To explore the need for pharmacists in Jamaica to be trained to the Doctorate of Pharmacy (PharmD) level to provide better pharmaceutical care practices UHWI Pharmacy Interns (September 2009 – February 2010)

Introduction Over the past four decades there has been a trend for pharmacy practice to move away from its original focus on medicine supply towards a more inclusive focus on patient care. The new approach has been given the name pharmaceutical care, the gold standard of Clinical Pharmacy. In some countries, clinical pharmacy with patient-focused practice is no longer the exception but the rule for most pharmacists. The pharmacy curricula have long been neglected at many learning institutions, which has helped perpetuate the undervalued status of pharmacists in the health care sector, particularly in developing countries such as Jamaica

Purpose of Study Whether pharmacists in Jamaica believe that it is necessary to be trained to the Pharm D level in Jamaica at this time. Aid in ascertaining whether more emphasis should be placed on upgrading pharmacist training/ education or whether the current BPharm level of training is sufficient to carry out the required functions of pharmacists. Help to optimise the practice of Pharmacy in Jamaica for the benefit of the Jamaican population in terms of health care. Whether the pharmacists’ view or assessment of their training has any implication on the status of the profession and the limitations pharmacists face in executing their required functions.

Objectives To determine whether pharmacists with a Bachelor of Pharmacy (BPharm) in Jamaica believe they are adequately trained to execute various functions in the pharmacy practice. To determine if there are any differences in the practice of pharmacy between graduates of a non-traditional Doctor of Pharmacy (PharmD) program and a Bachelor of of pharmacy program. To explore whether pharmacists with a Bachelor of Pharmacy degree intend to pursue a Doctorate of Pharmacy and their reasons.

Research Questions Do pharmacists in Jamaica with a Bachelor of Pharmacy (BPharm) degree believe they adequately trained to execute various functions in their pharmacy practice? Are there any differences in the practice of pharmacy between graduates of a non- traditional Doctor of Pharmacy (PharmD) program and a Bachelor of of pharmacy program? Do pharmacists in Jamaica with a Bachelor of Pharmacy degree intend to pursue a Doctorate of Pharmacy degree ?

Problem Statement The International Pharmaceutical Federation; the fundamental objective at all times must be the striving towards ever higher standards of practice, for the benefit of the patients and community being served, by achieving better outcomes as well as the development of the profession. World standards demand a more personalized, detailed patient care that focuses on therapeutic management as a whole rather than just the dispensing of medication. Pharmacists, trained as drug experts, should have a wealth of knowledge as it relates to pharmacological as well as non- pharmacological care. The traditional role of pharmacists is to manufacture and supply medicines, as such some pharmacists do not routinely counsel their patients, make documentations of interventions, follow up on patient care and monitor response etc.- PC.

Problem Statement This results in patients receiving substandard care which has far reaching implications for the general health of the workforce and the general population of Jamaica. This begs the question of whether BPharm trained Pharmacists believe they were adequately trained to carry out their functions especially as it relates to the clinical aspect of Pharmacy. Several developed countries have moved towards having this qualification as the minimum requirement for their Pharmacists. In our present system, there have been debates on the issue of the need for pharmacists trained to the PharmD level in Jamaica as pharmacists holding PharmDs have been complaining that there is no scope for them to practice in Jamaica.

Definitions Need: A necessity that is lacking; an area requiring relief; an unmet demand Relevant: pertinent; having a logical connection to the matter in hand Pharmacy practice: the roles carried out by the pharmacist.

Objectives To determine whether pharmacists with a Bachelor of Pharmacy (BPharm) in Jamaica believe they are adequately trained to execute various functions in their pharmacy practice. To determine if there are any differences in the practice of pharmacy between graduates of a non-traditional Doctor of Pharmacy (PharmD) program and a Bachelor of of pharmacy program.

Objectives (cont’d) To explore whether pharmacists with a Bachelor of Pharmacy degree intend to pursue a Doctorate of Pharmacy and their reasons.

Literature Review Is There A Need For Pharmacists Trained In The PharmD Level? Argued 2 ways: a)Since there is no distinction of duties between BPharm Pharmacists, Masters degree pharmacists and Pharm. D pharmacists in the professional settings (or even between the above mentioned groups and the Dip pharmacist in some settings), training of pharmacists to the Pharm. D level, by law of redundancy, would not be necessary.

Literature Review a)Upgrading of professionals in any field is imperative for the establishment and enhancement of esteem, self worth, and public perception of the said profession. Since the public perception of pharmacy and Pharmacists have in recent times been on a steady decline, it is now an importance of the highest priority that Pharmacists be trained to the Pharm. D level.

Literature Review-Argument A article from the American Journal of Pharmaceutical Education; 2009 August 28; 73(5): 92, entitled “PharmD or Needs Based Education: Which Comes First?” by Claire Anderson and Billy Futter - “We wonder what evidence would be needed to be satisfied that the PharmD degree was the way to go for everyone?

Literature Review – Argument A Surely we would need to see evidence of an overall decline in the number of medicine- related problems, fewer prescription errors, fewer medicine-related hospital admissions, increased medicines adherence, and perhaps an increase in life expectancy coupled with a decline in the national spending on these issues?

Literature Review-Argument A In developing countries, critical indicators would include increased access to, availability of, and appropriate use of safe, efficacious, and quality medicine. It would currently be very difficult to develop a convincing argument to support a relationship between these indicators and the introduction of the PharmD degree...”

Literature Review-Argument A this difficulty exists because, especially in Jamaica, the Bachelor of Pharmacy degree program is designed to train pharmacists to a level of competence in the relevant clinical and dispensary settings that would also facilitate the adequate execution of such duties.

Literature Review-Argument A Gary D. Byrd in his 2001 contribution to the Journal of Medical Library Association entitled, “Can the Profession of Pharmacy Serve as a Model for Health Informationist Professionals?” (J Med Library Assoc January; 90(1): 68–75.), “Until recently, most pharmacists graduated from five-year baccalaureate programs preparing them to understand drug products, sources of supply, and effective ways to dispense them to patients as prescribed by physicians.

Literature Review-Argument A Today, almost all pharmacy students graduate from six-year doctor of pharmacy programs that prepare them to be the primary providers of what their profession calls ‘pharmaceutical care.’ the baccalaureate programs in the US did not cover pharmaceutical care, as a result, the pharmD program was instituted to cover and concentrate in pharmaceutical care.

Literature Review-Argument A general education (including the humanities, social and behavioral sciences, oral and written communication, and computer and information technologies) basic physical and biological sciences and mathematics biomedical sciences (anatomy, physiology, biochemistry or molecular biology, immunology, and biostatistics)

Literature Review-Argument A pharmaceutical sciences clinical sciences (epidemiology, pathophysiology, clinical laboratory medicine, physical assessment, health promotion, and disease prevention) Practice experiences (in ambulatory, inpatient, and managed-care environments; in ethical principle applications and legal issues; and in drug information management).”

Literature Review-Argument A Due to the inability of pharmacists to experience professional actualization, where actual practice scarcely resembles what students are taught, students may become disappointed and upon becoming qualified pharmacists, may migrate for better career opportunities abroad where they are able to fully utilize their wealth of knowledge and skills.

Literature Review-Argument A Laurence Levy, in an article published in the British Medical Journal entitled ‘The First World’s Role In The Third World Brain Drain’ as he stated that “While the home situation remains unattractive compared with elsewhere, the void that is the northern hemisphere will continue to suck in qualified people from the third world in increasing numbers, and the third world will continue to finance it”

Literature Review-Argument B Study - “Results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study”, by Wendy A. Gattis, Vic Hasselblad, David J. Whellan, and Christopher M. O'Connor, published in Vol. 159 (16), September 13, 1999 issue of Archives of Internal Medicine, it was concluded that the outcomes of heart failure is improved when clinical pharmacists are a part of the multidisciplinary heart failure team, possibly due, in part, to closer follow-ups.

Literature Review-Argument B It can further be deduced that since a higher level of training (PharmD) will increase knowledge base and expertise of the pharmacist, then more efficient pharmacist interventions will be made, which will possibly result in even greater improvements. priority of pharmacists: to give the most efficient, effective and expert service and advice.

Literature Review-Argument B This can only be improved with increased specialized training which can be offered at the PharmD level When such a situation of multidisciplinary health care relationships becomes continuously successful, the importance and cementing of a more constant, permanent, integral place for pharmacists on the health care team will become priority

Literature Review-Argument B He further added that “in our anxiety to be part of and recognised as first world we in the third world have produced professionals whose expectations we cannot meet, because outside a few centres we do not have the financial resources to compete” (British Medical Journal, July ; 327:170. ).

Methodology descriptive in design survey was conducted and involved 80 pharmacists throughout the island February to April 2010 target population being pharmacists holding a BPharm and/or PharmD convenience sampling

Methodology Participants were taken from hospitals, retail pharmacies, distribution houses or wherever pharmacy interns/researchers where located at that point in time data collection employed the use of questionnaires 10 open-ended and closed-ended/optional questions

Methodology pilot study to validate whether the objectives of our study were being met through the questions Statistical analyses were conducted with the PASW version 18.0.

Analysis Analytical methods were employed to assess and test the following null hypotheses: 1.Pharmacists in Jamaica with Bachelor of Pharmacy (BPharm) degree do not believe that they are adequately trained to execute various functions in their pharmacy practice

Analysis 1.There are no differences in the practice of pharmacy between graduates of a non- traditional Doctor of Pharmacy (PharmD) program and a Bachelor of of pharmacy program 1.Pharmacists in Jamaica with a Bachelor of Pharmacy degree do not intend to pursue a Doctorate of Pharmacy degree

Results Overview of Data Collection – 80 questionnaires were distributed to pharmacist who were selected by convenience sampling – Of the 80 questionnaires distributed, 50 questionnaires (60.0% response rate), were returned and analysed.

Results Pharmacy Profile Respondents Bpharm degree (92.9 %) Hospital pharmacy (46.0%) Retail pharmacy (42.0%) Of the 50 respondents – 25 respondents have been practicing pharmacy for 1 – 5 years – 12 have been practicing pharmacy for 6 – 10 year – 5 have been practicing for 10 – 15 years – 8 have been practicing for over 10 years.

Results and Analysis Objective # 1 – To determine whether pharmacists with a Bachelor of Pharmacy (BPharm) in Jamaica believe they are adequately trained to execute various functions in the pharmacy practice.

Results and Analysis Adequacy of Training Percentage of respondents that believed they were adequately trained in the following areas of pharmacy practice: – Dispensing – 88.0% – Providing drug information – 91.8% – Collecting patient specific medical data – 78.0% – Assessing the data collected for drug related problems – 86.0% – Designing a pharmaceutical care plan with the aim to improve treatment – 62.0 % – Designing a pharmaceutical care plan to reduce or prevent drug related problems – 77.6% – Consulting with other members of the healthcare team – 86.0% – Assisting patients with medication and medical devices % – Monitoring and Following up patients – 70 %

Results and Analysis Adequacy of training Areas of designing pharmaceutical care plans to improve treatments and to reduce drug related problems and monitoring and following up patients, 32.0%, 18.0%, 26.0 % of the respondents respectively, felt that they were undertrained. Of the 4 respondents who were PharmD trained pharmacists, all 4 pharmacists believed they were adequately trained in all areas of practice evaluated.

Results and Analysis Objective # 2 – To determine if there are any differences in the practice of pharmacy between graduates of a non-traditional Doctor of Pharmacy (PharmD) program and a Bachelor of of pharmacy program. Null Hypothesis – There are no differences in the practice of pharmacy between graduates of a non-traditional Doctor of Pharmacy (PharmD) program and a Bachelor of pharmacy program

Results and Analysis Pharmacy Practice Mann - Whitney U test for two unrelated groups was employed to test if there was a significant difference in the practice of pharmacy between the non-traditional PharmD graduates and BPharm graduates. The results revealed a difference in three areas of practice: – The assessment of data to identify drug related problems – The design of a pharmaceutical care (PC) plan with the aim to improve treatment – The monitoring and following up of patients for whom care plans have been designed.

Results and Analysis Pharmacy Practice A rank correlation test - Spearman’s rho - was performed to test if there was a significant relationship between the differences in the pharmacy practice and the level of qualification – BPharm or PharmD. A positive and significant Spearman’s rho found for level of qualification and the following: – Assessment of data to identify drug related problems (.316, p <.05) – The design of a pharmaceutical care (PC) plan with the aim to improve treatment (.361, p <.05) – The monitoring and following up of patients for whom care plans have been designed (.396, p <.05)

Results and Analysis Objective # 3 – To explore whether pharmacists with a Bachelor of Pharmacy degree intend to pursue a Doctorate of Pharmacy and their reasons.

Results Do BPharm graduates intend to pursue a PharmD ? 47.6% said they were unsure 35.7% said yes

Results Reasons to pursue a PharmD: 'to increase knowledge that would help in managing patients‘ 'to increase knowledge that would help in the practice of clinical pharmacy‘ 'to increase pay' 'to acquire the skills to move to another country'

Results Reasons for being unsure about pursuing a PharmD: – 'limited scope based on the standards of practice in Jamaica‘ – 'lack of finances'

Discussion An important aspect of the Clinical Pharmacist’s function is the designing of a pharmaceutical care plan. The plan has many a components to it but ultimately, the best choice must be made for the patient and monitoring and follow up of the patient is key. It is through these latter components of the plan that an evaluation of the patient’s that the pharmacological management of the patient is assessed and also the value of the Clinical Pharmacist is rated. According to the results arrived at, there seems to be a limitation in the training offered to the BPharm graduates as the overall opinion is that they are undertrained in this area. The PharmD graduates on the other hand believe their training equips them to function adequately in this activity. This could be attributed to the fact that the PharmD programme is more clinically oriented, hence students are found more in the clinical area and the pharmaceutical care plan is there main tool. Using Jamaica as an example, the BPharm graduates spend less time in the clinical area and so find themselves having less practice with the care plan.

Discussion While both groups believe their training has its uniqueness about it, from the results, it can be seen that in practice, except for dispensing, both the BPharm and the PharmD graduates practice most aspects of the care plan ‘sometimes.’ Several factors could attribute to this ranging from lack of adequate remuneration, lack of legal coverage, lack of recognition, no ease in promotion and limited resources (both human and material). In countries where the value of the Clinical Pharmacist is valued, respect for the pharmacists came through documentation of their intervention and outcomes. It was on this foundation, that Clinical Pharmacists were able to lobby their importance as a part of the medical team. From our results, this was not a practice by the majority of our respondents, most of which were BPharm graduates. It was through this deficiency in documentation practice that we were unable to determine if there is a need for pharmacists to be trained to the PharmD level.

Discussion Many pharmacists holding a BPharm certification seem uncertain whether or not to pursue the PharmD degree for varying reasons which include: inadequate funds and limited scope in terms of practice. On the other hand, a large number seem to want to pursue the PharmD degree for both personal reasons and some to add to their knowledge gained through the BPharm programme which will in turn enhance the professional practice. The percentage difference between those wanting to pursue the PharmD degree and those who are uncertain was very minimal. The assumption could be made however, that those wanting to pursue same, would be doing it for either personal achievement or esteem of the profession.

Recommendations Pharmacy has an important role to play in the health sector reform process. To do so, the role of the pharmacist needs to be redefined. Pharmacists have the potential to improve therapeutic outcomes and must position themselves at the forefront of the health care system. The movement towards pharmaceutical care is a critical factor in this process.

Recommendations cont’d Pharmacy students and practitioners must be educated to assume the responsibility for managing drug therapy so that they can maintain and expand their position in the health care system and be compensated for their role in providing pharmaceutical care.

Recommendations cont’d An adequate level of remuneration for pharmacists is key in encouraging pharmacists to move towards improved pharmacy practice, and in particular towards pharmaceutical care. Efforts to ensure adequate re-compensation will require effective documentation of outcomes as well as agreement by funders that the PC offered has economic value.

Recommendations cont’d The main driving force for change, however, will have to come from pharmacists themselves. The pharmacists will need to be committed to change and to using their influence to convince the authorities of the need for change.

Recommendations cont’d In order to confirm if there is a need for the PharmD to practice in Jamaica and to determine the extent of such a need further research needs to be done which should include the use of longitudinal studies and probability sampling rather than convenience sampling as was used in this research.

Summary and Conclusion Based on the findings, hypothesis two was rejected for this sample, but hypotheses one and three cannot be accepted or rejected because of lack of adequate testing. It is believed however, that based on inferences drawn, it is probable that hypotheses one and three may be rejected for this sample. Generalisations could not be made to the general population given the sample size and the restriction of the sample. These are times of enormous change in health care and in the pharmacy profession. At no time in its recent history has the profession been faced with such challenges and opportunities. While the profession should articulate pharmaceutical care as the major contribution it has to offer to society, pharmaceutical education needs to develop the outcomes, competencies,content and process of the educational curriculum that is required to prepare students to render pharmaceutical care at the entry points in the health care system.

Reference American College of Clinical Pharmacy(2000). A vision of pharmacy’s future roles, responsibilities and manpower needs in the United States. White paper. Pharmacotherapy.20(8)991–1022. Available at: Byrd, Gary (2001). Can the Profession of Pharmacy Serve as a Model for Health Informationist Professionals?Journal of Medical Library Association. 90(1): 68–75. Claire Anderson, C. & Futter, B.(2009). PharmD or Needs Based Education: Which Comes First. American Journal of Pharmaceutical Education.73(5): 92.

Reference Gattis, W., Hasselblad, V.,Whellan, D.et al(1999) Results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Archives of Internal Medicine. Vol. 159 No. 16. Levy, Laurence(2003).The First World’s Role In The Third World Brain Drain. British Medical Journal. 327:170 (19 July). TFJ Trom(1999) Report of the Task Force for Implementing Pharmaceutical Care into the Curriculum. Kampen The Netherlands: University of Groningen Quality Institute for Pharmaceutical Care and European Association of Faculties of Pharmacy.

Reference The Hague Netherlands:International Pharmaceutical Federation(2002)FIP Statements of Professional Standards. Continuing professional development. Available at: Wiedenmayer, K; Summers, Rob S; Mackle, Clare A; et al(2006). Developing Pharmacy Practice- A focus on patient care, World Health OrganizationDepartment of Medicines Policy and Standards.Geneva, Switzerland, In collaboration with International Pharmaceutical Federation The Hague, The Netherlands.

Reference World Health Organization(1997)The role of the pharmacist in the health care system. Preparing the future pharmacist: curricular development. Report of the third WHO Consultative Group on the Role of the Pharmacist, Vancouver, Canada, 27–29 August Document no. WHO/PHARM/97/599. Available at: Wuliji T, Airaksinen M (2005) Counselling, concordance, and communication: innovative education for pharmacists. The Hague, The Netherlands: International Pharmaceutical Federation Pharmacy Information Section and International Pharmaceutical Students’ Federation.