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Across Canada, the provincial colleges of pharmacy issue licences to those meeting the registration requirements to practise pharmacy. But does one licence fit all? At a minimum, all pharmacists have an undergraduate degree, and many have additional formal training through a Canadian pharmacy residency program or a Doctor of Pharmacy program. All practising pharmacists are registered under the same licence category, even though they work in a wide variety of settings and provide vastly different services, including drug dispensing, patient counselling, adaptation of prescriptions, chronic disease clinics, therapeutic drug monitoring, delegated drug therapy management, medication reconciliation, participation in patient care rounds, interpretation of laboratory test results, and collaborative prescribing, all intended to achieve better patient outcomes. Not knowing what to expect from a pharmacist must be confusing for patients, physicians, and the rest of the health care team, not to mention the general public, health administrators, and ministries of health.
When a health care profession proposes a change to its scope of practice and the corresponding legislation, broad consultation must take place with stakeholder groups such as other health care professionals and the public. Given our duty to protect the public, we must be able to demonstrate that our training provides adequate skills and competence to perform these new functions, and that our profession has a process for ongoing assessment of these competencies. Do I feel that our undergraduate training provides adequate skills and competence for advanced clinical practice? I’m afraid I don’t—if it did, we wouldn’t need advanced training programs such as residencies and graduate degrees. So I am not surprised when proposed legislative changes related to the scope of pharmacists’ practice meet resistance from physician groups across the country.1 On the other hand, do I feel that there are many excellent clinical pharmacists being held back by our single licence category? Absolutely.
I believe the following are essential elements in defining an advanced practice pharmacist: graduation from an accredited experiential pharmacy training program such as a residency, clinical master’s program, or Doctor of Pharmacy program; ability to collaborate with the health care team in their clinical practice; ability to access and interpret comprehensive health information relevant to the patient’s care; ability to assess and monitor a patient’s signs, symptoms, and response to therapy; expectation to practice within the person’s scope of expertise; recognition of duty to incorporate evidence-based decisions and the patient’s goals and preferences into the care plan; recognition of duty to communicate interventions and plans to the rest of the care team; ability to monitor the outcomes of interventions; accountability to ensure appropriate follow-up; and responsibility for the patient’s care (Ensom RJ, Bachand R, Carr R, Corrigan S, de Lemos J, de Lemos M, et al. Advanced practice pharmacist overview. Unpublished discussion paper, prepared July 2009).
Advanced practice pharmacists would have greater flexibility and authority granted under their scope of practice to be able to care for patients and help them achieve desirable health outcomes. Such outcomes might include relief of symptoms, reduction in short- or long-term risk, resolution of an acute medical condition, or stabilization of a chronic disease. To meet these goals, the advanced practice pharmacist would be involved in assessing the condition, monitoring the patient’s progress, and prescribing drug therapy if deemed appropriate for the patient’s care. He or she would help to improve the safety, effectiveness, efficiency, and timeliness of drug therapy and would need to practise under a model of clinical services going well beyond the usual Monday to Friday routine. The new practice model would incorporate direct hand-over of patient care from one clinician to another, and provision of services 7 days a week in acute care settings, similar to the physician model.
We already have evidence supporting the need to go beyond patient counselling, provision of drug information, and provision of pharmacokinetic services, activities that do not affect patient mortality. By contrast, activities such as monitoring adverse drug reactions, obtaining histories on admission, managing drug protocols, and participating in medical rounds do correlate with reductions in mortality.2 In a recent Canadian comparison of advanced pharmacy practice with usual pharmacy care, indicators of quality of care were better and the frequency of re-admissions was lower at 3 months for patients receiving advanced practice care.3
Creating a separate licence category for advanced practice pharmacists would help by setting out clear expectations and accountability for qualifications, competencies, and patient care activities, both internally for our profession and externally for the teams with which we work and for the health care system more broadly. It is a necessary step of added quality assurance to satisfy stakeholder groups that the expanded scope of practice is being adopted with both the best interests and the safety of patients in mind. Pharmacists in Alberta are the first in North America to be granted independent prescribing privileges. Their regulatory model includes different categories of licensure and authorization for this privilege, which will ensure that the required competencies and quality assurances are met.4
Many clinical pharmacists in hospitals, ambulatory care, and long-term care settings are already doing the work of advanced practice pharmacists under established relationships with the team, hospital protocols, or delegated authority. We need to take the next step and give them full responsibility and accountability for their practice.
The new regulatory model should include a process whereby experienced clinicians who meet all the criteria for advanced practice except formal training beyond their undergraduate degree can undertake a competency assessment for the credential. Conversely, if pharmacists without residency training choose not to obtain an advanced practice license, the excellent care that they provide for their patients will not be affected. We are not defined by the licence category to which we belong, but rather by our own clinical practice. The licence category simply sets a minimum threshold of expectations.
About 35 to 40 years ago, trailblazers in our profession left the dispensary and began to provide clinical pharmacy services, such as pharmacokinetic interpretations. Those pharmacists raised the bar of clinical practice, and eventually other hospital pharmacists followed. It is now time for a new set of trailblazers to once again raise the level of clinical practice in our profession and move us to a higher standard of care. “Some pharmacists have not yet identified patient-care responsibilities commensurate with their extended functions, and the profession as a whole has made no clear social commitment that reflects its clinical functions. Some pharmacists will remain mired in the transitional period of professional adolescence until this step is taken”.5 This summary of the situation, by Hepler and Strand, was written in 1990, but unfortunately it still applies 19 years later. The time for action and professional growth is now.
I would like to acknowledge the members of the BC Health Authorities Advanced Practice Pharmacist Working Group, led by Dr Robin Ensom. In developing this article, I drew on our discussions and debate on this topic.
No, I do not believe that there should be a separate licence for advanced pharmacy practitioners. I see no advantage in creating such a licence, from either the patient care perspective or the perspective of advancing our profession. The definition of a licence is permission by law to do something.1 Once a pharmacist has a licence to practise pharmacy and provide patient care, he or she should not require further or special permission to care for patients with complex health care issues (the definition of an advanced practitioner).
One argument for a separate licence is to facilitate advancement of the profession. However, this is a tough sell if we consider that up until now advanced practitioners have not needed a separate licence to use their knowledge and skills to move the profession forward, nor have they needed a separate licence to improve patient care. Currently, no Canadian provinces have a separate licence for advanced practitioners, but the scope of pharmacy is expanding rapidly across Canada. At least 8 of the provinces have recommended or adopted some form of prescribing by pharmacists. One could argue that a separate licence for advanced practitioners would lead to a 2-tiered system, whereby only a select group of highly trained individuals would be able to perform specific tasks. Moreover, a 2-tiered system within the profession could severely limit expansion of the scope of practice and might actually stifle the advancement of our profession by leaving the majority of competent practitioners behind. This would ultimately be divisive.
In a report on the scope of contemporary pharmacy practice released earlier this year, the US Council on Credentialing in Pharmacy stated that “new professional services have been introduced and an expanded range of post-licensure credentials, education, and training have been created to assure the contemporary competence of all practitioners and to support their continuing professional development and career progression.”2 Notably, the Council supports postlicensure credentials, rather than further licensing. This authoritative body suggest that continuous professional development is what moves a profession forward, not the availability of a separate license for advanced practitioners.
This issue also becomes very complicated in terms of defining what exactly an advanced practitioner is and what he or she does. In addition, there are many different types of advanced practice, which vary not only by setting, disease state, and patient population, but also by roles and responsibilities. Should there be separate licensure for advanced general practitioners, advanced pediatric practitioners, advanced geriatric practitioners, and certified diabetic educators, or for pharmacotherapy specialists (or board-certified pharmacotherapy specialists) in nuclear pharmacy, nutrition support, oncology, psychiatry, and pharmacotherapy? Where would we draw the line? Compounding pharmacists have additional training and expertise, but should they too have a special licence? The National Association of Pharmacy Regulatory Authorities (NAPRA) has struggled with this issue for more than 10 years. In 1998, the development of a regulatory process and standards for specialization was viewed by the registrars as important for public protection, for maintaining the integrity of the profession, and for allowing pharmacists with special expertise to be recognized as such through the activation of protected title designations. Just recently, a framework for recognition of 4 specialaty areas has been published.3 If it is difficult for NAPRA to develop a set of guidelines for advanced practice, is it even possible to set criteria for an advanced pharmacy practice licence?
The one possible advantage to an advanced practice licence would be to limit those who are not qualified, but Canada’s pharmacists are self-regulated health care professionals. It is up to each of us to meet the minimum standard of practice but also to recognize and understand the limits of our knowledge and skills and to avoid practising beyond our own capabilities. The expanded scope of practice being recommended by many provincial authorities should be adopted by all competent practitioners; it should not be reserved for a select group of elitists. Pharmacists may require further education to meet the expanded scope of practice, but there is no need for a separate licence to fulfill a role that many have already accepted.
The creation of an ill-defined licence for a nebulous group of practitioners so that they can perform a few select tasks for a relatively small number of patients is the wrong approach for our profession. I believe that continuous professional development in the form of postlicensure credentialling, training, and education would best serve patient care, our profession, and the Canadian public.