The experiences of healthcare providers who refer to a campus-based pharmacy clinic: a qualitative analysis

Sampling and recruitment

Eligible participants were healthcare providers who had referred one or more patients for consultation at the Clinic between 1 January 2021 and 18 March 2022, and at least one of the provider’s referred patients attended their consultation prior to participant recruitment. Referral data was used to identify a sample of 33 eligible participants. Twenty-nine healthcare providers were invited to participate in the study, provided with the study information and consent form and invited to ask questions about the study via email. Four eligible participants could not be contacted. Fifteen participants consented and participated in the study (Table 3).

Data collection and analysis

All interviews were conducted by TW, a Clinic pharmacist and postgraduate student. Interviews were held either in-person at the Clinic or via Zoom and ranged in duration from 15 to 35 min. Two interview recordings were transcribed verbatim by TW. The remaining 13 interview recordings were transcribed using a third-party secure transcription service, Rev© (https://rev.com). Transcriptions were returned to each participant to check for accuracy. Any requested corrections were made prior to commencement of data analysis.

Data analysis was conducted using reflexive thematic analysis.^2,11,12 This method was chosen because it is congruent with the underlying philosophical assumptions, in particular acknowledging that the collection and analysis of data is influenced by the position of the researcher and the context in which the research is conducted. It also recognises that these influences are integral to the analytic outputs.¹¹

An inductive approach was used to identify words, phrases, sentences or paragraphs thought to provide insight or meaning to the research aim. Coding per transcript, not per question, facilitated pattern identification across the dataset. Two transcripts were independently coded by both TW and SL and the codes were discussed. TW conducted all remaining coding and analysis. Codes were then reviewed and merged, deleted or renamed as appropriate.

Codes were grouped into preliminary themes thought relevant to the research question. Themes were evaluated by re-visiting codes and checking the coded data to ensure each theme provided a robust and accurate representation of the dataset. Some preliminary themes were merged at this stage, and some were renamed to better reflect the codes they encompassed.^11,12 In this final phase the NPT framework was introduced and themes were categorised into the four NPT constructs. This implementation science lens was used to identify facilitators and barriers to the ‘normalisation’ of referral to the Clinic by local healthcare providers.

Ethical approval (Category B) was granted by the University of Otago School of Pharmacy Human Ethics Committee (D22/069).

Coherence: ‘Perceptions of pharmacists’

Coherence included participants’ understanding of the aims and objectives of the Clinic, how it differs from other services and the scope for how they will interact with it.^4,13 Participants recognised that pharmacists work across different healthcare settings and that the day-to-day duties of those pharmacists may differ. Clinic pharmacists were regarded as medication experts, which was a useful tool for achieving legitimacy, buy-in and engaging patients in their medication therapy.

I think there’s some benefit in having somebody perceived as a specialist in an area get the message across to a patient. I think, in a bizarre way, like I need to speak to the doctor, I think speaking to the specialist in, say, in pharmacy, I think is equally relevant, and they might have an ear to listen to it rather than listen to me. P5 (Physician)

If I can have that pharmacy stuff looked at by a specialist … it just means that there’s that specialty view and input, and even if it supports what I’m thinking of the decisions that I’ve made, it’s just really helpful. P9 (Nurse)

Cognitive participation: ‘Motivators and barriers for engagement’

Cognitive participation reflected referrers’ engagement with the Clinic.^4,13 Participants primarily chose to refer their patients to the Clinic due to medication safety concerns. Polypharmacy, high-risk medications (particularly opioids), complexity of co-morbidity and patients’ lack of understanding of medicines were common motivators for referral.

Some [patients referred to the Clinic] have been on complex medication regimes that just sort of need a good look at and a good sort out and perhaps some simplifying. P9 (Nurse)

[I referred] for clinical input […] I wanted the advice of the pharmacist on the best way to withdrawal from the opioids and to liaise directly with that person’s GP to make a plan. P13 (Physiotherapist)

I know a couple [of my referrals] have been around compliance and I guess sort of a lack of knowledge or understanding about their medications. P9 (Nurse)

Referrals were also made by providers seeking a second opinion. These included prescribers seeking a review of their prescribed pharmacotherapy, or pharmacists seeking support in medicines optimisation or patient education.

I feel a lot more safe and secure having someone else with more experience in some of those medications having a look. So a second opinion on ‘do you think these are actually warranted?’ or ‘have you considered this interaction with this medication?’ or ‘have you considered using a different drug instead for this reason?’. P6 (Physician)

Unfamiliarity with the Clinic was a barrier that prevented participants from referring more patients to the service. Unfamiliarity included knowledge gaps around service specification, operations, referral pathways and referral criteria. Patients requiring referral to multiple community-based providers may not be referred to the Clinic if their medication-related problem was not deemed of highest acuity.

When I then understood what the Clinic did, and actually benefited from talking to the pharmacists at work here, and the results … and how a consult might play out, it then became a lot easier to refer, because it could tell a patient ‘Actually this is what you’re going to expect’. P10 (Pharmacist)

Not always is there something overtly sort of putting its hand up to say ‘it’s medication and this really needs to be dealt with’, but I think probably it comes as a ‘it’s really important to do and we probably should do more of it’ … but I don’t know if that’s really going to be the highest priority for that person … and we might already have 10 others [referrals to make]. P1 (Dietician)

Time constraint was an important barrier to engaging with the Clinic.

It’s just you get busy and kind of just, you end up and you’re running the rat race rather than actually thinking and sitting back and thinking about things … so I probably need to use [the Clinic] more. P2 (Dietician)

At times patients had not consented to a referral. Reasons included not being interested, not feeling the timing was right, the location was inconvenient or believing the Clinic was student-run.

I’ve had a couple of people turn down the offers of being referred to the Clinic, because they’re just, ‘Oh, I’ve just broken a hip,’ … ‘I’ve just had a heart attack’ … ‘I’m not interested right now’ … and it’s possibly just overwhelming for them. P11 (Pharmacist)

Collective action: ‘Utility of pharmacist feedback’ and ‘Opportunities’

Collective action described the actions that referrers needed to change their practice and implement new ways of working.^4,13 Fourteen participants had received written feedback from the Clinic and described it as high-quality, thorough and detailed. Although satisfied with the quality of the written feedback, many participants did not specifically use the information in the ongoing care of their patient or act upon the pharmacists’ recommendations. This was usually because the patient was no longer under their care, or the recommendation was not within the referrer's scope of practice. Participants strongly agreed that the Clinic feedback would be most valuable for the patient’s general practitioner who had a responsibility to act upon any recommendations.

I don’t tend to do anything with [the pharmacist’s feedback] […] ‘cause we don’t have that ongoing [input]. P1 Dietician

[I didn’t implement any of the pharmacist’s recommendations] because it was up to the GP to, take charge of that so none of us are … I mean we didn’t prescribe the medications, so that was always discussed with the GP, and the GP slowly integrated those changes. P2 (Dietician)

Ongoing professional education was considered one of the main benefits of collaborating with the Clinic. Although providers may not have used the pharmacist’s feedback in the care of the referred patient, they were able to apply it to the care of other patients.

I learn a lot from the letters that come back as well and I make sure that I’m taking from that, learnings around what I thought was going on with the patient, compared to what my pharmacy colleagues think is going on … and that can guide me in my subsequent advice to the patients as well. So I learn a lot myself, consequently, which is beneficial I presume to the service … my subsequent information that I give patients, is probably more likely to be accurate. P15 (Physiotherapist)

Continuing to develop and grow professional working relationships was identified as a key opportunity for improved collaboration between the Clinic and referrers.

I think maybe keeping a regular contact with the service of like ‘this is who we are, this is how we work’ […] ‘this is what we’ve done for this client’ […] so that needs assessors can go ‘oh ok right, so that’s how that service has been used before, I might be able to do it like that too’. P1 (Dietician)

Specialist outpatient service providers believed a formal collaborative agreement with the Clinic would improve the quality of their current service provision and make the most of the resourcing they have, particularly if Clinic pharmacists were integrated into their multidisciplinary teams. Provision of pain medication information and advice for patients was highlighted as a particular area of need that a Clinic pharmacist could fulfil. Co-location was thought likely to enhance effective interprofessional collaboration and patient experience.

It’s all a matter of resourcing, and for us, [consultant] specialists are the people who do our medication input, but that’s a very limited resource […] so having a clinical pharmacist that can sit into that role makes a really efficient use of time and resources. P13 (Physiotherapist)

I think [close collaboration with the Clinic] is part of a wider review of service, where you think actually should this not be a cornerstone of how we manage these patients before they even get near [our specialist service]? […] I think if they came to me, me knowing they’ve seen you, and they’ve done all the other [rehabilitation], it’s a much easier journey for me to work out, say, ‘Right, yep. Fine. I think we’ve agreed on this, we’ve exhausted this. Let’s move on’. P5 (Physician)

Reflexive monitoring: ‘Referrers’ experiences’ and ‘Patient-centred care’

Reflexive monitoring encompasses critical, formal and informal evaluation of the Clinic.^4,13 Participants valued the interprofessional support they received by collaborating with the Clinic. They identified that the Clinic provided appropriate clinical support across various contexts including second opinion, peer review of prescribing and pharmacotherapy and clinical input when the patient’s needs were out of the referrer’s scope. Participants felt their prior patient communication was reinforced appropriately by pharmacists at the Clinic and indicated that their subsequent patient interactions became easier and more efficient after the appointment. Participants valued the addition of a clinical pharmacist’s skillset and expertise to the multidisciplinary package of care offered to their patients and felt supported by the ability to offer an alternate professional assessment and opinion.

I think [a benefit of the Clinic is] that collegial support, isn’t it? In a prescribing role and you’re dealing with complex people and medications, I think it goes without saying that even to be able to pick up the phone and have a conversation sometimes is helpful. P9 (Nurse)

I think the time that you spend with the patient is invaluable. General practitioners cannot spend an hour with a patient, discussing medication, so I think that’s probably your biggest winner, because you can unpack a lot of that back story in an hour that you can’t do in a shorter time. And a lot of these people have a lot to tell, a lot to share. P15 (Physiotherapist)