Pharmacists' Attitudes towards Medically Assisted Dying.

AIMS: We aimed to explore pharmacists' attitudes and support toward medically assisted dying (MaiD) through the End of Life Choice Act 2019 (EOLC), their willingness to provide services in this area of practice, and the influences on their decisions. METHODS: The study was conducted via an anonymous, online QualtricsTM survey of pharmacists. Registered New Zealand pharmacists who agreed to receive surveys from the two Schools of Pharmacy as part of their Annual Practicing Certificate renewal were invited to participate through an email with a Qualtrics URL link. The survey contained questions regarding demographics, awareness, knowledge, support for, and attitudes and willingness to participate. RESULTS: Of the 335 responses received, 289 were valid and included in the analysis. Most participants supported legally assisted medical dying (58%), almost a third of participants did not support it (29%), and 13% of respondents were unsure. The five primary considerations that participants perceived to be beneficial included support from legislation, respect for patient autonomy, discussions around morality, ending suffering, and preserving dignity. The main concerns were legal, personal bias, palliation, stigmatisation, and vulnerability. CONCLUSIONS: The influences on the decision by pharmacists to support and willingness to participate in the provision of services consistent with the EOLC are complex and multifactorial. Diverse factors may influence attitudes, of which religion is the most significant factor in not supporting the Act or willingness to participate. Clarity and standardised guidance to ensure that assisted dying queries are appropriately managed in practice would help to address any potential access issues.

A Qualitative Evaluation of the Australian Community Pharmacy Agreement.

The Australian Federal Government's Community Pharmacy Agreement (Agreement), initiated in 1990 and renegotiated every five years with a pharmacy owners' organisation, is the dominant policy directing community pharmacy. We studied the experience with the Agreements of 38 purposively selected individual pharmacists and others of diverse backgrounds, using in-depth, semi-structured interviews. Although perceived to lack transparency in negotiation and operation, as well as paucity of outcome measures, the Agreements have generally supported the viability of community pharmacies and on balance, contributed positively to the public's access to medicines. There were, however, contradictory opinions regarding the impact of the policy's regulation of pharmacy locations, including the suggestion that they provide existing owners with an undue commercial advantage. A reported shortcoming of the Agreements was their impact on pharmacists' abilities to expand their scopes of practice and assist patients to make better use of medicines, in part due to the funding being almost totally focused on supply-related functions. The support for programs such as medication management services was perceived to be limited, and opportunities for diversification in pharmacy practice appeared constrained. Future pharmacy policy developed by the government could be more inclusive of a diverse range of stakeholders, seek to better utilise pharmacists' expertise, and have a greater focus on health outcomes.

An evaluation of the Australian Community Pharmacy Agreement from a public policy perspective: industry policy cloaked as health policy?

BACKGROUND: A series of Community Pharmacy Agreements (Agreements) between the Federal government and a pharmacy-owners' body, the Pharmacy Guild of Australia (PGA) have been influential policy in Australian community pharmacy (CP) since 1990. While ostensibly to support the public's access and use of medicines, the core elements of the Agreements have been remuneration for dispensing and rules that limit the establishment of new pharmacies. Criticism has focused on the self-interest of pharmacy owners, the exclusion of other pharmacy stakeholders from the Agreement negotiations, the lack of transparency, and the impact on competition. The objective of this paper is to determine the true nature of the policy by examining the evolution of the CPA from a policy theory perspective. METHODS: A qualitative evaluation of all seven Agreement documents and their impact was undertaken using policy theories including a linear policy development model, Multiple Streams Framework, Incremental Theory, the Advocacy Coalition Framework, the Theory of Economic Regulation, the Punctuated Equilibrium Framework, and Elite Theory. The Agreements were evaluated using four lenses: their objectives, evidentiary base, stakeholders and beneficiaries. RESULTS: The PGA has acted as an elite organisation with long-standing influence on the policy's development and implementation. Notable has been the failure of other pharmacy stakeholders to establish broad-based advocacy coalitions in order to influence the Agreements. The incremental changes negotiated every 5 years to the core elements of the Agreements have supported the publics' access to medication, provided stability for the government, and security for existing pharmacy owners. Their impact on the evolution of pharmacists' scope of practice and through that, on the public's safe and appropriate use of medication, has been less clear. CONCLUSIONS: The Agreements can be characterised predominantly as industry policy benefiting pharmacy owners, rather than health policy. An emerging issue is whether incremental change will continue to be an adequate policy response to the social, political, and technological changes that are affecting health care, or whether policy disruption is likely to arise.

Understanding the Risk Factors and Stressors Impacting Optimal Work Practices in New Zealand Pharmacies: A S.H.E.L.L Model Analysis.

(1) Background: The safe performance of pharmacists is an important issue for patients and regulators. It is recognized that pharmacists interact with a variety of healthcare professionals and act as a bridge between other healthcare providers and systems and patients in the health setting. There has been growing activity in exploring factors that impact optimal performance and determinants that are linked with medication errors and practice incidents. The aviation and military industries have used S.H.E.L.L modeling to identify how personnel interact with factors that affect outcomes. A human factors approach is a useful angle to take when trying to improve optimal practice. Little is known about the experiences of New Zealand pharmacists and S.H.E.L.L factors that affect day-to-day practices in their work environment. (2) Methods: We investigated environment, team, and organizational considerations as the determining factors of optimal work practices using an anonymous online questionnaire. The questionnaire was built from a modified version of the software, hardware, environment, and liveware (S.H.E.L.L) model. This identified components of a work system that were vulnerable and that provided risks to optimal practice. Participants were New Zealand pharmacists approached through a subscriber list provided by the regulatory authority of the profession. (3) Results: We received responses from 260 participants (8.56%). The majority of participants indicated that optimal practice was occurring. More than 95% of respondents agreed that knowledge, fatigue interruptions, complacency, and stress affected optimal practice. Equipment and tools, medication arrangement on the shelf, lighting, physical layout, and communication with staff and patients were important factors for optimal practice. A smaller cohort of participants, 13 percent (n = 21), stated that dispensing processes, dissemination, and enforcement of standard operating procedures and procedural guidance did not affect pharmacy practice, 21.3% responded that professional and ethical requirements did not affect optimal practice, 20% stated that having a staffroom affected optimal practice, 20% did not think substance use affected optimal practice, and 30% did not state that cultural differences affected optimal practice. Optimal practice is constrained when there is a lack of experience, professionalism, and communication among staff, patients, and external agencies. COVID-19 also has had an impact on pharmacists both personally and in their work environments. Exploring how the pandemic has affected pharmacists and their work environment warrants further research. (4) Conclusions: Pharmacists across New Zealand agreed that optimal practices were occurring and considered other factors that were perceived to not affect optimal practice. A human factor S.H.E.L.L framework has been used to analyze themes to understand the optimal practice. The rising body of international literature on the effect of the pandemic on pharmacy practice serves as a foundation for many of these themes. Longitudinal data would be useful in exploring some factors, such as pharmacist well-being over time.

The pharmacist as entrepreneur: Whether, how, and when to educate?

INTRODUCTION: Policy and funding changes are transforming how community pharmacists deliver services, with a level of entrepreneurship required to fulfil their dual roles as retailers and health care professionals. This study explored pharmacists' own entrepreneurship skill development, their views on the need for entrepreneurship training, and how and when this should be delivered. METHODS: Qualitative, semi-structured interviews were conducted with 21 New Zealand practising community pharmacists and key pharmacy sector stakeholders known for having an entrepreneurial mindset. RESULTS: Thematic analysis revealed five broad themes in relation to the study aim. Pharmacists had gained skills in entrepreneurship via training and education in a range of settings, including 'on the job'. While views were divided regarding the feasibility of training individuals to be entrepreneurs, most felt that some form of training was required to address shortfalls in the current workforce. There was support for this being delivered as part of the undergraduate pharmacy degree, although some felt that clinical learning should remain the core focus at this level. There were also mixed views regarding the timing of education in entrepreneurship. CONCLUSIONS: This study adds to the literature addressing the pharmacists view of when and by whom education in entrepreneurship should be delivered. The divergence of opinion has implications for educational leaders, policymakers and practitioners. Findings highlight the important role of education and training in developing pharmacists with entrepreneurship skills. However, the format of this in terms of delivery, timing, appropriate training providers, and training content, needs to be better understood.

Service provision in the wake of a new funding model for community pharmacy.

BACKGROUND: Recently, New Zealand has taken a system wide approach providing the biggest reform to New Zealand community pharmacy for 70 years with the aim of providing more clinically orientated patient centred services through a new funding model. The aim of this study was to understand the types of services offered in New Zealand community pharmacies since introduction of the new funding model, what the barriers are to providing these services. METHOD: A survey of all community pharmacies were undertaken between August, 2014 and February, 2015. Basic descriptive statistics were completed and group comparisons were made using the chi squared test with significance set at p < 0.05. RESULTS: 528 responses were received. Education and advice on prescription and non-prescription medicines were the two top listed services provided. There were no significant differences in service provision between rural and metro based pharmacies. Many pharmacies were considering introducing new patient centred services. Four of the top ten frequently provided services have no public funding attached. Costs and staff availability are the most common barriers to undertake services, more predominantly in patient centred services. CONCLUSION: This study was the first to provide an evaluation of service provision in response to a new funding model for New Zealand Community Pharmacies. A broad range of services are being undertaken in New Zealand community pharmacies including patient-centred services. A number of barriers to service provision were identified. This study provides a baseline for the current levels of service provision upon which future studies can compare to and evaluate any changes in service provision with differing funding models going forward.

'The way things are around here': organisational culture is a concept missing from New Zealand healthcare policy, development, implementation, and research.

Internationally, healthcare sectors are coming under increasing pressure to perform and to be accountable for the use of public funds. In order to deliver on stakeholder expectation, transformation will need to occur across all levels of the health system. Outside of health care it has been recognised for some time that organisational culture (OC) can have a significant influence on performance and that it is a mediator for change. The health sector has been slow to adopt organisational theory and specifically the benefits of understanding OC and impacts on performance. During a visit to health research units in the United Kingdom (UK) I realised the stark differences in the practice of health reform and its evaluation. OC is a firmly established concept within policy development, implementation and research in the UK. Unfortunately, the same cannot be said for New Zealand. There has been unrelenting reform and structural redesign, particularly of the primary healthcare sector under multiple governments over the past 20 to 30 years. However, there has been an underwhelming focus on the human aspects of organisational change. This seems set to continue and the aim of this viewpoint is to introduce the concept of OC and outline why New Zealand policy reformists and health services researchers should be thinking explicitly about OC. Culture is not solely the domain of the organisational scientist and current understandings of the influence of OC on performance are outlined in this commentary. Potential benefits of thinking about culture are argued and a proposed research agenda is presented.

An organizational culture gap analysis in 6 New Zealand community pharmacies.

BACKGROUND: The barriers to moving forward and meeting the expectations of policy makers and professional pharmacy bodies appear to relate to the organizational culture of community pharmacy. Despite the importance of cultural change for business transformation, organizational culture has largely gone unnoticed in community pharmacy practice research. OBJECTIVES: To perform an organizational culture gap analysis in 6 New Zealand community pharmacies. METHODS: Mean scores from a cultural rating survey (n=47) were calculated for 8 cultural clusters and mapped onto a typical and a beneficial pattern match (ladder diagram) for each case site. These ladder diagrams provide an understanding of the gap between the 2 ratings based on the gradient of the lines joining cultural clusters-the rungs of the ladder. Software can be used to generate a Pearson correlation describing the strength of the relationship between the typical and beneficial ratings. RESULTS: Eight cultural clusters were mapped: "leadership and staff management"; "valuing each other and the team"; "free-thinking, fun and, open to challenge"; "trusted behavior"; "customer relations"; "focus on external integration"; "provision of systematic advice"; and the "embracing of innovation." Analysis suggested a high level of correlation between the means of the typical and beneficial ratings. Although the variance between average ratings might be quite small, the relative difference can still be meaningful to participants in the cultural setting. The diagrams suggest a requirement for external integration, the provision of systematic advice, and the embracing of innovation to become more typical in most pharmacies. Trusted behavior is the most typical and most beneficial cultural dimension in most pharmacies, whereas valuing each other and the team is the least beneficial. CONCLUSIONS: Gaps in organizational culture have been identified through the use of a rating survey. The dimensions of focus on external integration, providing systematic advice, and embracing innovation require further exploration through interviews in case site pharmacies.