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Abstract
Objective To provide an initial understanding of problems and potential solution strategies for part-time clinical pharmacist work in China, and provide references for the training of part-time clinical pharmacists.
Methods The study was conducted in a tertiary teaching hospital in China, and the project lasted 6 months. Phenomenological methods were used to guide the research design. Research data were obtained by conducting one-to-one semistructured interviews with part-time clinical pharmacists, and interview data were coded and analysed through thematic analysis.
Results A total of 21 pharmacists were interviewed in a semistructured manner, and the results showed that following problems exist in the work of part-time clinical pharmacists: the existing professional knowledge is not adequate to meet the demands of clinical service; the career orientation of part-time clinical pharmacists is not clear; lack of professional self-confidence in clinical pharmacy practice; there is no suitable entry point to carry out pharmacy service work; it is difficult to communicate effectively, and for in addition, 17 potential solution strategies are proposed for the current problems, which can provide reference for the development of part-time clinical pharmacists’ work.
Conclusions The work performed by part-time clinical pharmacists is currently immature and the strategies derived from this study may serve as potential solutions to resolve the part-time clinical pharmacy practice challenges.
- health services
- China
- chronic disease
- clinical pharmacology
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The strength of this study lies in the use of a qualitative method. This approach can fully tap the work practice and psychological experience of part-time clinical pharmacists, and the findings are highly practical.
Based on the rootedness theory, this study tapped into the influencing factors in the current work process of part-time clinical pharmacists and preliminarily explored potential solutions to the problem, which can provide some lessons for other healthcare organisations to carry out this work.
The study was conducted in a large teaching hospital, and the results may be suitable for large teaching hospitals and less applicable to primary hospitals.
Introduction
Since the implementation of the clinical pharmacist system in China, the role of clinical pharmacists is gaining more and more recognition and acknowledgement in promoting rational clinical use of and safeguarding patient access to medication.1 2 A systematic review showed that clinical pharmacists play an important role in antimicrobial management, chronic disease state management and multidimensional clinical pharmaceutical services at present in China.3 Clinical pharmacists are becoming an integral part of the healthcare team with their ability to improve patient outcomes and save on healthcare costs.4 Many medical institutions, especially teaching hospitals, take clinical pharmacists as an important member of the medical team or multidisciplinary treatment group.5–8 Due to China’s large population base and ageing society, there is a huge demand for clinical pharmacy services.9 However, due to the late start of clinical pharmacy in China, the numbers and services of clinical pharmacists are far from meeting the demand.10 11 There is a huge difference in developed countries, where clinical pharmacy has developed into an independent discipline, and become an important part of hospital inpatient monitoring.4 12 In view of the huge difference between developed countries, there is an urgent need to explore a new suitable clinical pharmacy model for the current situation in China.
Given the current development status of hospital pharmacy in China, a large-scale expansion of the clinical pharmacist team in a short period of time is not feasible.13 Chinese hospital pharmacists are mainly engaged in the dispensing of medicines. However, they are required to have an educational background in pharmacy and to pass the appropriate qualification exams so they have a better background in basic pharmacy knowledge. The results of our previous study showed that the hospital pharmacists played an important professional value in the treatment of COVID-19 patients and affirmed by other healthcare professionals in China.14 15 Hospital pharmacists have the foundation and scenario to transform into part-time clinical pharmacists, this may be an important measure to solve the serious shortage of clinical pharmacists’ size. The results of a cross-sectional study in China showed that most hospital pharmacists have the desire to transform into clinical pharmacists.1 16 Hospital pharmacists could combine drug dispensing security with clinical pharmacy service, which is more convenient to serve patients. Therefore, many domestic teaching hospitals have started to try the systematic transformation of hospital pharmacists.17–19 However, the transformation of hospital pharmacists into part-time clinical pharmacists is still in the exploration stage in China, and there is a lack of exploration of what problems part-time clinical pharmacists face in this process and how to make systematic improvements, which restricts the continuous optimisation of the work. Therefore, we conducted a qualitative study based on the transition practice of hospital pharmacists in a large teaching hospital in central China and explored the current problems and potential solutions to carry out clinical pharmacy services for part-time clinical pharmacists.
Methods
A part-time clinical pharmacist is defined as hospital pharmacist engaged in the dispensing of medicines, who use their free time to carry out clinical pharmacy services while completing their normal work of ensuring the supply of medications. The study was conducted at the First Affiliated Hospital of Zhengzhou University (the largest teaching hospital in China), currently, 65 part-time clinical pharmacists routinely provide pharmacy services in the clinic.
Study population
A purposive sampling method20 and typical case sampling method21 were used to select participants. At present, the work of part-time clinical pharmacists has not formed a system, and only a few large-scale teaching hospitals have carried out this pilot work in China. The First Affiliated Hospital of Zhengzhou University has been one of the earliest hospitals in China to start this innovative work since 2016, and it has accumulated rich experience with the problems and the corresponding solution strategies in carrying out the part-time clinical pharmacist pilot work. Therefore, this study we took the First Affiliated Hospital of Zhengzhou University as the sampling object and adopted the principle of purposive sampling to select the participants who worked in the hospital. To guarantee the representativeness of the research subjects, the inclusion criteria for pharmacists as interviewees were as follows: (1) were engaged or had been engaged in part-time clinical pharmacy work for more than 3 months and (2) were willing to participate in the study and signed a written informed consent. Exclusion of those unwilling to sign an informed consent form or to undergo an audio-recorded interview.
Data collection
The study used exploratory qualitative methods to conduct a one-on-one semistructured interview from June 2022 to December 2022. Combined with the purpose and topic of this study, through discussions within our research group, consultation with clinical pharmacy administrators and full-time clinical pharmacists. Ultimately, we initially identified the main questions of the interview: (1) What problems have you encountered while working as a part-time clinical pharmacist? (2) In response to the current problems, what aspects of preparation or what measures do you think can solve them? The study began with preinterviews with four part-time clinical pharmacists and further revising and refining the interview outline with the results of the preinterviews (see online supplemental materials S1 for the formal interview outline).
Supplemental material
Each interview lasted approximately 35 min and was recorded in do-not-disturb mode via a smartphone or other recording device. Before conducting the formal interviews, the researcher first introduces the purpose of this study so that the respondents can understand the direction and facilitate the development of the subsequent in-depth interviews. Each interview was carried out by 2–3 members of the research team, with one main interviewer and 1–2 recorders to record the key information in the process. The main interviewer meets the following criteria: (1) received more than 3 months of qualitative research training, (2) participated in more than 3 projects of qualitative research practice and (3) passed the assessment to be able to conduct research independently. The interview process and text transcription were conducted in standard Chinese Mandarin.
Basic information about the participants was collected, including gender, academic background and clinical pharmacy training experience used paper questionnaires. Although we designed the interview outline in advance, the participants’ responses determined the exact flow and order of the discussion. Interviewers checked participants in real time during the interview to ensure that they understood the participants’ views and opinions. The recordings were transcribed into text by the research assistant within 24 hours after the interviews were completed, then the reviewed information was returned to the interviewee for further verification of the content and the interviewees’ identifying information was removed at the end of the interview.
Qualitative analysis
Thematic analysis is commonly used to assess participants’ perspectives and identify similarities and differences in responses, creating a rich description of the data.22 This study used thematic analysis to identify, analyse, organise, describe and report themes guided by the social constructivism theory. The first interview data were first reviewed independently by four members of the research team (including two with extensive experience in qualitative methods) and a preliminary coding was developed using comparison and consensus, then each interview profile was independently coded by two separate research team members using this coding. The codebook was collaboratively reviewed and refined as new codes emerged or existing codes required clarification. Codes were iteratively grouped into themes. Thematic saturation was reached when the codes managed new data without further modification. All transcripts were independently recoded by two members of the research team once the codebook was finalised. Any discrepancies in coding were discussed until a consensus was reached. To ensure that the study was trustworthy, the following considerations were made: (1) The principal investigators of the project (XJ, ZY and WZ) received a qualitative study training programme offered by Peking University, and the other participants participated in the in-house training of the research project; (2) the text transcriptions were returned to the interviewees to confirm the authenticity and completeness of the content and (3) two members of the subject group independently conducted the same data to refine the themes and subthemes, and the themes were further summarised through collective discussions in the research group. Finally, the research themes and typical questions were recorded in standard English and sent back to the participants for further confirmation to ensure that the information was correct. Data were reported under the guidance of the Consolidated Criteria for Reporting Qualitative Studies checklist (online supplemental material S2)23 and Standards for Reporting Qualitative Research checklist (online supplemental material S3).24
Patient and public involvement
Patients and the public were not involved in the production of the present research.
Results
The included part-time clinical pharmacists were recruited through the Part-Time Clinical Pharmacist Pilot Programme at the First Affiliated Hospital of Zhengzhou University, and all participating pharmacists were proactive in participating as part-time clinical pharmacists. A total of 21 of them were finally included in this study, 85.7% of them were female, the highest education level was master’s degree, the time spent in part-time clinical pharmacist work was mainly 1–3 years and only 3 of them had participated in clinical pharmacist training programmes (training programme for full-time clinical pharmacist qualification in China), details are shown in table 1.
Basic information of the participants
Problems of part-time clinical pharmacists engaged in clinical pharmacy services
Problem 1: the existing professional knowledge is not adequate to meet the demands of clinical service
Although part-time clinical pharmacists have a good educational background in basic pharmacy, however, they generally lack training in clinical practice skills. Therefore, pharmacists’ knowledge of disease mastery and comprehensive clinical application of drugs is relatively scarce. They are unable to use a systematic clinical thinking model to carry out pharmacy service work.
P4: When I go to the clinic, I feel that the knowledge I have mastered is not comprehensive enough, and it is difficult to discuss complex medication problems with doctors at my current level.
P8: I am not familiar with the diagnosis, testing and treatment of common clinical diseases, and I do not know how to integrate my pharmacy knowledge with clinical needs.
P10: I do not have a clear understanding of the treatment process of patients, and I am unable to make a clear understanding of the patient’s medication.
P14: Some of what we know is from the guidelines or literature, but what the doctor needs to solve is more practical, and the actual application may still be different from the guidelines.
P19: The same patient may have many diseases and complications at the same time, and the patient’s nutritional problems and psychological problems are also considered in clinical treatment, which require comprehensive judgment, but none of these elements are in the pharmacist’s knowledge system.
Problem 2: the career orientation of part-time clinical pharmacists is not clear
Because the main work of part-time clinical pharmacists is still focused on securing drug supply, clinical pharmacy services are often suspended due to the need to participate in medication reconciliation efforts, and the work content of part-time clinical pharmacists lacks unified standards. The clinical orientation of part-time clinical pharmacists is unclear, resulting in a lack of clear professional orientation by themselves, doctors, nurses and patients, and a generally low sense of professional identity, which urgently needs to be further strengthened.
P9: I do not know what work should actively carry out when I go to the clinic…….
P7: we need to explain our work content repeatedly and continuously with doctors and nurses, and the working hours of part-time clinical pharmacists are not fixed, so the work lacks continuity.
P13: When I first went to the clinic, the clinicians had high expectations of the pharmacist’s career and thought that all drug-related problems were more professional, However, the professional competence of pharmacists is not sufficient for complex medication problems.
P10: Patients do not understand the part-time clinical pharmacist profession and are not clear about what aspects of the pharmacist can provide help to them, and some patients even think that the pharmacist is just here to sell drugs.
P3: Other hospital pharmacists do not see the feedback of part-time clinical pharmacists and think that it is easy and idle to work in clinical pharmacy.
Problem 3: lack of professional self-confidence in clinical pharmacy practice
Part-time clinical pharmacists generally lack professional self-confidence in both the preparation and working periods of clinical pharmacy services. This is mainly reflected in the fear of unknown clinical problems, lack of confidence in their current knowledge structure, anxiety about communication between other healthcare professionals and patients, and lack of professional identity. Thus, they are unable to achieve the expected effect.
Preparation period
P3: During the preparation process of getting ready to work as a part-time clinical pharmacist, I was in a very apprehensive state of mind, always worrying that I wouldn't be able to answer most of the questions posed by the doctors, and that I would feel a little bit humiliated.
P11: I was more worried and scared before I had to go to the clinic, and I was afraid that I would feel especially embarrassed by the doctor’s difficult questions.
P7: I am not confident in my professional knowledge and I am afraid that I will not be able to answer the doctor’s in-depth questions about clinical issues.
Working period
P15: After I went there, I really felt that I was not worthy of the job. I felt that my ability was too poor……"
P16: The director of the clinical department raised a problem today I have not yet solved, and then the next day raised a problem, and then there will be a lot of questions every day, and the fear is increasing day by day, which will bring a huge invisible pressure on myself.
Problem 4: lack of appropriate entry points for clinical service
Part-time clinical pharmacists are all transformed from hospital pharmacists and have no experience in patient pharmacy services. Therefore, they have not formed a fixed working pattern in China so far. In terms of working hours, there is a need to collaborate on drug dispensing and clinical pharmacy service. In terms of work style, there is no suitable work entry point for service delivery. This is not conducive to the development of the part-time clinical pharmacist career and the continuous improvement of the team.
P13: I am not very familiar with clinical pharmacy service work, so I am very confused to find a suitable work status and appropriate work entry point.
P15: I was unfamiliar with clinical pharmacy services and felt overwhelmed with work.
P17: When I first came to the clinic, I had to find an entry point…… I feel it is quite difficult to let us assist in carrying out some of the work.
P18: There is no fixed clinical work time, often because of the busy pharmacy work, the clinical services are canceled, so that clinicians feel that we do not pay attention to bedside work.
Problem 5: lack of communication skills and difficulty in effective communication with doctors, nurses and patients
Part-time clinical pharmacists lack clinical practice experience and are generally not trained in communication skills. Therefore, they are unable to communicate effectively when carrying out clinical pharmacy services. Thus, the expected effect of pharmacy services could not be achieved, and there is an urgent need to strengthen the training of pharmacists’ communication skills in the future.
P12: I often don't dare to think about my own ideas and express my own opinions.
P13: Some patients may be heavily ill and may not be in a good mood, so I worry about how to communicate with them.
P15: I think the most difficult thing is communication and exchange…… I don't know what to say, how to communicate and cooperate.
P19: Some patients are not highly educated…… they need to repeat it again and again. I don't know what other communication skills can solve these problems.
Potential strategies to solve the current problems
By systematically organising and summarising the qualitative study data of 21 part-time clinical pharmacists, a total of 17 potential solution strategies were obtained. Strategies 1–6 are potential solution strategies for ‘problem 1’; strategies 7–8 are potential solution strategies for ‘problem 2’; strategies 9–10 are potential solution strategies for ‘problem 3’; strategies 11–15 are potential solution strategies for ‘problem 4’ and strategies 16–17 are potential solution strategies for ‘problem 5’. We summarised the frequency of these strategies among the respondents, and found that ‘strategy 10—increase introductory training in clinical pharmacy services’, ‘strategy 16—develop communication skills and methods training’ and ‘strategy 9—increase the service teaching of experienced clinical pharmacists’ were the top three solution strategies, and the detailed solution strategies are shown in table 2.
Results of potential solution strategies for difficulties faced by part-time clinical pharmacists
Discussion
As far as we know, this study is one of the earliest studies to explore the work of part-time clinical pharmacists in China. The results revealed five major problems in the work of part-time clinical pharmacists in China: the existing professional knowledge is not adequate to meet the needs of clinical services; the unclear professional orientation of part-time clinical pharmacists; lack of professional self-confidence; lack of appropriate entry points for pharmacy service delivery and lack of communication skills. 17 potential solution strategies were explored through this study, which can provide a reference for systematic training of part-time clinical pharmacists.
This study showed that the current existing professional knowledge of part-time clinical pharmacists cannot meet the work demands of clinical services. Since the implementation of the clinical pharmacist system in China since 2017, the training of clinical pharmacists has been classified as a national scarce talent training programme,5 25 26 and training programmes for clinical pharmacists have started to emerge in China. There are training programmes led by government health departments and specialty associations, all of which aim to improve the clinical service capabilities of pharmacists through a 6-month to 1-year training effort.27–29 However, the focus of part-time clinical pharmacists’ daily work is still ensuring the supply of medicines, lack of sufficient time to guarantee large-scale training. Therefore, part-time clinical pharmacists lack clinical practice sessions and are generally not competent for clinical pharmacy services. In response to the reality, the potential solution strategies obtained from this study are more suitable for the large-scale professional transformation of hospital pharmacists. Strategies 1–4 emphasise the importance of pharmacists undertaking self-directed learning related to their profession. Previous studies have also shown that self-directed learning in various forms is conducive to the establishment of pharmacists’ knowledge system and the enhancement of their job competencies.30 31 Strategy 5 emphasises clinical rotation learning to develop pharmacists’ clinical thinking and familiarity with common diseases and medicines in the department, and strategy 6 emphasises the importance of training pharmacists in evidence-based thinking to provide problem-solving ideas for subsequent pharmacists when they encounter clinical problems. Overall, these six potential solution strategies are more suitable for the actual work of hospital pharmacists, more operable and implementable and can provide important references for the competency development of part-time clinical pharmacists.
This study showed that part-time clinical pharmacists lack professional self-confidence both before and during the work of clinical pharmacy services. The negative psychology arose from fear of the unknown professional environment, fear of social interaction in the process of direct pharmacy services and most importantly, pharmacists were not confident in their professional abilities and worried about their inability to perform the work of clinical pharmacy services and the resulting professional disapproval. These similar problems also existed during the development of full-time clinical pharmacists in China.1 32 Both strategy 7 and strategy 8 emphasised the importance of increasing pharmacist mentoring and introductory training. In the future, before part-time clinical pharmacists carry out pharmacy services, they can increase the clinical practice tutoring of full-time clinical pharmacists in their own units so that pharmacists can accumulate certain clinical practice experience, and then gradually transition to independent pharmacy service work. This can increase the professional self-confidence of part-time clinical pharmacists.
This study shows that part-time clinical pharmacists have a poor career orientation, and they need to balance the drug dispensing and clinical pharmacy service. The formation of professional orientation is a process of long-term friction and exploration, so focusing on accumulating and summarising problems in daily work, gradually forming their own professional expertise, forming professional complementarity with medical and nursing, and establishing a pharmacy service team work model to jointly carry out collaborative pharmacy services may be an important potential strategy to solve this problem.
The results of this study show that part-time clinical pharmacists currently lack a fixed working model and do not have a suitable entry point to carry out pharmacy service work. Our findings suggest that the clinical pharmacy services can be individualised by combining the pharmacist’s own knowledge structure, professional expertise and the pharmacy service needs of the clinical department as well as the characteristics of the patients in the department, Initially, one or more of the strategies 11–15 presented in this study, drug dispensing service extension, scientific research collaboration, individualised medication use, monitoring of key drugs or feedback on problematic medical prescriptions, can be used as an entry point.
The results of this study show that part-time clinical pharmacists generally lack communication skills and have difficulty in communicating effectively with doctors, nurses and patients. As part-time clinical pharmacists work mainly in the drug dispensing room, they have relatively little professional communication with patients and doctors and nurses, and they do not understand the traditional physician–nurse collaboration model so they lack the relevant communication skills and have miscommunication. Good communication skills are one of the core competencies of pharmacists to be able to perform pharmacy services33 so strengthening the training of pharmacists’ communication skills is an important prerequisite for pharmacists to carry out quality pharmacy services, and several previous studies have emphasised the importance of this.34–36 Therefore, it is necessary to strengthen the training of pharmacists’ communication skills and methods through a variety of forms, and in addition, it is necessary to play the subjective initiative of the pharmacists, take the initiative to communicate with the clinic and clarify the department’s pharmacy service needs.
Future pharmacy departments can apply a combination of the 17 potential solution strategies proposed in this study when developing part-time clinical pharmacists. Strategies 1–4, 7 and 17 all emphasise the subjective initiative of part-time clinical pharmacists. It is recommended to be listed as a self-improvement component for pharmacists, which can be assigned as a self-learning programme or an assessment programme; Strategies 5–6 emphasise the importance of clinical practice. Pharmacy departments can collaborate with healthcare administration to establish part-time clinical pharmacist practice departments, to develop pharmacists' clinical practice skills and evidence-based thinking patterns; Strategies 8–10 and 16 can be achieved through the harmonisation of training programmes by pharmacy departments. Reasonable arrangement of professional tutoring by full-time clinical pharmacists and the construction of pharmacist service teams are realised; strategies 11–15 provide entry points for part-time clinical pharmacists to carry out pharmacy service work. Part-time clinical pharmacists can combine the current work status of the clinical departments they serve to establish the direction of the pharmacist’s work priorities, first identifying a few of them as priorities to carry out and then gradually improving to form a work system.
The limitations of the study are as follows: (1) As this study was an exploratory study, only pharmacists from a large teaching hospital were included as subjects, which may make the content of the study more suitable for large teaching hospitals and less applicable to primary hospitals; (2) Most of the subjects included in this study were female, which corresponds to the current male-to-female ratio of pharmacists in Chinese hospitals, but the impact of gender on the research questions could not be explored and (3) Since English is not our native language and we conducted the study in Chinese Standard Mandarin, some of the content may not be expressed in a particularly artistic way during the translation and transcription process.
Conclusion
Chinese part-time clinical pharmacists have problems with poor communication skills, lack of professional competency and scattered work patterns in the process of carrying out clinical pharmacy services. The coping strategies proposed in this study may respond to the current problems to some extent, and future research strategies need to be incorporated into the core training system of part-time clinical pharmacists to further improve the professional competency of part-time clinical pharmacists.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (No. KY-2022-0470). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to thank interns Yuwei Li and Mengjuan Xu for their help in organising data and information, and all pharmacists who participated in the study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors Conception and design: SD, ZY, JK and XJ; Project administration: JK and SD; Collection and assembly of data: XJ, WZ, F-YS, XY, LW, MW and JZ; Data analysis and interpretation: XJ and ZY; Manuscript writing: XJ and ZY; Final approval of manuscript: all authors. XJ is the guarantor responsible for the overall content.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.