Impact statements

  • This study provides a better understanding of the work of pharmacists in general practice, which supports further implementation and integration of general practice-based pharmacists.

  • An overview of the broad variety of pharmacists’ drug-related tasks may facilitate definition and clarification of the scope of pharmacists’ practice in primary care.

  • This study indicates that future research should focus on the development and implementation of advanced tasks in general practice, such as responsibility for the evaluation of treatment effects in certain patients.

Introduction

The aging population and increased prevalence of multimorbidity result in the prescription of more medications and thereby complex pharmacotherapy [1]. This complexity may lead to individual therapies becoming inappropriate and even harmful for patients, putting pressure on healthcare systems [2]. At the same time, there are increasing shortages of physicians and nurses in many countries [3]. In primary care—central to the provision of health care and a gatekeeper to hospital care—general practitioners (GPs) are experiencing an increased workload, challenging the provision of high-quality care [4,5,6]. Pharmacists, who are qualified medication experts with a range of knowledge and skills, have been introduced in general practice to cope with this challenge [7, 8]. Evidence suggests that pharmacists can provide valuable services to ease the burden on general practice in addition to improving patient safety and health outcomes [9,10,11]. Some countries including Australia, Canada, the United Kingdom (UK) and the United States of America (USA), have well-established general practice-based pharmacists compared to other parts of the world. The pharmacists in these countries undertake a range of activities such as medication reviews and management of chronic conditions [11, 12]. In many European countries like Sweden, the concept of pharmacists in general practice is relatively new, and literature on their work is scarce. A lack of knowledge about what these pharmacists can contribute to general practice may hinder the development of the profession. A better understanding of pharmacists’ current tasks can promote further implementation of pharmacists in general practice, increasing their contribution to high-quality care and patient safety.

Aim

The aim of this study was to explore the tasks performed by pharmacists in general practice in Sweden.

Ethics approval

Ethical considerations were made, informed consent was obtained from all individual participants. All data were deidentified during analysis and reporting to ensure the participants’ anonymity. According to the Swedish Ethical Review Act [13], no ethical approval was required for this study.

Method

Study design

This study employed a qualitative case study approach that involved 3 data-collection methods: self-reporting tasks, participant observation and semi-structured interviews. A case study is an in-depth investigation of a phenomenon within a specific social system (a case) in its real-life context [14]. For this study, the case of pharmacists in general practice within Region Uppsala, Sweden, was investigated, with focus on the tasks that these pharmacists performed.

Setting

Region Uppsala is steered by the local county government and responsibilities include health care of all 390,000 inhabitants in Uppsala County [15]. Approximately half of the general practices within the county are operated by the region. Since 2019, Region Uppsala has invested in permanent pharmacist positions within general practice to improve medication use and safety in primary care. The primary role of these pharmacists was to conduct medication reviews to identify, resolve and prevent drug-related problems in older patients using multiple medications (polypharmacy). Other tasks could be performed based on the needs and prerequisites of the specific workplace. For this study, all 7 general practices where pharmacists were working, either physically or remotely, within Region Uppsala were included. One of these practices, the geriatric outpatient unit, was for people aged over 65 years with chronic conditions and who had difficulties accessing their general practice. The other 6 practices were considered standard general practices serving between 8000 and 19,000 patients.

Sampling and recruitment

The 9 pharmacists working at or for the general practices constituted the potential study population. For the self-reported tasks and interviews, all 8 pharmacists working in general practice within Region Uppsala during the data collection period were approached by e-mail and agreed to participate (one pharmacist being on parental leave during each part). Two pharmacists were recruited for participant observation. They were chosen because they were the only two pharmacists with at least 1 year experience working in general practice, were on location during the Covid-19 pandemic, and were not one of the authors. Additionally, we aimed to conduct a semi-structured interview with one pharmacist from each of the general practices, including those who had been observed.

Data collection

Tasks were self-reported by pharmacists working throughout March 2021. They were instructed to report all performed tasks, on a daily basis, including requests from other healthcare professionals (HCPs), besides conducting medication reviews and excluding non-clinical work (e.g., participating in workplace meetings). The rationale for not including medication reviews was that we already knew that pharmacists perform this activity on a daily basis as their main task. For each task, the following information was reported in an online shared Microsoft Excel® spreadsheet, only accessible for the pharmacists: date, one-sentence description of the task and who initiated/requested the task.

Participant observation and semi-structured interviews were conducted between October and November 2021 by RK. Two pharmacists were observed during two full working days each. The observations were unstructured to allow an inductive approach. An observation protocol, adapted from a previous study [16], was used to record the tasks/activities the pharmacists performed, including when, how, where and with whom they interacted (Supplementary material). Apart from observations, the researcher also noted her own thoughts and interpretations, as well as information provided by the pharmacists during informal interviews, which was also considered relevant data for the purpose of this study.

For the semi-structured interviews, an interview guide was developed using Jacobs et al. [17]. The interview topics were based on the previous experience and knowledge of the researchers: the pharmacist’s tasks and work activities, patient population, collaboration with other HCPs, workplace and setting as well as perspectives on the future development of and challenges for pharmacists in general practice (Supplementary material). The interviews were conducted online through Zoom (a video conferencing system), audio-recorded and transcribed verbatim by the same researcher (RK).

Data analysis

Data were analysed iteratively with conventional content analysis [18]. Self-reported tasks were analysed by the first author (TK) including familiarisation with the data, coding tasks and task groups. A second categorisation was performed according to the medications (drug group or drug treatment) involved in each task, if such data were available. The free text data about who had initiated or requested the task were also categorised. Finally, categories were analysed with descriptive statistics. Observation and interview data were thematically analysed by the same researcher (RK) who had collected the data along with one of the other researchers (SKS for observation data and TK for interview data). First, each pair of researchers independently read the data to perform initial coding. Then, a discussion was held between the two researchers about conflicting codes to reach consensus on a coding scheme and categorisation. RK then further categorised and (re)coded the data under the supervision of the other researchers. Afterwards, the third researcher (TK for observation data and SKS for interview data) critically reviewed the results. Finally, the results of the observations were incorporated in the themes and categories that emerged from the interviews, as all observations fitted into the interview themes and categories.

Research team and trustworthiness

All observations and interviews were performed by a final-year pharmacy student without prior experience of qualitative research (RK). Before the study, she received an introduction to qualitative research (by SKS) and familiarised herself with the basic concepts of participant observation and semi-structured interviewing. SKS is a social scientist with extensive experience in qualitative research within pharmacy practice. TK is a pharmacist and assistant professor of pharmaceutical care. He worked as a pharmacist in general practice in Region Uppsala during data collection, hence participating in the self-reporting and in a semi-structured interview. He is trained and experienced in qualitative research. He was aware that being both researcher and participant had the potential risk of having a too positive view on the pharmacists’ work and mixing study data with personal experience, hence paying close attention to the reported findings being linked to the data.

A process of member checking by participating pharmacists was conducted in September 2022. All pharmacists working in general practice within Region Uppsala were sent a summary of the observation and interview findings and invited to provide reflections to verify the description of the tasks identified. SKS and TK held an online discussion with the pharmacists via Zoom, during which the pharmacists provided feedback on the study findings (Supplementary material). The study findings were adapted accordingly. An audit trail of participant recruitment, data collection and analysis was kept by RK to trace the course of the study and increase confirmability. The Standards for Reporting Qualitative Research were adhered to [19].

Results

Self-reported tasks

In total, 174 tasks were reported by 8 pharmacists (Table 1). Of these, 161 were requested by other health professionals: 124 (76%) by GPs, 26 (16%) by nurses and 13 (8%) by either an assistant nurse, dietician, general practice manager, medical secretary, midwife or patient. The most frequently reported task was drug-related requests or problems concerning an individual patient (n = 80, 46%), followed by questions about the electronic health record (EHR), the multidose drug dispensing (MDD; a dosing aid for patients with disposable bags containing the medications) system or about licences for non-registered drugs (n = 41, 24%; e.g., how to change a prescription to MDD).

Table 1 Pharmacists’ self-reported tasks (n = 174, reported by 8 pharmacists)
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In 106 cases, the drug group or drug treatment involved was reported (Table 2). Pharmacists described dealing with requests or problems related to all kinds of pharmacotherapy relevant to primary care. The most frequently involved drug group or treatment was antidepressants and anxiolytics (n = 16; 15%), followed by pain treatment (n = 12; 11%).

Table 2 Drug group or treatment involved in the self-reported tasks (n = 106)
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Discussion

This study employed a case study approach with data generated from self-reported tasks, participant observations and semi-structured interviews to investigate what tasks pharmacists perform in general practice in Region Uppsala, Sweden. In addition to conducting medication reviews for older patients with polypharmacy, pharmacists handled a broad variety of drug-related requests and problems for which they mainly collaborated with GPs and nurses.

Similar to the findings from two literature reviews with mainly studies from the UK, USA, Australia and Canada [11, 12], and a recent study in Australia [20], pharmacists in Region Uppsala mostly performed tasks related to medication management (e.g., medication reviews, DRPs and repeat prescriptions), hence were involved in detecting, resolving and preventing DRPs. In countries where pharmacists can prescribe medications, medication management also included prescribing activities [11, 12], which was an option carefully considered for the future by some pharmacists in the current study. Other activities were related to collaboration with various HCPs, serving as a liaison between general practice and community pharmacy, and counselling and educating patients and other HCPs [11, 12].

Pharmacists in Region Uppsala performed fewer tasks related to patient examination and screening (e.g., ordering and reviewing laboratory tests and physical examination), chronic disease management (e.g., formulating and following-up on care plans for patients) compared to reports in other studies [11, 12, 20]. These activities require a higher degree of autonomy and responsibility for patient care. Similar to previous studies in Canada [21, 22], pharmacists in the present study expressed a desire to perform such tasks in the future, and assume greater responsibility for patient care. Systematic reviews on the effects of pharmacist services in general practice appear to report more favourable results in studies involving pharmacists in the follow-up of patients, rather than delivering medication reviews, education or drug information [9, 10].

Activities related to auditing and quality assurance are commonly reported by general practice pharmacists in different countries [11, 12, 20]. In this study, these activities were rarely performed but mentioned as potential tasks. Pharmacists stressed that it would be impossible to perform all these activities, as there were too few pharmacists to meet the increasing demand in general practice. Providing a clearer task description may enhance pharmacists’ contribution in general practice, as successful multi-professional collaboration and teamwork are dependent on understanding each other’s roles [23, 24]. At the same time, general practices have different needs, hence efficient use of pharmacists will likely include performing a variety of tasks [7]. The pharmacists in the present study felt that their work became more efficient and valuable over time, as other HCPs understood what pharmacists could contribute to. They adapted their work to local needs, hence becoming more integrated in the general practice. The presence of a pharmacist in the practice is essential for such local work adaptation and successful collaboration with other HCPs [7, 25, 26].

Methodological strengths and limitations

Research trustworthiness and rigour [27] were addressed in diverse ways throughout the research process (Table 5). Some limitations also need to be considered. First, the number of pharmacists observed (n = 2) and interviewed (n = 6) is limited and interview transcripts were neither checked for accuracy nor returned to the participants for comments. However, all pharmacists working in general practice in Region Uppsala participated in this study and preliminary results were member checked. Second, data collection could have been influenced by the pharmacy-background of two of the researchers (TK and RK) and the participants themselves, possibly presenting a more positive description of pharmacists’ performance. This potential risk was mitigated by the involvement of a third researcher (SKS) with a social science background who scrutinized all study findings. In addition, the researchers chose to acknowledge their predispositions and tried to describe the tasks as reported and observed, leaving judgement of their value and relevance to the reader. Third, the study was carried out during the Covid-19 pandemic, which reduced the number of pharmacists working in general practice, possibly having a negative impact on their tasks, for example having fewer face-to-face patient contact.

Table 5 Strategies to ensure the trustworthiness and rigour of the research process [27] employed in this study
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Interpretation and implications

This study provides a better understanding of what pharmacists do in general practice, showing a broad variety of drug-related tasks, and thus supporting further implementation and integration of general practice-based pharmacists. Involving relevant stakeholders (e.g., other HCPs, patients and policy makers) in this process may result in a better comprehension of and more support for the pharmacist’s role in general practice. To further enhance the pharmacists’ contribution in patient care, decisions should also be made at policy or practice level about tasks that require a higher degree of autonomy and responsibility. Future research may focus on the development, implementation and evaluation of such advanced tasks in general practice that include patient examination and screening as well as formal chronic disease management.

Conclusion

Pharmacists in general practice in Sweden perform a broad variety of tasks related to identifying, resolving and preventing drug-related problems, mainly in older patients with polypharmacy.