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Accepted Manuscript
Identification of the relationship between barriers and facilitators of pharmacist
prescribing and self-reported prescribing activity using the theoretical domains
framework
Jennifer E. Isenor, Laura V. Minard, Samuel A. Stewart, Janet A. Curran, Heidi Deal,
Glenn Rodrigues, Ingrid S. Sketris
PII:
S1551-7411(17)30476-X
DOI:
10.1016/j.sapharm.2017.10.004
Reference:
RSAP 962
To appear in:
Research in Social & Administrative Pharmacy
Received Date: 10 May 2017
Revised Date:
2 October 2017
Accepted Date: 8 October 2017
Please cite this article as: Isenor JE, Minard LV, Stewart SA, Curran JA, Deal H, Rodrigues G, Sketris
IS, Identification of the relationship between barriers and facilitators of pharmacist prescribing and
self-reported prescribing activity using the theoretical domains framework, Research in Social &
Administrative Pharmacy (2017), doi: 10.1016/j.sapharm.2017.10.004.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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Identification of the relationship between barriers and facilitators of pharmacist
prescribing and self-reported prescribing activity using the theoretical domains framework
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Author names and affiliations
Jennifer E Isenora
Laura V Minardb
Samuel A Stewartc
Janet A Currand
Heidi Deala
Glenn Rodriguese
Ingrid S Sketrisa
a
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College of Pharmacy, Dalhousie University, 5968 College Street, PO Box 15000, Halifax, Nova
Scotia, Canada B3H 4R2, jennifer.isenor@dal.ca, heidi.deal@dal.ca, ingrid.sketris@dal.ca
b
Department of Pharmacy, Nova Scotia Health Authority, 1276 South Park Street, Halifax, Nova
Scotia, Canada B3H 2Y9, LauraV.Minard@nshealth.ca
c
Medical Informatics, Dalhousie University, 5849 University Ave, Halifax, NS, Canada, B3H
4R2, sam.stewart@dal.ca
d
School of Nursing, Dalhousie University, 5890 University Ave, Halifax, Nova Scotia, Canada,
B3H 4R2, jacurran@dal.ca
e
Sobeys Pharmacy Group, Dartmouth, Nova Scotia, Canada, glenn.rodrigues@dal.ca
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Corresponding author:
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Dr. Ingrid Sketris
College of Pharmacy, Dalhousie University
5968 College Street, PO Box 15000
Halifax, Nova Scotia, Canada B3H 4R2
Ingrid.Sketris@dal.ca
Phone: (902) 494-3755
Fax: (902) 494-1396
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Acknowledgements
We would like to acknowledge participants of the stakeholder group, pharmacists who
completed the questionnaire, the Dalhousie Pharmacy Endowment Fund for financial support of
the project, the Pharmacy Association of Nova Scotia for distributing the questionnaire, Dal
Continuing Pharmacy Education for providing a draw for conference registration and promoting
the questionnaire, Poh Chua from Dalhousie for Opinio assistance, Michael Weale and Tania
Alia for sending out fax reminders to pharmacies and Beth O’Reilly for her assistance with
manuscript preparation.
Funding
This work was supported by a grant from the Dalhousie Pharmacy Endowment Fund [no grant
number assigned].
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Background: The scope of pharmacist practice has expanded in many jurisdictions, including Nova
Scotia, Canada, to include prescribing of medications. Objective: To identify the relationship between
barriers and facilitators to pharmacist prescribing and self-reported prescribing activity using the
Theoretical Domains Framework version 2 (TDF(v2)). Methods: The study was a self-administered
electronic survey of all registered pharmacists (approximately 1300) in Nova Scotia, Canada. The
questionnaire was developed using a consensus process that mapped facilitators and barriers to
prescribing with the 14 domains of the TDF(v2). The questionnaire captured information about the type
and rate of pharmacists’ prescribing activities, pharmacists’ perceptions of their prescribing role at the
patient, pharmacist, pharmacy organization and health system level, and pharmacist demographics and
practice settings. A 5-point Likert scale was used for most TDF(v2) domains. Cronbach’s alpha was used
to study the internal consistency of responses within each of the TDF(v2) domains and simple logistic
regression was used to measure the relationship between TDF(v2) domain responses and self-reported
prescribing activity. Open-ended questions were analyzed separately. Results: Eighty-seven pharmacists
completed the questionnaire. The majority of respondents were female (71 %), staff pharmacists (52 %)
practicing pharmacy for a mean of 18 years. The three domains that respondents most positively
associated with prescribing were Knowledge (84 %), Reinforcement (81 %) and Intentions (78 %). The
largest effect on prescribing activity was the Skills domain (OR 4.41, 95% CI, 1.34-14.47). Conclusions:
We determined the TDF(v2) domains associated with pharmacist self-reported prescribing behaviours.
This understanding can assist the development of policy and program interventions at the pharmacist,
pharmacy, and health system levels, to increase the uptake of pharmacist prescribing. Further work is
needed to develop and implement interventions based on the domains identified, and to test these in
pilot settings and then in large-scale interventions.
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Introduction
In Canada, nine of the 10 provinces have passed legislation that permits some form of pharmacist
prescribing as of December 2016.1 Pharmacists are well trained in the appropriate selection,
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management and monitoring of drugs, and in the prevention and management of adverse drug
events.2 They are readily accessible in the community and able to provide advice and prescribe
medications. A recent Cochrane review concluded that prescribing by pharmacists and nurses
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was as effective as prescribing by physicians on a wide variety of outcomes.3 Policies that
expand the scope and role of pharmacists in prescribing and managing medications may improve
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the safety and quality of drug use, as well as cost-effectiveness.4-7 Current legislation in Canada
differs between provinces allowing pharmacist prescribing in various ways, including granting
pharmacists the ability to adapt, substitute and continue existing prescriptions, prescribe in an
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emergency and independently initiate other drug therapies.1,8-10
In Nova Scotia, pharmacists gained independent prescribing authority with legislative changes in
2010 and standards of practice approval in 2011. Nova Scotia pharmacists have the authority to:
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renew existing prescriptions up to 90 days; adapt the dosage, formulation, regimen or length of
time a drug is to be taken; perform therapeutic substitutions; prescribe in an emergency;
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prescribe Schedule II and III drugs; prescribe for specific conditions, including from a list of
specific common minor ailments, and prescribe in a collaborative setting when a diagnosis is
provided.11,12 In conjunction with the legislative approval and standards of practice, an
education program was developed, which focused on understanding the Standards of Practice
and their implications, which were attended by most community pharmacists in the province.
Additional education programs focused on the pharmacist’s role and identity, therapeutic
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knowledge in specific disease states and specific skills related to prescribing (e.g.,
documentation, developing monitoring plans) that were attended by small numbers of
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pharmacists.
Other Canadian and international jurisdictions have evaluated pharmacist prescribing with
respect to such issues as scope and scale of uptake of pharmacist prescribing, impact on quality
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of care and patient safety, clinical appropriateness, patient experience, and response of other
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health care practitioners.13-36
Canadian studies that specifically examined factors that influence pharmacist prescribing
behaviour have been limited.28,37-39 Exploring these factors through a theoretical lens can assist
with specifying important barriers that are amenable to change and developing strategies to
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overcome them as well as facilitators which can promote change.40 The Theoretical Domains
Framework version 2 (TDF(v2)) was developed through a process of consensus, drawing on 33
theories from various disciplines relevant to implementation science and resulting in 14 domains
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(Table 1).41 Understanding environment and context is critical for implementing new practices
and using the TDF can identify barriers and facilitators at the individual pharmacist and
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pharmacy team levels, as well as in the broader context including ethical, legal, political and
financial dimensions, but also those that are less quantifiable, such as nonfinancial organizational
incentives, and peer pressure.42,43
While the TDF and other theories have been used to explore barriers and facilitators to change
across a number of practice settings and health conditions and to examine public health and
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clinical interventions, few studies have examined the barriers and facilitators to pharmacist
prescribing using such an approach and to our knowledge, none have used the TDF to examine
pharmacist prescribing.44-49 In our study, the TDF was used to identify and quantify facilitators
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and barriers to pharmacist prescribing. Many such barriers have also been identified in studies
using other approaches. Makowsky et al used the Greenhalgh model for the Diffusion of
Innovations in health service organizations to understand factors that influence pharmacist
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adoption of prescribing, such as knowledge, skills, confidence and relationships with
physicians.39 An Australian study on pharmacist prescribing identified three main barriers to
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implementation: logistics, organizational priorities, and lack of awareness of other health care
professionals.35 Other previously identified barriers include community pharmacy environment,
remuneration, concern related to liability, relationship with physicians and patients, conflict of
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interest, and level of documentation needed.4,50,51
The TDF(v2) provides a useful approach to map and integrate facilitators and barriers to practice
change, which has been demonstrated by a number of qualitative studies.52-54 Murphy et al
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conducted a qualitative analysis guided by the TDF and its constructs, and determined that the
most frequently coded barriers and facilitators for pharmacists providing services to people with
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lived experience of mental illness and addictions were Social/Professional Role and Identity,
Environmental Context and Resources, Social Influences, and Beliefs about Capabilities.59
The goals of this study were to 1) determine the extent of self-reported pharmacist prescribing in
Nova Scotia, 2) examine Nova Scotia pharmacists’ perceptions on their prescribing role, 3)
identify barriers and facilitators to pharmacist prescribing in Nova Scotia using the TDF(v2), and
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4) determine the relationship between respondents’ perceptions of factors that may influence
pharmacist prescribing by TDF domain and self-reported prescribing activity.
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Table 1: List and brief description of the 14 domains of the Theoretical Domains Framework.
Adapted from Cane et al.41
Optimism
Beliefs about Consequences
Reinforcement
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Intentions
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Social Professional Role and Identity
Beliefs about Capabilities
Goals
Memory, Attention, Decision Processes
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Social Influences
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Environmental Context and Resources
Emotion
Behavioural Regulation
Brief Description
Awareness of something
Ability or proficiency attained through
practice
Behaviours or qualities of individuals in a
work setting
Acceptance of ability, talent or facility that a
person can act
Confidence that things will happen for the
best
Acceptance of truth of outcomes of a
behaviour
Increase response through relation between
response and stimulus
A conscious decision or resolve in a certain
way
Mental representation of end state
Ability to retain information and choose
between alternatives
Aspects of a person situation or environment
that affects skill development, ability,
competence
Interpersonal processes that cause individuals
to change
Reaction pattern of experiential, behavioural
or psychological elements
Anything aimed at changing actions
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Domain
Knowledge
Skills
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Methods
Design
The study design was a cross-sectional self-administered electronic survey of registered
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pharmacists from Nova Scotia.
Setting
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Nova Scotia is one of 10 provinces in Canada. At the time of the study, the province had a
population of over 900,000 people and approximately 1000 licensed pharmacists practicing in
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the community setting (of the 1300 licensed pharmacists in the province).45,46 Pharmaceutical
services provided in Nova Scotia community pharmacies are funded through government
insurance (mainly for those > 65 years of age and families with low household incomes), private
insurance and individuals themselves.47 Pharmacist prescribing services are generally not
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covered through government or private insurance, so most services are paid through individual
out of pocket payment or as part of the health spending account of their private insurance plan.
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Questionnaire development
A literature search in PubMed/MEDLINE and EMBASE was performed to identify any studies
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of previously administered questionnaires related to pharmacist prescribing, per predetermined
criteria (Appendix I). Studies were found from countries such as the United Kingdom, Australia
and the United States of America, and focused on supplementary or independent prescribing in
various practice settings. At least one investigator reviewed each study for relevant content.
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Sixty-six articles were reviewed, but an existing tool that would address the research questions in
the Nova Scotia context was not identified. Five team members reviewed these questionnaires
for relevant questions, themes and ideas, and then composed a set of questions suited to
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pharmacist prescribing in the Nova Scotia context that would be included in the draft
questionnaire, which consisted of 94 questions. Team members reached consensus on the
individual questions to be included in the questionnaire. Next, two reviewers independently
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mapped each question to a domain within the TDF(v2). Reviewers met to compare results and
any inconsistent assignment of questions was reconciled through discussion and consensus.
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Usability testing was conducted with seven stakeholders, consisting of pharmacists, regulators
and research experts to assist in developing the questionnaire for the Nova Scotia context. These
individuals were then excluded from the study. Changes made based on usability testing included
wording clarification, separation of questions and strengthening of wording. A total of six
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questions/statements were added to the questionnaire following usability testing resulting in 100
items in the final questionnaire (Appendix II).
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Questions were both open- and closed-ended and were grouped under the following sections: 1)
pharmacists' prescribing activities, including frequency if applicable, 2) pharmacists’ perceptions
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of their role related to pharmacist prescribing, including barriers and facilitators to pharmacist
prescribing at the patient, pharmacist, pharmacy organization, and health system levels mapped
to domains of the TDF(v2), 3) pharmacists' reasons for not prescribing, if applicable, 4) basic
demographic information such as gender, age, years since beginning practice, education and
training, employment position, practice setting (e.g. pharmacy location, number of prescriptions
dispensed), hours worked in the dispensary, hours devoted to clinical activities, and staffing and
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workflow, and 5) pharmacists' additional comments. Several questions to assess the level of
agreement/disagreement with various statements using a 5-point Likert scale format were also
developed and used in section 2) described above. Four open-ended questions for which
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responses were mapped to the 14 domains of the TDF(v2) were also included in sections 3) and
5) described above. As the survey reflected a new scope of practice for pharmacists and we
anticipated it would be completed by many who did not prescribe, we included definitions of
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pharmacist prescribing, including details on specific categories of prescribing, with the
questionnaire, as a reference for respondents. Respondents could access definitions by scrolling
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their cursor over underlined words and the definition box would open. The final questionnaire is
available in Appendix II.
Participants
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To estimate the prescribing rate of pharmacists in the province with a margin of error of 5 % a
sample of 386 pharmacists was needed, with 163 respondents needed for a margin of error of 7.5
%. At the time of the survey, there were approximately 1100 licensed pharmacists that were
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members of the Pharmacy Association of Nova Scotia (PANS) (of the approximately 1300
licensed pharmacists in the province), so a response rate of 35 % would have been adequate to
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conduct the analyses.
Recruitment
A link to the electronic questionnaire was distributed to pharmacists through PANS via an
emailed weekly newsletter. PANS members who chose to open the email could read through the
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newsletter to find detailed information about the study and a direct link to an electronic
questionnaire for potential participants to use to complete the questionnaire.
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To attempt to achieve an adequate response rate, study information, including a link to the
electronic questionnaire, was included in the newsletter to PANS members for three consecutive
weeks. Paper-based copies of questionnaires were available to participants upon request.
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Recruitment was also facilitated through use of a variety of traditional and social media
mechanisms (e.g. PANS and a local continuing education provider via Facebook and Twitter and
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a local university through Facebook). Response rates were low with the original plan, so an
amendment was approved by the research ethics board to re-open the questionnaire and attempt
additional recruitment strategies. Specifically, a fax reminder was sent to each pharmacy in the
province of Nova Scotia (n = 322) to alert pharmacists to the survey and a link to the
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questionnaire was included in the PANS weekly emailed newsletter for four additional weeks. It
was expected that the fax reminder reached most community pharmacists (approximately 1000)
in the province.57 Other recruitment strategies in the amendment included promotion at the
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regional hospital Pharmacy Research Day and at the annual “Fall Refresher” pharmacy
conference held jointly by a local continuing education provider and PANS. The questionnaire
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was open to participants from January 2014 to October 2014.
Informed consent
Ethics approval was received from the BLINDED, REB #2013-3060, on September 16, 2013
with amendments and annual renewals approved until September 16, 2018.
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Prior to beginning the questionnaire, participants were directed to read an information letter that
outlined the purpose of the study, study procedures, risks, benefits, and the role of participants in
the study. Participants were informed that by clicking the link to the questionnaire they were
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providing their consent to participate.
Data analysis
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Data were exported from Opinio (http://www.objectplanet.com/opinio/) and coded, managed,
and analyzed using statistical software (SPSS version 21.0 and R version 3.2.2). Descriptive
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statistics were used to summarize demographic data and responses to the questionnaire, and to
compare the study population to the Canadian Institute for Health Information (CIHI) data on
pharmacist demographics. For presentation, all cell counts less than five were rounded up to five,
though they were left as-is during analysis. Likert scale (5-point) responses were converted to a
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numerical scale (-2 to 2, where -2 = strongly disagree, -1 = disagree, 0 = uncertain, +1 = agree
and +2 = strongly agree) for analysis, and then collapsed to create three categories (positive,
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neutral and negative) for presentation purposes.
To measure prescribing activity, we asked participants how often they had prescribed in any of
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the following categories: in an emergency, renewal, adaptation, therapeutic substitution,
Schedule II/III drugs, minor and common ailments and collaborative prescribing when diagnosis
provided. We also asked respondents to check yes or no to the statement “I have prescribed in
any of the above categories” which we had planned to use as the primary outcome for the study.
Upon study completion, we observed that this second question correlated poorly with the first, as
pharmacists that indicated they had not prescribing in any of the above categories had in fact
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performed some prescribing tasks. We attributed this to confusion over the wording in the
second question (i.e. what exactly constitutes prescribing), and thus decided to create our own
measure of active prescribing from the first question (see Appendix II for prescribing definitions
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in Nova Scotia). We decided that performing one of the tasks at least once a week (or four times
a month) would be a good indication of “active” prescribing, so a participant was denoted as a
prescriber if they had performed at least one task at least four times a month. We extensively
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investigated other potential definitions of prescribing and this seemed to both divide the
intuitive, and understandable definition.
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participants well between active and inactive prescribers as well as provide an appropriate,
Some questions were coded on a “reverse axis”, where a response of agree (normally +1) or
strongly agree (normally +2) would be a negative opinion (for example, “I fear taking legal
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liability when I prescribe” is a question where agreement is a negative opinion). For these
questions the coding was reversed, so that -2 would be strongly agree and +2 would be strongly
disagree. This ensures that positive opinions are consistently coded as +1 or +2 and negative
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opinions as -1 or -2.
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Cronbach’s alpha was used to study the internal consistency of responses within each of the TDF
domains, and simple logistic regression was used to measure the relationship between responses
and self-reported prescribing activity.
Open-ended questions were analyzed separately using directed-content analysis and the 14
domains of the TDF as the coding framework.59 The coding team was comprised of a licensed
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pharmacist, with a graduate PharmD degree and 14 years in pharmacy practice, and a Clinician
Scientist at the (BLINDED) with a PhD in Interdisciplinary Studies and a Postdoctoral
Fellowship focusing on knowledge translation, as well as several previous publications related to
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the theoretical domains framework.
The two investigators (BLINDED) met prior to coding to discuss initial coding definitions,
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independently coded all transcripts, and met again after coding the first and third transcripts to
compare results and identify discrepancies. Discussion was used to achieve consensus in coding
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and refine definitions (documented in a coding manual), and the investigators met a final time
after all coding was complete to compare results. Consensus was used to resolve outstanding
discrepancies in coding. Findings of the qualitative analysis were brought back to the research
Results
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team which had representatives from various pharmacy stakeholder groups.
A total of 126 pharmacists out of the approximately 1100 pharmacists registered with PANS
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partially completed the questionnaire for a response rate of almost 11.5 %. Of these, 39 were
only partially completed questionnaires and were omitted from the analysis as there was
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insufficient information to contribute to the analysis. Therefore, the final response rate was
closer to 8 %. The majority of respondents were female (71 %) and staff pharmacists (52 %).
They had a mean duration of practice of 18 years (Table 2). Respondents were compared to the
Nova Scotia pharmacist population as determined by CIHI (Table 2) and were comparable with
respect to distribution of gender, age, years practicing, and primary position.46 This study
included proportionately more pharmacists practicing in community.
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Table 2: Comparison of respondent demographics to Canadian Institute for Health Information
(CIHI) human resources data for pharmacists in Nova Scotia in 2014.57
Number of pharmacists
Gender
Completed
Partially completed
Female
Male
Age (years)
Years Practicing
Primary position
87
39
70 %
30 %
23 to 64 (mean 42)
0 to 41 (mean 18)
54 %
24 %
22 %
90 %
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Staff pharmacist
Owner/manager
Other
Practice setting
Community
a
CIHI data provided in age bands
Nova Scotia
Pharmacist
Population57
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Study Result
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Characteristic
1310
73 %
27 %
40-44 (15 %a)
11-20 (27 %a)
62 %
27 %
10 %
76.3 %
Seventy-seven percent of pharmacists reported prescribing at least once in any of the approved
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prescribing categories; however, when “prescribing activity” was defined as an individual
responding that they prescribed at least four times per month in at least one prescribing category,
there were 41 prescribers (47 %) and 46 non-prescribers (53 %), and this was the definition of
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“prescriber” we used throughout the analysis. This definition for “prescriber” was developed
after review of the data with team discussion (see Methods). The three most commonly
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performed (more than four times per month) prescribing activities were prescription renewal (32
%), prescription adaptation (16 %) and prescribing for Schedule II or III drugs (15 %) (Fig. 1).
The TDF(v2) responses are summarized in Table 3 (TDF(v2) domains were sorted by positivity
of responses). Eighty-four percent of respondents indicated positive responses in the Knowledge
domain, and 81 % in Reinforcement, 78% in Intentions, and 77% in Skills. At the other end of the
spectrum only 34 % were positive about Behavioural Regulation and 10 % about Goals.
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Cronbach’s alpha, which measures the internal consistency of a domain, i.e. how likely a
response to one question will match responses to other questions in that same domain, is
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provided in cases where a TDF domain has at least three questions in it. The internal consistency
of all TDF domains was reasonable, except for Professional Role and Identity, which had an
alpha of only 0.377. This domain mixed questions related to pharmacist prescribing as a
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professional role and questions related to the general role pharmacists play on the healthcare
team. Respondents believed they are an important part of the healthcare team (96 %), but were
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more divided on how prescribing fits into their professional role and identity.
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Table 3: Respondents’ perceptions of facilitators and barriers to pharmacist prescribing by most
positive to least positive responsesa as grouped by the domains of the Theoretical Domains
Framework Version 2. Note that cell counts less than five have been rounded up to five.
Negative
Positive
Knowledge (1)
Reinforcement (4)
Intentions (4)
Skills (18)
Optimism (2)
Social Influences
(2)
Professional Role
and Identity (5)
Beliefs about
Consequences
(13)
Emotion (5)
Beliefs about
Capabilities (2)
Environmental
Context and
Resources (8)
Behavioural
Regulation (5)
Goals (1)
TOTAL
5 (6%)
22 (6%)
20 (6%)
85 (5%)
19 (11%)
9 (10%)
30 (9%)
40 (12%)
209 (13%)
32 (18%)
74 (84%)
282 (81%)
272 (78%)
1205 (77%)
120 (69%)
36 (21%)
20 (12%)
108 (62%)
10 (6%)
105 (24%)
65 (15%)
257 (59%)
8 (2%)
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217 (19%)
67 (15%)
633 (56%)
229 (53%)
46 (4%)
20 (5%)
32 (18%)
44 (25%)
90 (52%)
8 (5%)
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235 (21%)
119 (27%)
Cronbach’s
alphab
0.734 [0.56, 0.9]
0.88 [0.76, 1.00]
0.922 [0.88, 0.96]
0.377 [0.14, 0.62]
0.772 [0.68, 0.86]
0.794 [0.66, 0.93]
0.676 [0.54, 0.81]
207 (30%)
114 (16%)
339 (49%)
36 (5%)
160 (37%)
59 (68%)
96 (22%)
13 (15%)
149 (34%)
9 (10%)
30 (7%)
6 (7%)
1129 (18%)
966 (16%)
3815 (62%)
268 (4%)
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a
0 (0%)
14 (4%)
16 (5%)
67 (4%)
3 (2%)
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Number of responses (%)
Missing
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Neutral
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Theoretical
Domains
Framework
domain (number
of questionnaire
questions in
domain)
0.698 [0.54, 0.86]
0.94 [0.93, 0.96]
Likert scale (5-point; strongly disagree to strongly agree) was collapsed to create three
categories (positive, neutral and negative) for presentation purposes.
b
Cronbach’s alpha (a measure of consistency between questions) is included for TDF domains
with at least three questions.
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In the category of Environmental Context and Resources many respondents felt they did not have
adequate time (47 %), staffing (53 %) or reimbursement (55 %) to fully adopt prescribing.
Twenty-six (30 %) respondents indicated they disagreed or strongly disagreed when asked if
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they had access to enough patient health information to prescribe and another 20 (23 %)
indicated they were uncertain. Many respondents believed they had support of their employer (67
%) and many enjoyed the support of their colleagues to discuss specific prescribing concerns (78
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%).
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Simple logistic regressions were used to predict self-reported prescribing activity (prescribing in
at least one category more than four times per month) using TDF domain scores on a 5-point
scale. Table 4 presents the results of the regressions in terms of odds ratios (ORs) and 95 %
confidence intervals (table sorted by the magnitude of the OR). For example, for a 1-point
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increase in Skills score, such as an increase from agree [+1] to strongly agree [+2], the odds of a
respondent's likelihood to prescribe increases 4.41 times (p-value = 0.014). This effect of Skills
on prescribing activity was the largest in the study, but Social Influences (OR=3.7, 95% CI, 1.52-
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9.16) and Emotion (OR=3.3, 95% CI,1.6-7.0) both had significant effects and ORs over 3,
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suggesting a large effect on prescribing activity.
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Table 4: Predictors of pharmacist prescribing activity based on positivity of response by
Theoretical Domains Framework domain.a
ORb
CIc
p-value
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Theoretical Domains Framework domain
0.014
0.004
0.002
0.043
0.111
0.011
0.012
0.052
0.093
0.147
0.022
0.347
0.689
0.876
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Skills
4.41
[1.34,14.47]
Social Influences
3.73
[1.52,9.16]
Emotion
3.33
[1.58,7.04]
Environmental Context and Resources
2.68
[1.03,6.99]
Beliefs about Consequences
2.55
[0.81,8.05]
Knowledge
2.48
[1.23,4.99]
Beliefs about Capabilities
2.19
[1.19,4.05]
Intentions
2.08
[0.99,4.34]
Reinforcement
1.97
[0.89,4.37]
Behaviour Regulation
1.74
[0.82,3.69]
Memory, Attention and Decision Processes
1.71
[1.08,2.71]
Social/Professional Role and Identity
1.55
[0.62,3.86]
Goals
1.11
[0.65,1.9]
Optimism
0.95
[0.5,1.8]
a
As determined by simple logistic regressions (see Methods)
b
OR; Odds Ratio
c
CI; 95 % confidence interval
In all TDF domains, except Optimism, a positive response indicated an increase in the probability
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of prescribing, though the magnitude of the effect of each domain and statistical significance
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varied greatly. The largest effect on prescribing activity was the Skills domain.
Content analysis of qualitative data from open ended questions was used to further elucidate
barriers and facilitators to prescribing. Thirty respondents indicated no prescribing activity and
were redirected to two open-ended questions. One question asked about their reasons for not
prescribing and the other asked what would make them more likely to prescribe. Twenty-four of
the 30 respondents (80 %) provided written comments regarding why they were not prescribing.
Thirteen of these 24 respondents (54 %) commented on a lack of time and staff (Environmental
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Context and Resources domain, sample quotes from respondents: “…too much paperwork and
time…”, “limited staffing, paper work involved…”), three (13 %) commented on a lack of
knowledge around paperwork and third party billing (Knowledge domain, sample quotes from
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respondents: “…unsure regarding third party coverage…”, “…need to figure out what paperwork
is required…”) and three (13 %) commented on not having taken a training program (Skills
domain, sample quotes from respondents “…not fully trained…”, “…did not take the training
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program…”).
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Twenty of the 30 respondents (67 %) who indicated no prescribing activity provided written
comments when asked what would make them more likely to prescribe. Seven of these 20
respondents (35 %) indicated that they would be interested in taking programs or courses (e.g.
“…[taking] the minor ailments course…”), which aligns with the TDF domain Behavioural
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Regulation, as the decision to participate in training is self-determined. Six of the 20 respondents
(30 %) indicated they would be more likely to prescribe if there was enough staff and less
Discussion
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paperwork, which aligns with the Environmental Context and Resources domain.
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In this study, 47 % of pharmacists reported that they prescribed at least four times per month in
one of the approved prescribing categories and 77 % of pharmacists reported prescribing at least
once in any of the approved prescribing categories. In a study completed in Alberta, 93.4 % of
surveyed pharmacists reported that they had prescribed.28 Both studies included between 6 and 8
% of licensed pharmacists in their respective provinces. Prescribing in Alberta could be higher
than in Nova Scotia since Alberta was the first Canadian province to authorize prescribing in
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2007 with all pharmacists being eligible to prescribe in 2009 (versus 2012 in Nova Scotia).8 In
addition, pharmacists in Alberta can be granted an "additional prescribing authorization"
designation; hospital pharmacists with this designation reported prescribing for nearly 50 % of
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their patients in an average week.49 Other jurisdictions have reported on varying degrees of
pharmacist prescribing. For example, in the USA, 41 % of Veterans Health Administration
clinical pharmacists have prescribing authority, and generated 1.9 million prescriptions in
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2015.50
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Applying the TDF(v2), our study identified barriers and facilitators at the individual practitioner
(e.g. knowledge and skills), pharmacy (e.g. adequate time and staffing for prescribing),
regulatory (e.g. concerns related to liability) and health care system (e.g. physician relationship,
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limited reimbursement) levels.
This study suggests that Skills had the strongest effect on pharmacist prescribing (OR=4.41, 95%
CI, 1.34-14.47), indicating that when respondents felt they had the skills to prescribe they were
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more likely to prescribe. This is similar to a study in the UK of 25 nurse and five pharmacist
(two who worked in the community setting) independent prescribers, who raised a number of
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concerns including competencies.62 In particular, a community based pharmacist noted the need
for training and courses at the appropriate level including related to the disease condition.62
In a systematic review of 552 papers (50 reviewed) that studied barriers to health-related
behaviour changes of health care professionals or the general public, Mosavianpour et al found
that the most frequently explored barriers fell under the Environmental Context and Resources
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(84 %), Beliefs about Consequences (74 %) and Social Influences (60 %).63 These domains align
very closely with those identified in this study as having the greatest effect on pharmacist
prescribing activity (Table 4), as our study showed Social Influences (OR=3.73, 95% CI, 1.52-
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9.16), Environmental Context and Resources (OR=2.68, 95% CI, 1.03-6.99), and Beliefs about
Consequences (OR=2.55, 95% CI, 081-8.05) were also important TDF constructs, having the
second, fourth, and fifth largest effects on pharmacist prescribing activity, respectively. Social
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Influences include those working with you, such as the pharmacy team and those who influence
the pharmacists. Interventions could include those that promote team functioning including,
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building trust and delegating tasks and could also involve a pharmacy opinion leader or
champion who was respected and trusted in the province.
This study advances the use of the TDF(v2) by employing it for the development of a
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questionnaire categorizing previously defined barriers and facilitators related to the adoption of
pharmacist prescribing into each domain. While there is a growing body of literature on the use
of the TDF(v2) to examine implementation problems or evaluate and design interventions across
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a range of health contexts, most studies have used qualitative methods.47,64 There has been
limited methodological discussion regarding analysis of survey questionnaires in relation to the
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TDF, with only a few studies published that used surveys and none evaluated pharmacist
prescribing.65 Cronbach’s alpha provided some insight into the consistency of the TDF domains.
A low Cronbach’s alpha may suggest that there are sub-domains within a TDF(v2) domain that
are worthy of further investigation. The TDF(v2) domains provided a valuable structure for
comparing respondent beliefs and attitudes about a primary outcome variable (prescribing
activity). This allowed for the simple logistic regressions to be built, but the inherent co-linearity
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between TDF(v2) domains prevents a multivariate model from being produced, which makes it
challenging to study how the TDF(v2) domains may be related to one another. Our questionnaire
development, findings, and analysis can help other researchers refine their survey instruments
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and qualitative interview guides to study pharmacist prescribing using the TDF(v2). Future
studies may further consider number of questions per domain, overlap between domains, and
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classification of topics within a domain.
The facilitators and barriers identified in this study can be mapped to potential implementation
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strategies using taxonomies or structured lists, such as the Behavioural Change Techniques (v1)
and tools, such as the Behaviour Change Wheel and the Expert Recommendations for
Implementing Change (ERIC) discrete implementation strategy compilation.41,66-69 For example,
the TDF findings of our study can be mapped to the Behaviour Change Wheel to identify
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behaviour change techniques that could be used, such as interventions to promote restructuring
of the environment, like the building of a private counselling room (13 respondents indicated
they worked at a pharmacy that did not meet this prescribing requirement), which could address
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the Environmental Context and Resources domain.67
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The results of this study support the idea that pharmacists require some level of knowledge and
skill to engage in prescribing. Continuing professional development programs support
knowledge and skill development. Those that also address other factors that correlate to
prescribing activity may be more effective. In England, 82 % of pharmacists agreed that their
prescribing training courses were useful, and 62 % indicated that the necessary prescribing skills
were gained.67 Programs that involve pharmacy teams (including such personnel as pharmacists,
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pharmacy managers, corporate management, pharmacy information technology managers, and
pharmacy assistants), and subsequently impact Social Influences, rather than individual
pharmacists, may broaden the level of support. Educational programs that assist not only with
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improving knowledge and skills at the pharmacist level, but provide skills at implementing new
services at the organization level (e.g., revising the role of pharmacists and other staff, workflow
and workload management, technological resources, alterations to the physical environment,
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strategic, operational and marketing plan development) would create an opportunity for
pharmacists to apply newly acquired knowledge and skills to enhance the level of support and
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prescribing activity.
This study examined both individual and contextual variables affecting pharmacists’ prescribing.
In many studies of barriers, the emphasis is on the individual level, with less attention paid to
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context.51 Understanding environment and context is critical and important factors were
suggested by this study such as characteristics, norms, values, relationships and interactions of
pharmacists and the providers and staff they work with and patients they serve, the pharmacy
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organization, and the broader context including ethical, legal, political and financial dimensions,
but also those that are less quantifiable, such as nonfinancial organizational incentives, and peer
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pressure.42,43 The TDF identifies the barriers and facilitators, but the modifiability of these, the
feasibility to implement change and the potential unintended consequences of addressing only
one barrier or facilitator on the community pharmacy system will need further investigation.
One limitation to this study was the low response rate; however, this study sampled 8 % of all
licensed pharmacists in the province of Nova Scotia, which is similar to that reported
elsewhere.28 The study sample was largely similar in demographics to the Nova Scotia
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pharmacist population; however, it is likely that the study sample differs from the general
pharmacist population in the province in that the respondents may have been more interested in
prescribing. This study has also raised key methodologic challenges. Some challenges are related
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to defining prescribing and to operationalizing the TDF(v2). For example, although definitions
for many terms used in the study were included in the questionnaire, some pharmacists may not
have considered prescription adaptation as pharmacist prescribing and this needs to be clarified
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in future study. It is also unclear if pharmacists considered providing a continuing care
prescription (a maximum one month continuation of a prescription under specific parameters that
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differ from prescribing), which is not pharmacist prescribing, as prescribing under the category
of prescription renewal. Other researchers have found that the definition of "prescribing" is not
static, but has several different meanings to pharmacists.71 To offset some of the challenges
related to survey research, we included open ended questions where participants were able to
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express their opinions in their own words. We were unable to determine characteristics of nonresponders or their reasons for not responding due to the anonymity of the survey. Another
limitation is the self-reported nature of the questionnaire. For example, most respondents felt that
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they had clinical assessment skills, but this was not independently verified. There may also be
response and social desirability biases. A limitation of the qualitative aspect of the study was
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that because participants provided written comments to specific open-ended questions, some of
the comments were quite brief and we did not have the opportunity to explore the themes further
with participants due to the anonymous nature of the survey. Future work could involve focus
groups or interviews with community pharmacists to explore these issues further.
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Conclusion
The TDF(v2) was a useful framework for identifying key determinants influencing pharmacist
prescribing; Skills, Social Influences, and Emotion.67 An understanding of these domains
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provides a strong foundation to help develop tailored interventions with stakeholders to increase
the uptake and the quality of pharmacist prescribing. One approach would be to map these to the
Capability, Opportunity, Motivation, Behaviour Model (COM-B) of the Behaviour Change
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Wheel (BCW), which could assist with identifying specific behaviour change techniques to
address relevant TDF domains.67 We acknowledge that pharmacist prescribing may be
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influenced by other stakeholder groups and suggest using the TDF to examine facilitators and
barriers to the uptake of pharmacist prescribing by other professionals (e.g., physicians) and
patients. The results can also provide direction for community pharmacy managers who aim to
increase pharmacist prescribing by increasing their awareness of the many factors that influence
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prescribing uptake beyond individual pharmacist knowledge and skills and taking these into
account in their planning. Future work is needed to develop further understanding of the factors
identified through qualitative interviews of pharmacists, physicians, and patients and to pilot test
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interventions based on the domains identified prior to wide scale implementation.
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References
1. Canadian Pharmacist's Association. Pharmacists' scope of practice in Canada.
RI
PT
https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-theissues/ScopeofPracticeinCanada_DEC2016.pdf. Updated 2016. Accessed Jan 16, 2017.
2. Zarowitz B, Miller W, Helling D, Nappi J, Wells B, Nahata M. Optimal medication therapy
SC
prescribing and management: Meeting patients' needs in an evolving health care system.
Pharmacotherapy. 2010;30:1198.
M
AN
U
3. Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical
prescribing for acute and chronic disease management in primary and secondary care.
Cochrane.Database.Syst.Rev. 2016;11:CD011227.
4. Gauvin F, Lavis J, McCarthy L. Evidence brief: Exploring models for pharmacist prescribing
in primary and community care settings in Ontario.
TE
D
https://www.mcmasterhealthforum.org/docs/default-source/Product-Documents/evidencebriefs/models-for-pharmacist-prescribing-in-ontario-eb.pdf?sfvrsn=4. Updated 2015. Accessed
EP
Jan 16, 2016.
5. Mossialos E, Courtin E, Naci H, et al. From "retailers" to health care providers: Transforming
AC
C
the role of community pharmacists in chronic disease management. Health Policy.
2015;119:628-39.
6. Canadian Academy of Health Sciences. Optimizing scopes of practice: New models of care
for a new health care system. http://cahs-acss.ca/optimizing-scopes-of-practice-new-models-ofcare-for-a-new-health-care-system/. Updated 2014. Accessed Dec 13, 2016.
7. Chisholm-Burns M, Graff Zivin J, Lee J, et al. Economic effects of pharmacists on health
outcomes in the united states: A systematic review. Am J Health Syst Pharm. 2010;67:1624-34.
ACCEPTED MANUSCRIPT
8. Law M, Ma T, Fisher J, Sketris I. Independent pharmacists prescribing in Canada. Can Pharm
J. 2012;145:17-23.
9. Sketris I. Extending prescribing privileges in Canada. Can Pharm J. 2009;142:17-19.
RI
PT
10. Taylor JG, Joubert R. Pharmacist-led minor ailment programs: A aCanadian perspective.
Int.J.Gen.Med. 2016;9:291.
11. Nova Scotia College of Pharmacists. Standards of practice: Prescribing drugs.
SC
www.nspharmacists.ca/wp-content/uploads/2016/05/PrescribingStandardsOfPractice.pdf.
Updated 2015. Accessed Dec 13, 2016.
M
AN
U
12. Province of Nova Scotia. Pharmacist drug prescribing regulations made under section 83 of
the pharmacy act. http://www.novascotia.ca/just/regulations/regs/pharmdrugrx.htm. Updated
2013. Accessed Dec 13, 2016.
13. Buckley P, Grime J, Blenkinsopp A. Inter- and intra-professional perspectives on non-
TE
D
medical prescribing in an NHS trust. Pharm J. 2006;277:394-98.
14. Faruquee C, Guirguis L. A scoping review of research on the prescribing practice of
Canadian pharmacists. Can Pharm J. 2015;148:325-48.
EP
15. Dapar M, McCaig D, Cunningham I, Diack L, Stewart D. Facilitators and barriers to
pharmacist prescribing: Exploring the association of pharmacy practice setting. Int J pharm
AC
C
Pract. 2010. 18;SUPPL 1(38-9).
16. Fittock A. Non-medical prescribing by nurses, optometrists, pharmacists, physiotherapists,
podiatrist and radiographers. http://www.npc.co.uk/prescribers/resources/NMP_QuickGuide.pdf.
Updated 2010. Accessed Jan 5, 2011.
ACCEPTED MANUSCRIPT
17. Hoti K, Sunderland B, Hughes J, Parsons R. An evaluation of Australian pharmacist's
attitudes on expanding their prescribing role. Pharm World Sci. 2010;32:610-621. doi:
10.1007/s11096-010-9400-2; 10.1007/s11096-010-9400-2.
RI
PT
18. Latter S, Smith A, Blenkinsopp A, Nicholls P, Little P, Chapman S. Are nuse and pharmacist
independent prescribers making clinically appropriate prescribing decisions? an analysis of
consultations. J Health Serv Res Policy. 2012;17:149-56.
pharmacists. BMC Health Serv Res. 2010;10:313.
SC
19. Law M, Morgan S, Majumdar S, Lynd L, Marra C. Effects of prescription adaptation by
M
AN
U
20. Lloyd F, Hughes C. Pharmacists' and mentors' views on the introduction of pharmacist
supplementary prescribing: A qualitative evaluation of views and context. Int J Pharm Pract.
2007;15:31-37.
21. McIntosh T, Munro K, McLay J, Stewart D. A cross sectional survey of the views of newly
TE
D
registered pharmacists in Great Britain on their potential prescribing role: A cautious approach.
Br J Clin Pharmacol. 2012;73:656-660. doi: 10.1111/j.1365-2125.2011.04133.x; 10.1111/j.13652125.2011.04133.x.
EP
22. Nkansah N, Mostovetsky O, Yu C, et al. Effect of outpatient pharmacists' non-dispensing
roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev.
AC
C
2010;7:CD0000336.
23. Smith S, O'Kelly S, O'Dowd T. GPs' and pharmacists' experiences of managing
multimorbidity: A 'Pandora's box'. Br J Gen Pract. 2010;60:285-94.
24. Stewart D, George J, Bond C, Diack H, McCaig D, Cunningham S. Views of pharmacist
prescribers, doctors and patients on pharmacist prescribing implementation. Int J Pharm Pract.
2009;17:89-94.
ACCEPTED MANUSCRIPT
25. Tonna A, Stewart D, West B, McCaig D. Pharmacist prescribing in the UK - a literature
review of current practice and research. J Clin Pharm Ther. 2007;32:545-56.
26. Tonna A, Stewart D, West B, McCaig D. Exploring pharmacists' perceptions of the
RI
PT
feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland. In
J Pharm Pract. 2010;18:312-9.
27. Yuksel N, Eberhart G, Bungard T. Prescribing by pharmacists in Alberta. Am J Health Syst
SC
Pharm. 2008;65:2126-32.
28. Guirguis L, Hughes C, Makowsky M, Sadowski C, Schindel T, Yuksel N. Survey of
M
AN
U
pharmacist prescribing practices in Alberta. Am J Health Syst Pharm. 2017;74:62-69.
29. Schindel T, Yuksel N, Breault R, Daniels J, Varnhagen S, Hughes C. Perceptions of
pharmacists' roles in the era of expanding scopes of practice. Res.Social.Adm.Pharm.
2017;13:148-161.
TE
D
30. Bishop A, Boyle T, Morrison B, et al. Public perceptions of pharmacist expanded scope of
practice services in nova scotia. Can.Pharm.J. 2015;148:274-283.
31. Guirguis L, Makowsky M, Hughes C, Sadowski C, Schindel T, Yuksel N. How have
EP
pharmacists in different practice settings integrated prescribing privileges into practice in
alberta? A qualitative exploration. J.Clin.Pharm.Ther. 2014;39:390-398.
AC
C
32. Pojskic N, MacKeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in
Ontario regarding independent prescriptive authority for pharmacists. Res.Social.Adm.Pharm.
2014;10:341-354.
33. Hoti K, Hughes J, Sunderland B. Expanded prescribing: A comparison of the views of
Australian hospital and community pharmacists. Int.J.Clin.Pharm. 2013;35:469.
ACCEPTED MANUSCRIPT
34. Murawski M, Villa KR, Dole EJ, et al. Advanced-practice pharmacists: Practice
characteristics and reimbursement of pharmacists certified for collaborative clinical practice in
10.2146/ajhp110351; 10.2146/ajhp110351.
RI
PT
New Mexico and North Carolina. Am J Health Syst Pharm. 2011;68:2341-2350. doi:
35. Lloyd F, Parsons C, Hughes C. 'It's showed me the skills that he has': Pharmacists' and
mentors' views on pharmacist supplementary prescribing. Int.J.Pharm.Pract. 2010;18:29-36.
prescribing authority. Pharm.World.Sci. 2007;29:628-634.
SC
36. Tully M, Latif S, Cantrill J, Parker D. Pharmacists' changing views of their supplementary
M
AN
U
37. Hutchison M, Lindblad A, Guirguis L, Cooney D, Rodway M. Survey of Alberta hospital
pharmacists' perspectives on additional prescribing authorization. Am J Health Syst Pharm.
2012;69:1983-1992. doi: 10.2146/ajhp110538; 10.2146/ajhp110538.
38. Rosenthal M, Houle S, Eberhart G, Tsuyuki R. Prescribing by pharmacists in Alberta and its
TE
D
relation to culture and personality traits. Res.Social.Adm.Pharm. 2015;11:401-411.
39. Makowsky M, Guirguis L, Hughes C, Sadowski C, Yuksel N. Factors influencing
pharmacists' adoption of prescribing: Qualitative application of the diffusion of innovations
EP
theory. Implement.Sci. 2013:109.
40. Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in
AC
C
improvement. BMJ.Qual.Saf. 2015;24:228-38.
41. Cane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in
behaviour change and implementation research. Implement.Sci. 2012;7:37.
42. Pfadenhauer L, Rohwer A, Burns J, et al. Guidance for the assessment of context and
implementation in health technology assessments (HTA) and systematic reviews of complex
interventions: The context and implementation of complex interventions (CICI) framework.
ACCEPTED MANUSCRIPT
https://www.researchgate.net/profile/Lisa_Pfadenhauer/publication/298340571_Guidance_for_th
e_Assessment_of_Context_and_Implementation_in_Health_Technology_Assessments_HTA_an
d_Systematic_Reviews_of_Complex_Interventions_The_Context_and_Implementation_of_Com
RI
PT
plex_Interventions_C/links/56e936b508ae9bcb3e1e55a0.pdf. Updated 2016.
43. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering
implementation of health services research findings into practice: A consolidated framework for
SC
advancing implementation science. Implement.Sci. 2009;4:50.
44. Tavender E, Bosch M, Gruen R, et al. Understanding practice: The factors that influence
M
AN
U
management of mild traumatic brain injury in the emergency department - a qualitative study
using the theoretical domains framework. Implement.Sci. 2014;9:8.
45. Islam R, Tinmouth A, Francis J, et al. A cross-country comparison of intensive care
physicians' beliefs about their transfusion behaviour: A qualitative study using the theoretical
TE
D
domains framework. Implement.Sci. 2012;7:93.
46. Duncan E, Francis J, Johnston M, et al. Learning curves, taking instructions, and patient
safety: Using a theoretical domains framework in an interview study to investigate prescribing
EP
errors among trainee doctors. Implement.Sci. 2012;7:86.
47. Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and behaviour
AC
C
change across the social and behavioural sciences: A scoping review. Healthy.Psychol.Rev.
2015;9:323-44.
48. Cadogan C, Ryan C, Francis J, et al. Improving appropriate polypharmacy for older people in
primary care: Selecting components of an evidence-based intervention to target prescribing and
dispensing. Implement Sci. 2015;10:161.
ACCEPTED MANUSCRIPT
49. Glanz K, Bishop DB. The role of behavioral science theory in development and
implementation of public health interventions. Annu Rev Public Health. 2010;31:399-418.
50. Doucette WR, Nevins JC, Gaither C, et al. Organizational factors influencing pharmacy
RI
PT
practice change. Res.Social Adm.Pharm. 2012;8:274-84.
51. Roberts A, Benrimoj S, Chen T, Williams K, Aslani P. Implementing cognitive services in
community pharmacy: A review of models and frameworks for change. Int.J.Pharm.Pract.
SC
2006;14:105-113.
52. Kirk J, Sivertsen D, Petersen J, Nilsen P, Petersen H. Barriers and facilitators for
M
AN
U
implementing a new screening tool in an emergency department: A qualitative study applying
the theoretical domains framework. J Clin Nurs. 2016;25:2786-97.
53. Alqubaisi M, Tonna A, Strath A, Stewart D. Quantifying behavioural determinants relating to
health professional reporting of medication errors: A cross-sectional survey using the theoretical
TE
D
domains framework. Eur J Clin Pharmacol. 2016;72:1401-11.
54. Lawton R, Heyhow J, Louch G, et al. Using the theoretical domains framework (TDF) to
understand adherence to multiple evidence-based indicators in primary care: A qualitative study.
EP
Implement Sci. 2016;11:113.
55. Murphy A, Phelan H, Haslam S, Martin-Misener R, Kutcher S, Gardner D. Community
AC
C
pharmacists' experiences in mental illness and addictions care: A qualitative study.
Subst.Abuse.Treat.Prev.Policy. 2016;11:6.
56. Statistics Canada. Focus on geography series, 2011 census.
http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-preng.cfm?Lang=Eng&GC=12. Updated 2012. Accessed Dec 13, 2016.
ACCEPTED MANUSCRIPT
57. Canadian Institute for Health Information. Pharmacists. https://www.cihi.ca/en/spendingand-health-workforce/health-workforce/pharmacists. Accessed Dec 13, 2016.
58. Province of Nova Scotia. Nova Scotia Pharmacare. http://novascotia.ca/dhw/pharmacare/.
RI
PT
Updated 2016. Accessed Dec 13, 2016.
59. Hsieh H, Shannon S. Three approaches to qualitative content analysis. Qual.Health.Res.
2005;15:1277-88.
SC
60. Heck T, Gunther M, Bresee L, Mysak T, Mcmillan C, Koshman S. Independent prescribing
by hospital pharmacists: Patterns and practices in a Canadian province. Am.J.Health.Syst.Pharm.
M
AN
U
2015;72:2166-2175.
61. Ourth H, Groppi J, Morreale A, Quicci-Roberts K. Clinical pharmacist prescribing activities
in the Veterans Health Administration. Am.J.Health.Syst.Pharm. 2016;73:1406-1415.
62. Maddox C, Halsall D, Hall J, Tully M. Factors influencing nurse and pharmacist willingness
TE
D
to take or not take responsibility for non-medical prescribing. Res.Social Adm.Pharm.
2016;12:41-55.
63. Mosavianpour M, Sarmast H, Kissoon N, Collet J. Theoretical domains framework to assess
EP
barriers to change for planning health care quality interventions: A systematic literature review. J
Multidiscip Healthc. 2016;9:303-10.
AC
C
64. Francis J, O'Connor D, Curran J. Theories of behaviour change synthesised into a set of
theoretical groupings: Introducing a thematic series on the theoretical domains framework.
Implement.Sci. 2012;7:35.
65. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun
H, Grimshaw JM, Lawton R, Michie S. A guide to using the Theoretical Domains Framework of
behaviour change to investigate implementation problems. Implement.Sci. 2017;12(1):77.
ACCEPTED MANUSCRIPT
66. Hendriks A, Habraken J, Jansen M, et al. 'Are we there yet?' - operationalizing the concept of
integrated public health policies. Health.Policy. 2014;114:174-82.
67. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for
RI
PT
characterising and designing behaviour change interventions. Implement.Sci. 2011;6:42.
68. Powell B, Waltz T, Chinman M, et al. A refined compilation of implementation strategies:
Results from the expert recommendations for implementing change (ERIC) project.
SC
Implement.Sci. 2015;10:21.
69. Steinmo S, Fuller C, Stone SP, Michie S. Characterising an implementation intervention in
Implement.Sci. 2015;10:111.
M
AN
U
terms of behaviour change techniques and theory: the ‘Sepsis Six’ clinical care bundle.
70. Cooper RJ, Lymn J, Anderson C, et al. Learning to prescribe - pharmacists' experiences of
supplementary prescribing training in England. BMC Med Educ. 2008;8:57-6920-8-57. doi:
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10.1186/1472-6920-8-57; 10.1186/1472-6920-8-57.
71. Hughes C, Makowsky M, Sadowski C, Schindel T, Yuksel N, Guirguis L. What prescribing
means to pharmacists: A qualitative exploration of practising pharmacists in Alberta.
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Int.J.Pharm.Pract. 2014;22:283-291.
ACCEPTED MANUSCRIPT
Fig. 1: Self-reported frequency of prescribing activity of respondents to the question “In a typical
AC
C
EP
TE
D
M
AN
U
SC
RI
PT
month, please indicate how often you perform the following activities:”
14
8
11
5
0
0
0
9
7
9
15 per month
30 per month
34
32
28
23
5
13
7
5
5
5
37
6
5
5
5
0
Collaborative
Prescribing when
Diagnosis Provided
50
RI
PT
53
Minor/Common
Ailment Prescribing
42
SC
40
M
AN
U
16
TE
D
60
Prescribing
Schedule II or III
5
at least 1 a month
4 per month
Therapeutic
Substitution
20
EP
28
AC
C
10
Never
< 1 per month
Prescription
Adaptation
30
Prescription
Renewal
70
Prescribing
in an Emergency
Number of Respondents
ACCEPTED MANUSCRIPT
69
37
29
23
14
17
9
5
5
5
0
0
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