Original Research
Pharmacist's identity development within multidisciplinary primary health care teams in Ontario; qualitative results from the IMPACT (†) project

https://doi.org/10.1016/j.sapharm.2008.12.002Get rights and content

Abstract

Background

Multidisciplinary team development generates changes in roles, responsibilities, and identities of individual health care providers. The Integrating Family Medicine and Pharmacy to Advance Primary Care Therapeutics (IMPACT) project introduced pharmacists into family practice teams across Ontario, Canada, to provide medication assessments, drug information, and academic detailing and to develop office system enhancements to improve drug therapy.

Objective

To analyze pharmacists' narrative accounts during early integration to study identity development within emerging team-based care.

Method

Qualitative design using 63 pharmacist narrative reports of pharmacists' experiences over a 9-month integration period. Four independent researchers with varied professional backgrounds used immersion and crystallization to identify codes and iterative grounded theory to determine and debate process and content themes relevant to identity development.

Results

The pharmacists' narratives spoke of the daily experiences of integrating into a family practice setting: feeling valued and contributing concretely to patient care; feeling underutilized; feeling like a nuisance, or feeling as though working too slowly. Pharmacist mentors helped deal with uncertainty and complexity of care. Pharmacists perceived that complementary clinical contributions enhanced their status with physicians and motivated pharmacists to take on new responsibilities. Changes in perspective, clinic-relevant skill development, and a new sense of professionalism signaled an emerging pharmacist family practice identity.

Conclusion

Pharmacists found that the integration into team-based primary health care provided both challenges and fresh opportunities. Pharmacists' professional identities evolved in relation to valued role models, emerging practice-level opportunities, and their patient-related contributions.

Introduction

Primary health care team development generates change in roles, responsibilities, and identities of individual practitioners.1 The IMPACT project aimed to improve drug therapy using a practice model integrating nondispensing pharmacists as members of family practice teams. Individual pharmacists provided patient medication assessments, drug information, education detailing, and office system innovations.2 This article presents the experience of 7 pharmacists with a focus on their professional identity as they integrated into family practice teams.

In response to challenges to professional autonomy, the pharmacy profession has shifted pharmacists from technical to clinical roles.3 The growth of the pharmaceutical industry has decreased the technical role of pharmacist but has simultaneously created a potential role for “drug brokers” who can help limit drug-induced illness (drug errors, overprescribing) and improve drug therapy.4, 5, 6, 7 The emergence of clinical pharmacy and the pharmaceutical care ideology8 asserts that pharmacists not only provide drug education but also take responsibility for patient outcomes, leading to a more active and sustained role in patient care.9, 10, 11, 12

The majority of Canadian pharmacists (71%) work outside of clinical care settings. Community pharmacists in commercial settings lack access to patient records6, 13, 14 and regular face-to-face contact with other health care team members, which may make an active role in patient care difficult. Integrating pharmacists into team-based primary care involves reskilling. Reskilling, the reacquisition of knowledge and skills, is context dependent and influenced by mixed attitudes of enthusiasm and antipathy, approval and disquiet.15 Other authors have noted marked changes in professionals' sense of self while negotiating shifting professional roles and contexts.16, 17 Related IMPACT publications report on shifting medication-related responsibilities18 and physicians' perspectives.19 This article reports on the development of pharmacist's roles, responsibilities, and identities during their integration into primary care teams as part of the IMPACT project.

Section snippets

Methods

This study used a qualitative design using pharmacists' narratives of their intellectual and emotional experiences over a 9-month integration period.20 Four researchers with varied professional backgrounds used iterative grounded theory to determine process and content themes. Research ethics approval was obtained from the Research Ethics Boards of the Élisabeth Bruyère Research Institute and McMaster University.

Early days: influences and supports

The first 2 narrative reports convey an “integration shock” experienced by some of the pharmacists in their first months in family practice. They noted feelings of disorientation, feeling like a nuisance in the busy new setting, feeling like an outsider, and in some cases, unvalued by people in the setting.

The first couple of days at the clinic were very unsettling. The clinic auxiliary staff, nurses, secretaries, etc [sic] were great, in fact everyone seemed really nice but I just kind of felt

Discussion

The narratives provide pharmacists' viewpoints, sympathies, skills, and sense of professionalism. They also suggest a shift toward a new family practice pharmacist identity. Time, adaptability, and support facilitated this achievement.

Team-based care comes with both challenges.31 The results show the interplay among the effects of setting, skills, and identity as pharmacists undertook a journey of integration into family practice settings. As team members, the pharmacists spoke of access to

Limitations

We acknowledge the project supports available to facilitate role development and that these would have had some impact on pharmacist self-presentation. In addition, we acknowledge the limitation that the recruited pharmacists and family practices likely represent early adopters. Finally, these results are based on the experiences of 7 pharmacists, 6 of whom were female. The limited number of male pharmacists did not permit a separate gender analysis.

Conclusions

Everyday elements shaped pharmacists' responsibilities and identities within these emerging team-based family practice settings. Setting, skills, and perspectives influenced professional identity formation. In addition, mentorship to support the integration into multidisciplinary teams surfaced as a key facilitator, and this has implications for the pharmacy profession and other initiatives aimed at developing team-based care.

Pharmacists integrating into family practice should consider taking

Acknowledgments

This article is published on behalf of the IMPACT team members: Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics. We would also like to acknowledge feedback from Jeff Poston on earlier drafts of this manuscript. IMPACT was a large-scale demonstration project funded by the Ontario Ministry of Health and Long-Term Care through the Primary Health Care Transition Fund. The views expressed in the report/article are the views of the authors and do not necessarily reflect

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    IMPACT: Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics.

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