Hospital Pharmacy Leadership Conference - June 1 - 3, 2007
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
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.”
of Practice–Views of Other Professions
Dr. Andrew Gomori, BSc, MD, FAAN, FRCPC
Associate Professor, Section of Neurology, Department of Medicine
University of Manitoba
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.
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.
British Columbia, pharmacists may prescribe Schedule 4 medications
within approved guidelines.
Quebec, pharmacists with required certification may initiate
or adjust medication and provide emergency contraceptives.
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
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
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
“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
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,”