Canadian Pharmacists: Evolving Scope of Practice

Background: Many Canadian jurisdictions have granted pharmacists the authority to initiate, modify, and maintain prescriptions independently, which has been proven to improve patient outcomes. However, inconsistent regulations and legislation governing pharmacists' prescribing across provinces have sparked ongoing debates. The criteria and processes for granting prescribing authority to pharmacists are often unclear. An additional issue that must be investigated is the common perception that pharmacists have "not stepped up to the plate" and adopted changes to their practice scope and expanded roles with sufficient speed or commitment. This perception might reflect underlying issues such as confidence deficits, personal attributes, inertia, or unrealistic remuneration expectations. This thesis explored Canadian regulators' procedures for authorizing changes or expansions in pharmacy practice and investigated the factors influencing pharmacists' willingness to adopt these changes. Methods: This thesis comprises two studies: 1) a qualitative analysis and 2) a scoping review. The qualitative analysis study conducted online semi-structured interviews with Canadian pharmacy regulators and government representatives to analyze the processes for authorizing pharmacists to prescribe. It gathered insights into authorization boards, procedures, considerations, monitoring approaches, as well as opportunities, challenges, and suggestions for addressing these issues. The second study, a scoping review, collected qualitative data on the non-technical factors (social, cognitive, and personal management) affecting pharmacists and their expanded roles in Australia, the UK, and Canada. These countries were specifically chosen because they all have publicly funded healthcare systems, where the government plays a significant role in financing and regulating healthcare services, primarily funded through general taxation or specific health levies. They also share high-income status, advanced development, and comparable life expectancies. The review also highlighted pharmacists' suggestions for overcoming these factors. Results: A total of 18 individuals participated in the qualitative analysis study, including 9 regulators and 9 government representatives from Ontario, Prince Edward Island (PEI), Nova Scotia, British Columbia (BC), Newfoundland and Labrador, Quebec, Alberta, and Manitoba. The analysis identified three main themes: the authorization board, the authorization process, and monitoring and evaluation. The first theme examined the significant variability in the composition of authorizing boards or councils across provinces. Membership ranges from 9 to 20 individuals, including elected and appointed pharmacists, pharmacy technicians, public members, and pharmacy school deans. The second theme emphasized that expanding pharmacists' scope of practice is a shared responsibility between regulatory colleges and provincial governments, with final authority to approve or reject such expansions resting with the governments. The third theme examined how authorities use various methods to monitor and evaluate pharmacists' prescribing practices to ensure efficiency and public safety. These methods include analyzing clinical and patient outcomes, collaborating with academic partners and researchers to conduct surveys, performing inspections, addressing complaints, and coordinating with other provincial healthcare regulatory colleges and pharmacy regulators across Canada. The scoping review identified a total of 8,803 citations from both peer-reviewed and grey literature. 67 studies from searching the databases and registers met the eligibility criteria, including 20 from the UK, 22 from Canada, and 19 from Australia. Additionally, 24 references were sourced from grey literature. The analysis identified five key themes: pharmacy-related factors highlighted issues such as lack of motivation, uncertainty about new roles, regulatory unawareness, and concerns about negative implications and professional criticism; practice-related factors included enablers like pharmacists' skills and drug knowledge, alongside challenges such as time constraints, insufficient training, limited access to patient records, and resistance from other healthcare providers; physical environment and resource-related factors noted benefits like walk-in services and convenient locations, but also pointed out issues like inadequate infrastructure and shortages of staff and diagnostic tools; regulation covered problems such as unclear policies, lack of promotion for new services, and insufficient remuneration; and patients' related factors involved challenges including low awareness, public mistrust, preference for general practitioners, and reluctance to pay for services. Conclusion: Canadian provinces have varying regulations and legislation regarding pharmacists' prescribing practices, aiming to improve their capabilities, reduce healthcare strain, and ensure high-quality care. However, challenges and non-technical factors hinder pharmacists from adopting expanded roles. Effective collaboration among regulatory colleges, pharmacy associations, government bodies, and the public is crucial for overcoming these obstacles and enabling pharmacists to practice to their full potential.

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