledge they need about therapeutic medication.

“We must strive to find the places where we can share the important work that needs to be done, and celebrate how we work together and enhance and enrich each other’s work,” Syme concluded.