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A Qualitative Assessment of the Practice Experiences of Certified Diabetes Educator Pharmacists
Can J Diabetes 39 (2015) 254e258
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
A Qualitative Assessment of the Practice Experiences of Certified Diabetes Educator Pharmacists Fahad Alzahrani BPharm, MSc a, Jeff Taylor BSP, MSc, PhD a, Jason Perepelkin BA, BComm, MSc, PhD a, Kerry Mansell BSP, PharmD a, * a
University of Saskatchewan, Saskatoon, Saskatchewan, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 July 2014 Received in revised form 26 September 2014 Accepted 21 November 2014
Objective: To describe the practice experiences of Certified Diabetes Educator (CDE) pharmacists in Saskatchewan and determine what impact the CDE designation has had on their personal practices. Methods: A qualitative research approach was used. All pharmacists in Saskatchewan were e-mailed about the study, and eventually, a purposive sampling method was used to select a range of CDE pharmacists. Semistructured, in-person interviews were performed. An interview guide was developed to assess the work activities performed, the benefits of becoming a CDE and the challenges and resultant solutions that optimize their CDE designations. All interviews were transcribed verbatim and coded using deductive thematic analysis to identify the main themes that described the experiences of respondents, with the aid of QSR NVivo. Results: A total of 14 CDE pharmacists from various communities and work settings chose to participate. All of the participants indicated they were engaging in increased diabetes-related activities since becoming CDEs. All participants indicated they were happy with their decisions to become CDEs and described numerous benefits as a direct result of achieving this designation. Although some solutions were offered, participants still face challenges in optimizing their role as CDEs, such as devoting enough time to diabetes management and remuneration for providing diabetes services. Conclusions: CDE pharmacists in Saskatchewan report performing enhanced diabetes-related activities subsequent to becoming CDEs and that obtaining this designation has had a positive impact on their personal practices. A larger, cross-country study is necessary to determine whether these results are consistent amongst all pharmacists in Canada. Ó 2015 Canadian Diabetes Association
Keywords: certified diabetes educator pharmacists qualitative assessment
r é s u m é Mots clés : éducateur agréé en diabète pharmaciens évaluation qualitative
Objectif : Décrire l’expérience pratique des pharmaciens éducateurs agréés en diabète (ÉAD) de la Saskatchewan et déterminer les conséquences liées au titre de ÉAD sur les pratiques individuelles. Méthodes: La recherche selon l’approche qualitative a été utilisée. Tous les pharmaciens de la Saskatchewan ont reçu un courriel à propos de l’étude. Par la suite, une méthode d’échantillonnage raisonné a été utilisée pour sélectionner un éventail de pharmaciens ÉAD. Des entretiens semi-structurés en personne ont été réalisés. Un guide d’entretien a été mis au point pour évaluer les activités professionnelles réalisées, les avantages et les inconvénients liés au titre de ÉAD ainsi que les solutions engendrées qui optimisent leur titre de ÉAD. À l’aide du logiciel NVivo de QSR international, tous les entretiens ont été transcrits textuellement et encodés selon l’analyse thématique déductive pour déterminer les thèmes principaux qui décrivaient l’expérience des répondants. Résultats: Un total de 14 pharmaciens ÉAD provenant de communautés et de milieux de travail divers ont choisi de participer. Tous les participants ont indiqué avoir pris part à plus d’activités liées au diabète depuis l’obtention de leur titre de ÉAD. Tous les participants ont indiqué être satisfaits de leur décision de devenir ÉAD et ont décrit les nombreux avantages comme une conséquence directe de l’obtention de ce titre. Bien que certaines solutions aient été proposées, les participants se heurtent encore aux difficultés
* Address for correspondence: Kerry Mansell, BSP, PharmD, College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place, Saskatoon, Saskatchewan S7N 5E5, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.11.004
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liées à l’optimisation de leur rôle de ÉAD comme le fait de consacrer assez de temps à la prise en charge du diabète et la rémunération liée à la prestation de services aux personnes diabétiques. Conclusions : Les pharmaciens ÉAD de la Saskatchewan rapportent avoir réalisé plus d’activités liées au diabète depuis qu’ils sont ÉAD et que l’obtention de ce titre a eu des conséquences positives sur leur pratique individuelle. Une étude pancanadienne plus vaste est nécessaire pour déterminer si ces résultats sont uniformes chez tous les pharmaciens du Canada. Ó 2015 Canadian Diabetes Association
Introduction Diabetes has been called one of the greatest health crises of the 21st century (1). Currently, there are more than 9 million Canadians living with or at risk for developing diabetes (2). With increased incidence and prevalence rates come additional pressure on the healthcare system and a corresponding increased need for resources to help manage this chronic condition. Ideally, people with diabetes are taught the importance of selfmanagement through diabetes education. Diabetes education has been a recognized cornerstone of diabetes care, and education contributes to improved self-care and glycemic control in patients with diabetes (3,4). Increasingly, healthcare professionals are seeking certification as diabetes educators as recognition of specialization in diabetes management. In Canada, this certification is offered through the Canadian Diabetes Educator Certification Board (CDECB). There are currently 3760 certified diabetes educators (CDEs) in Canada, of which 1379 are pharmacists (personal communication, CDECB, March 3, 2014). As a profession, pharmacists represent one-third of all CDEs in Canada and are the fastest growing segment of CDEs in Canada (5). Given their accessibility and recent earnestness in seeking the CDE designation, an enormous opportunity exists for pharmacists to become more involved in diabetes education and management. However, it is not clear what impact, if any, becoming a CDE has had on pharmacists themselves and the patients for whom they provide diabetes-related services. The purpose of this study was to elucidate which diabetes-related activities CDE pharmacists are engaging in, what the impact of becoming a CDE has had on their personal practices and what challenges (and corresponding solutions) CDE pharmacists face when they engage in educating people about diabetes management.
Methods A qualitative and descriptive method of investigation was used. Such an approach is preferred when a straight description of an event is desired and provides a comprehensive summary of people’s experiences as they occur in everyday life (6). Participants were chosen using a purposive sampling method to select a range of CDE pharmacists practicing in Saskatchewan. Information about the study was e-mailed to all licensed pharmacists in Saskatchewan for whom the Saskatchewan College of Pharmacists had an e-mail address. Those pharmacists who were interested in participating were asked to contact the study investigators directly, and a small honorarium was offered to participants for their participation. For data collection, individual, face-to-face, semistructured interviews were scheduled; the same investigator was used for all interviews. Interviews were performed between June and September 2012 at times and locations chosen by the participants. Interview data were collected via written notes and audio recordings. Once all interviews were completed, they were transcribed verbatim by a separate experienced transcriber and
double-checked against the recording for accuracy. All participants were provided their transcripts as member checks. A validated interview guide to describe CDE pharmacists’ experiences in diabetes management could not be found, so one was constructed for the goals of this study. The interview guide contained a list of open- and close-ended questions derived from both Canadian and international literature (7e18). The interview guide consisted of 5 components: description of work activities, benefits of a CDE designation, challenges related to providing diabetes services, corresponding possible solutions and respondents’ demographics. Each component included between 4 and 8 questions with a number of probes. The interview guide was reviewed independently by pharmacists and nonpharmacists to support face validity prior to the commencement of data collection and was piloted by 1 CDE pharmacist. The interview guide is available on request from the corresponding author. The study was approved by the University of Saskatchewan’s Behavioural Research Ethics Board. Data Analysis Braun and Clarke’s 6 phases of thematic data analysis was followed (19). To facilitate the organizing and analyzing process, QSR NVivo v. 10 software (QSR International, Burlington, Massachusetts, United States) was utilized. Once deductive thematic analysis was performed (whereby the data were coded, as it seemed appropriate to the researcher, with a predetermined outline in which the data fit), an external auditor experienced in qualitative research reviewed the findings. Results A total of 14 CDE pharmacists expressed interest in the study, and all 14 agreed to participate; all but 1 were female. There was an equal mix of pharmacists practicing in rural and urban communities. The majority of participants described their primary practice sites as community pharmacies, although 4 of these participants indicated they also worked in diabetes clinics outside of their pharmacies. Four participants were employed in institutional settings (hospital pharmacy or primary care centres) or with government. Overall, participants had been licensed for an average of 24 years, and their experience as CDEs ranged from 1 to 14 years. From the transcribed interviews, 755 significant statements were extracted, reflecting the practice experiences of CDE pharmacists; 200 cluster themes were formed, and they further merged into 4 main themes (Table 1). Theme 1: Work activities of CDE pharmacists The work activities described by respondent CDE pharmacists were broken down into 4 subcategories: diabetes education, follow up, recommendations and referrals, and peer assistance and program development. Regarding diabetes-specific education, all participants identified education about drug therapy as the most frequent activity they performed. They believed that one of their
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Table 1 Major themes and subthemes Themes
Subthemes
Work activities of CDE pharmacists Diabetes education Follow up and monitoring Recommendations and referrals Peer assistance and program development Benefits of CDE certification Personal and professional satisfaction Improved patient outcomes Collaboration, respect and recognition Clinical knowledge and skills Challenges in practice Lack of pharmacist motivation Lake of awareness Resistance from other healthcare providers Infrastructure and resources Prescriptive authority Patient-related issues Strategies to overcome challenges Relationship building Time and reimbursement issues Increasing public awareness Enhancing patient motivation CDE, certified diabetes educator.
primary responsibilities was helping patients understand each diabetes medication. Further, 1 participant, who practises in an urban setting, indicated involvement with insulin-pump training: I do work with pump training, insulin pump starts, so I currently do some independent training so I’ll get referred a patient who’s interested in a pump and I’ll get them trained. (CDE3, community pharmacist) The majority of participants indicated that they were frequently involved with insulin starts and insulin dose titrations. One participant who practiced in an urban community pharmacy setting stated: Many times we’ll identify someone who could benefit from insulin. We’ll talk about it with the patient and then I’ll offer to obtain a prescription for them to start insulin and then I’ll fax the doctor and ask if I can have the prescription along with the authority to make adjustments to try to titrate them up. (CDE1, community pharmacist) Almost all participants indicated that they provide counselling on both acute and chronic complications of diabetes as well as related medical conditions. One participant from a rural community practice stated: And counselling on.medications for their blood glucose control as well as lipid and blood pressure control or you know, depression, smoking cessation, whatever other issues may be going on in relation to their diabetes. (CDE4, community pharmacist) All participants indicated that they provide education concerning lifestyle modifications. Particularly, they all indicated that they provide some degree of basic dietary advice, such as healthful eating, following Canada’s Food Guide and carbohydrate counting. Although several participants indicated that they might suggest increased physical activity, they were much less comfortable and active in discussing this than in discussing dietary measures. Participants also indicated that follow up and monitoring of patients are large components of the job, particularly with new medication and insulin starts. Consequently, all participants indicated that they were active in helping their patients interpret selfmonitoring of blood glucose (SMBG) results. Theme 2: Benefits of CDE certification Participants were asked whether they found value in obtaining the CDE designation. Most participants indicated both increased
personal and professional satisfaction after attaining the CDE designation. Furthermore, the majority of participants also indicated an increased confidence in being able to provide diabetes management. Participants indicated that the greatest personal benefit came from improved job satisfaction and a sense of workplace empowerment. One participant, who practiced in an urban community pharmacy setting, indicated: Since I got my CDE, I now have more hours to devote towards specific hours that are meant towards that patient consult and I’ve been able to remove myself from that daily traditional dispensing to allow that and had I not had my CDE, that opportunity probably would not have been there. So, it’s completely changed the work I’m doing on a day-to-day basis. (CDE1, community pharmacy) Another benefit of becoming a CDE that was expressed by almost all participants was increased knowledge and skills in diabetes management. Several pharmacists indicated that they now deal with more complex issues when treating patients with diabetes and are often consulted by other healthcare professionals (HCPs) for such purposes. Furthermore, almost all participants indicated that their relationships with other HCPs improved as a result of becoming CDEs; most felt an increased sense of respect and credibility from their colleagues. Those who indicated there was no improvement stated that it was because they already had strong, established relationships with the physicians in their communities. Some participants also indicated that their relationships with patients had improved as well, and many believed that becoming a CDE led to improved patient outcomes and satisfaction (although this outcome was not measured). Some also felt a sense of responsibility in mentoring other pharmacists who were interested in becoming CDEs. Of significant interest, one participant indicated that becoming a CDE led to a collaborative prescribing agreement with a physician that allowed for various diabetes-related activities normally permitted only to a physician (e.g. prescribing a new antihyperglycemic agent) to be performed by the pharmacist. Similarly, another pharmacist indicated that a “transfer of function” was set up with a physician to allow greater responsibility and flexibility in managing patients with diabetes. Overall, all of the participants indicated they were happy with their decisions to become CDEs, and all indicated that they planned to recertify when the time arises. Theme 3: Challenges in practice As expected, all participants identified certain challenges in the workplace that they felt hindered them from putting their knowledge and skills in diabetes management to full use. The 5 main challenges were identified as lack of motivation; lack of awareness; lack of infrastructure and resources; resistance from other HCPs and patient-specific issues. Regarding lack of motivation on the pharmacists’ part, several participants indicated that they had had difficulty in altering the ways in which they normally function in the workplace. This was expressed as being personally challenging and that changing roles from what was comfortable was difficult. Second, study participants frequently reported lack of external awareness (of their being CDEs) as a challenge to delivering diabetes management services; this applied to both the public and the other HCPs. All participants indicated that they were trying different strategies (e.g. calling physicians or handing out pamphlets) to try to increase awareness. Some participants felt that not all HCPs were receptive to their roles as a CDEs. Most indicated that they encountered “turf protection” at one point or another, in particular from nurses. This may
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have occurred as isolated events and, overall, most participants described this situation as being not particularly troublesome and generally described positive support from other HCPs. All study participants described at least 1 challenge under the subheading of infrastructure and resources. Lack of time to deliver diabetes-related services was the most commonly cited challenge, followed closely by a shortage in funding for them to provide diabetes education and services. One participant working in a rural community pharmacy stated: Well, there’s a lot of different reasons [for providing free services], particularly, nobody has ever in Canada.paid for these things before. Because it’s a public healthcare system funded by the government, a lot of people wouldn’t really have an appetite for that [paying for diabetes services] and partly I would feel way too guilty. (CDE14, community pharmacist) Many participants indicated a lack of access to electronic health records and laboratory results as being a challenge; it is difficult to make decisions without a full health history, and tracking down this information takes time. Participants also indicated a lack of prescribing authority (i.e. pharmacists’ being able to prescribe medications in certain conditions after signing an agreement with a physician) as a challenge. Last, many participants in rural settings felt staffing shortages (pharmacists and pharmacy technicians) greatly impeded their abilities to provide the diabetes management they would like to provide. The ultimate challenges faced by many study participants related to patient-specific issues. Many participants mentioned that it was difficult to deliver diabetes care to patients who are not motivated or interested in what you have to say. Furthermore, patients’ actual capacities to access pharmacists’ services (for various reasons) were listed as challenges for some participants. Two reasons cited were: A huge problem with our First Nations people is being able to access healthcare in general. Whether that be to get to a regular physician, to get to a regular pharmacy, to be able to show up for an appointment that you have scheduled, to get to any place that is providing help, because they have huge transportation issues, they have huge issues with social support. (CDE4, community pharmacist) For the most part, when you start talking about nutrition and proper nutrition.a lot of people really can’t afford, unfortunately, you know what I mean? (CDE14, community pharmacist). Theme 4: Strategies to overcome challenges Participants were asked to describe strategies they have used to help overcome challenges encountered when trying to deliver diabetes services and capitalize on the CDE designation. Building relationships was one of the common subthemes that emerged. Physicians were identified as the primary HCPs to try to connect with. A variety of other strategies to overcome challenges were also listed by participants. Regarding lack of awareness of their being CDEs, various examples of trying to overcome this were provided, from giving public presentations, to building relationships with pharmaceutical representatives, to basic promotional materials such as posters and newspaper ads. One participant suggested a mechanism that might overcome the lack of funding and the reimbursement issuesdto charge the patient for the services provideddyet they did not actually do so. Making patients adhere to booked appointments and utilizing technology (e.g. text messaging the SMBG’s results) were reported as strategies to overcome time barriers, but by and large, time and reimbursement were challenges most participants had not yet found answers for. Regarding
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strategies used to increase patient motivation, some participants indicated using motivational interviewing to help build rapport with their patients and to learn what was important to them. Discussion Although pharmacists have become increasingly involved in diabetes management in recent years, pharmacists’ functioning as CDEs in their natural work environment is relatively new. Certification in any area has the potential to affect roles and responsibilities. As such, this study aimed to determine the practice experiences of CDE pharmacists through a qualitative assessment. The 4 major themes have helped to provide an understanding of CDE pharmacists’ experiences in delivering diabetes-related activities. Based on the interview responses, it appears that all participating CDE pharmacists are engaged in various levels of diabetes management, and this level of involvement has increased since they became CDEs. As expected, these pharmacists felt their primary responsibility was to educate patients about appropriate medication use. Many of these pharmacists are very comfortable with and involved in insulin management, interpretation of SMBG results and insulin dose titration. This aligns somewhat with previous literature, which found non-CDE pharmacists are not comfortable counselling on insulin use (20). Most participants also thought it was their responsibility to counsel patients about related chronic conditions and both the acute and the chronic complications of diabetes, regardless of the work setting. All participants indicated that they provide some degree of nutritional counselling and were comfortable in doing so, which has not always been the case for pharmacists (17). These participants did not spend a great deal of time discussing physical-activity interventions, and some suggested this to be the responsibility of other HCPs, although they did not provide any examples of who these HCPs may be. Given the number of interactions pharmacists have with these patients and the opportunities to discuss introducing physical activity, this remains a significant gap, and pharmacists may require additional training to improve their comfort levels in this area. All participants interviewed felt that becoming a CDE had benefited them personally and professionally. They described becoming a CDE as being beneficial with respect to their job duties, relationships with other healthcare professionals, job satisfaction and delivery of information as it relates to diabetes management. A few pharmacists indicated that their jobs had changed as a result of becoming CDEs; the changes ranged from obtaining prescribing agreements or transfers of function with physicians to more work time devoted strictly to diabetes education away from the dispensary. The majority of participants indicated increased confidence as a result of becoming CDEs and increased recognition by their colleagues, which is consistent with previous literature and certification in other instances (7,21). All participants were happy with their decisions to become CDEs and would encourage others to do so as well. These findings support previously published studies investigating the value of certification among pharmacists (17,22). In addition, several other studies have indicated the benefits of professional certification for other healthcare professionals (23,24). The challenges identified by participants in this study are consistent with previous studies of pharmacy practice in general, such as lack of recourse, lack of funding, increased demands on pharmacists’ time and patient barriers (18,25e27). Participants reported facing several complex problems when trying to provide diabetes-related education and clinical services, similar to those of most other practising pharmacists in general. Although participants described increased engagement in diabetes management since becoming CDEs, the majority still reported that these challenges
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(e.g. time, funding) prevented them from practising to the full scope of their abilities. Similar to previous literature, lack of awareness was also cited as a major challenge (28), although it appears that these participants are engaged in various strategies to try to overcome this lack. It is interesting that some participants mentioned that the absence of a collaborative prescribing agreement with a physician hindered their abilities to practice to their full scope. This is in contrast to previous literature (29,30) in that it indicates these participants are seeking more responsibility for the provision of patient care, further demonstrating the increased confidence these pharmacists have. Limitations As with other qualitative approaches, a number of essential limitations are relevant, such as researchers’ biases, their abilities to generalize the findings and time consumption. Although the results reported provide rich explanations of the practice experiences of CDE pharmacists in Saskatchewan, these findings may not be generalizable to a wider population of CDE pharmacists across Canada or even within Saskatchewan for those CDE pharmacists who chose not to participate. A sample size of 14 may seem low, but in qualitative design the focus is on the value and richness of information achieved from participants (6), and that endeavour is not associated with the number of participants. The majority of participants were from community pharmacies, and the results could vary substantially across practice settings. It is always possible that those participants who chose to participate were motivated and may not be representative of the larger sample. Finally, this study did not evaluate the differences in patient outcomes realized by having a CDE pharmacist involved in their care. Conclusion This is the first study to obtain an in-depth qualitative description of CDE pharmacists’ activities and to evaluate the effects of becoming CDEs have on pharmacists. It appears from all accounts that the pharmacists interviewed are putting their CDE designations to use and are finding ways to harness this designation. All of the pharmacists interviewed indicated that becoming CDEs has been beneficial to them for a variety of reasons. Although challenges exist in providing diabetes-related services, these pharmacists are engaging in a broad variety of diabetes management-related activities. A larger, cross-country study is necessary to determine whether these results are consistent amongst all pharmacists in Canada as well as a study to determine the impact of CDE pharmacists’ roles in patient outcomes. Acknowledgements The authors acknowledge the contribution of the pharmacists who participated in this study, and we sincerely thank them for allowing us to share their experiences. The authors also thank Scarlett Ewan for proofreading the findings in the final stages. The authors also thank the Saudi Arabian Cultural Bureau in Canada for helping fund a portion of this research.
References 1. Tabish SA. Is diabetes becoming the biggest epidemic of the twenty-first century? Int J Health Sci 2007;1:VeVIII. 2. Canadian Diabetes Cost Model. Estimated diabetes statistics in Canada. http:// www.diabetes.ca/getmedia/513a0f6c-b1c9-4e56-a77c-6a492bf7350f/diabetescharter-backgrounder-national-english.pdf.aspx; updated 2014. Accessed June 25, 2014. 3. Mulcahy K, Maryniuk M, Peeples M, et al. Diabetes self-management education core outcomes measures. Diabetes Educ 2003;29:768e88. 4. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes selfmanagement education. Diabetes Care 2011;34(Suppl 1):S89e96. 5. Roscoe R. Role of pharmacist in diabetes care. http://www.diabetescareguide. com/role-pharmacist-diabetes-care/; updated 2013. Accessed June 28, 2014. 6. Sandelowski M. Focus on research methods: Whatever happened to qualitative description? Res Nurs Health 2000;23:334e40. 7. Simpson SH, Haggarty S, Johnson JA, et al. Survey of pharmacist activities and attitudes in diabetes management. Can Pharm J 2009;142:128e34. 8. Beney J, Bero L, Bond C. Expanding the roles of outpatient pharmacists: Effects on health services utilisation, costs, and patient outcomes. Cochrane Database Syst Rev. 2010;(7):CD000336. 9. Hartnell NR, MacKinnon NJ, Sketris IS, et al. The roles of community pharmacists in managing patients with diabetes: Perceptions of health care professionals in Nova Scotia. Can Pharm J 2005;138:46e53. 10. Valentine V, Kulkarni K, Hinnen D. Evolving roles: From diabetes educators to advanced diabetes managers. Diabetes Spectrum 2003;16:27e31. 11. Plake K, Chesnut R, Biebighauser S. Impact of a diabetes certificate program on pharmacists’ diabetes care activities. Am J Pharm Educ 2003;67:116. 12. Douglas E, Power A, Hudson S. Pharmaceutical care of the patient with diabetes mellitus: Pharmacists’ priorities for services and educational needs in Scotland. Int J Pharm Pract 2007;15:47e52. 13. Kaufman MW, All AC, Davis H. The scope of practice of diabetes educators in the state of Georgia. Diabetes Educ 1999;25:56e64. 14. McDonald PE, Tilley BC, Havstad SL. Nurses’ perceptions: Issues that arise in caring for patients with diabetes. J Adv Nurs 1999;30:425e30. 15. Scahill S, Harrison J, Sheridan J. The ABC of New Zealand’s ten-year vision for pharmacists: Awareness, barriers and consultation. Int J Pharm Pract 2009;17: 135e42. 16. Mil J, Boer W, Tromp T. European barriers to the implementation of pharmaceutical care. Int J Pharm Pract 2001;9:163e8. 17. Shane-McWhorter L, Fermo JD, Bultemeier NC, et al. National survey of pharmacist certified diabetes educators. Pharmacotherapy 2002;22:1579e93. 18. Williams DM, Newsom JF, Brock TP. An evaluation of smoking cessation-related activities by pharmacists. J Am Pharm Assoc 2000;40:366e70. 19. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77e101. 20. Younis WS, Campbell S, Slack MK. Pharmacists’ attitudes toward diabetes and their involvement in diabetes education. Ann Pharmacother 2001;35:841e5. 21. McArtor JP, Rascati KL. Benefits of certification for pharmacy specialists. J Am Pharm Assoc 1996;NS36:128e34. 22. Pradel FG, Palumbo FB, Flowers L, et al. White paper: Value of specialty certification in pharmacy. J Am Pharm Assoc 2004;44:612e20. 23. Grief CL. The perceived value of BCEN certification. J Emerg Nurs 2007;33: 214e6. 24. Niebuhr B, Biel M. The value of specialty nursing certification. Nurs Outlook 2007;55:176e81. 25. O’Donnell DC, Brown CM, Dastani HB. Barriers to counseling patients with obesity: A study of Texas community pharmacists. J Am Pharm Assoc 2006;46: 465e71. 26. Smith SR, Golin CE, Reif S. Influence of time stress and other variables on counseling by pharmacists about antiretroviral medications. Am J Health Syst Pharm 2004;61:1120e9. 27. Nadaira N, Ouellet C, René-Henri N, et al. Factors influencing a community pharmacist’s interventions in asthma care. Can Pharm J 2009;142:240e6. 28. Berdine H, Dougherty T, Ference J, et al. The pharmacists’ role in the patientcentered medical home (PCMH): A white paper created by the health policy committee of the Pennsylvania pharmacists association (PPA). Ann Pharmacother 2012;46:723e50. 29. Emmerton L, Marriott J, Bessell T, et al. Pharmacists and prescribing rights: Review of international developments. J Pharm Sci 2005;8:217e25. 30. Hutchison M, Lindblad A, Guirguis L, et al. Survey of Alberta hospital pharmacists’ perspectives on additional prescribing authorization. Am J Health Syst Pharm 2012;69:1983e92.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
A Qualitative Assessment of the Practice Experiences of Certified Diabetes Educator Pharmacists Fahad Alzahrani BPharm, MSc a, Jeff Taylor BSP, MSc, PhD a, Jason Perepelkin BA, BComm, MSc, PhD a, Kerry Mansell BSP, PharmD a, * a
University of Saskatchewan, Saskatoon, Saskatchewan, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 July 2014 Received in revised form 26 September 2014 Accepted 21 November 2014
Objective: To describe the practice experiences of Certified Diabetes Educator (CDE) pharmacists in Saskatchewan and determine what impact the CDE designation has had on their personal practices. Methods: A qualitative research approach was used. All pharmacists in Saskatchewan were e-mailed about the study, and eventually, a purposive sampling method was used to select a range of CDE pharmacists. Semistructured, in-person interviews were performed. An interview guide was developed to assess the work activities performed, the benefits of becoming a CDE and the challenges and resultant solutions that optimize their CDE designations. All interviews were transcribed verbatim and coded using deductive thematic analysis to identify the main themes that described the experiences of respondents, with the aid of QSR NVivo. Results: A total of 14 CDE pharmacists from various communities and work settings chose to participate. All of the participants indicated they were engaging in increased diabetes-related activities since becoming CDEs. All participants indicated they were happy with their decisions to become CDEs and described numerous benefits as a direct result of achieving this designation. Although some solutions were offered, participants still face challenges in optimizing their role as CDEs, such as devoting enough time to diabetes management and remuneration for providing diabetes services. Conclusions: CDE pharmacists in Saskatchewan report performing enhanced diabetes-related activities subsequent to becoming CDEs and that obtaining this designation has had a positive impact on their personal practices. A larger, cross-country study is necessary to determine whether these results are consistent amongst all pharmacists in Canada. Ó 2015 Canadian Diabetes Association
Keywords: certified diabetes educator pharmacists qualitative assessment
r é s u m é Mots clés : éducateur agréé en diabète pharmaciens évaluation qualitative
Objectif : Décrire l’expérience pratique des pharmaciens éducateurs agréés en diabète (ÉAD) de la Saskatchewan et déterminer les conséquences liées au titre de ÉAD sur les pratiques individuelles. Méthodes: La recherche selon l’approche qualitative a été utilisée. Tous les pharmaciens de la Saskatchewan ont reçu un courriel à propos de l’étude. Par la suite, une méthode d’échantillonnage raisonné a été utilisée pour sélectionner un éventail de pharmaciens ÉAD. Des entretiens semi-structurés en personne ont été réalisés. Un guide d’entretien a été mis au point pour évaluer les activités professionnelles réalisées, les avantages et les inconvénients liés au titre de ÉAD ainsi que les solutions engendrées qui optimisent leur titre de ÉAD. À l’aide du logiciel NVivo de QSR international, tous les entretiens ont été transcrits textuellement et encodés selon l’analyse thématique déductive pour déterminer les thèmes principaux qui décrivaient l’expérience des répondants. Résultats: Un total de 14 pharmaciens ÉAD provenant de communautés et de milieux de travail divers ont choisi de participer. Tous les participants ont indiqué avoir pris part à plus d’activités liées au diabète depuis l’obtention de leur titre de ÉAD. Tous les participants ont indiqué être satisfaits de leur décision de devenir ÉAD et ont décrit les nombreux avantages comme une conséquence directe de l’obtention de ce titre. Bien que certaines solutions aient été proposées, les participants se heurtent encore aux difficultés
* Address for correspondence: Kerry Mansell, BSP, PharmD, College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place, Saskatoon, Saskatchewan S7N 5E5, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.11.004
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liées à l’optimisation de leur rôle de ÉAD comme le fait de consacrer assez de temps à la prise en charge du diabète et la rémunération liée à la prestation de services aux personnes diabétiques. Conclusions : Les pharmaciens ÉAD de la Saskatchewan rapportent avoir réalisé plus d’activités liées au diabète depuis qu’ils sont ÉAD et que l’obtention de ce titre a eu des conséquences positives sur leur pratique individuelle. Une étude pancanadienne plus vaste est nécessaire pour déterminer si ces résultats sont uniformes chez tous les pharmaciens du Canada. Ó 2015 Canadian Diabetes Association
Introduction Diabetes has been called one of the greatest health crises of the 21st century (1). Currently, there are more than 9 million Canadians living with or at risk for developing diabetes (2). With increased incidence and prevalence rates come additional pressure on the healthcare system and a corresponding increased need for resources to help manage this chronic condition. Ideally, people with diabetes are taught the importance of selfmanagement through diabetes education. Diabetes education has been a recognized cornerstone of diabetes care, and education contributes to improved self-care and glycemic control in patients with diabetes (3,4). Increasingly, healthcare professionals are seeking certification as diabetes educators as recognition of specialization in diabetes management. In Canada, this certification is offered through the Canadian Diabetes Educator Certification Board (CDECB). There are currently 3760 certified diabetes educators (CDEs) in Canada, of which 1379 are pharmacists (personal communication, CDECB, March 3, 2014). As a profession, pharmacists represent one-third of all CDEs in Canada and are the fastest growing segment of CDEs in Canada (5). Given their accessibility and recent earnestness in seeking the CDE designation, an enormous opportunity exists for pharmacists to become more involved in diabetes education and management. However, it is not clear what impact, if any, becoming a CDE has had on pharmacists themselves and the patients for whom they provide diabetes-related services. The purpose of this study was to elucidate which diabetes-related activities CDE pharmacists are engaging in, what the impact of becoming a CDE has had on their personal practices and what challenges (and corresponding solutions) CDE pharmacists face when they engage in educating people about diabetes management.
Methods A qualitative and descriptive method of investigation was used. Such an approach is preferred when a straight description of an event is desired and provides a comprehensive summary of people’s experiences as they occur in everyday life (6). Participants were chosen using a purposive sampling method to select a range of CDE pharmacists practicing in Saskatchewan. Information about the study was e-mailed to all licensed pharmacists in Saskatchewan for whom the Saskatchewan College of Pharmacists had an e-mail address. Those pharmacists who were interested in participating were asked to contact the study investigators directly, and a small honorarium was offered to participants for their participation. For data collection, individual, face-to-face, semistructured interviews were scheduled; the same investigator was used for all interviews. Interviews were performed between June and September 2012 at times and locations chosen by the participants. Interview data were collected via written notes and audio recordings. Once all interviews were completed, they were transcribed verbatim by a separate experienced transcriber and
double-checked against the recording for accuracy. All participants were provided their transcripts as member checks. A validated interview guide to describe CDE pharmacists’ experiences in diabetes management could not be found, so one was constructed for the goals of this study. The interview guide contained a list of open- and close-ended questions derived from both Canadian and international literature (7e18). The interview guide consisted of 5 components: description of work activities, benefits of a CDE designation, challenges related to providing diabetes services, corresponding possible solutions and respondents’ demographics. Each component included between 4 and 8 questions with a number of probes. The interview guide was reviewed independently by pharmacists and nonpharmacists to support face validity prior to the commencement of data collection and was piloted by 1 CDE pharmacist. The interview guide is available on request from the corresponding author. The study was approved by the University of Saskatchewan’s Behavioural Research Ethics Board. Data Analysis Braun and Clarke’s 6 phases of thematic data analysis was followed (19). To facilitate the organizing and analyzing process, QSR NVivo v. 10 software (QSR International, Burlington, Massachusetts, United States) was utilized. Once deductive thematic analysis was performed (whereby the data were coded, as it seemed appropriate to the researcher, with a predetermined outline in which the data fit), an external auditor experienced in qualitative research reviewed the findings. Results A total of 14 CDE pharmacists expressed interest in the study, and all 14 agreed to participate; all but 1 were female. There was an equal mix of pharmacists practicing in rural and urban communities. The majority of participants described their primary practice sites as community pharmacies, although 4 of these participants indicated they also worked in diabetes clinics outside of their pharmacies. Four participants were employed in institutional settings (hospital pharmacy or primary care centres) or with government. Overall, participants had been licensed for an average of 24 years, and their experience as CDEs ranged from 1 to 14 years. From the transcribed interviews, 755 significant statements were extracted, reflecting the practice experiences of CDE pharmacists; 200 cluster themes were formed, and they further merged into 4 main themes (Table 1). Theme 1: Work activities of CDE pharmacists The work activities described by respondent CDE pharmacists were broken down into 4 subcategories: diabetes education, follow up, recommendations and referrals, and peer assistance and program development. Regarding diabetes-specific education, all participants identified education about drug therapy as the most frequent activity they performed. They believed that one of their
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Table 1 Major themes and subthemes Themes
Subthemes
Work activities of CDE pharmacists Diabetes education Follow up and monitoring Recommendations and referrals Peer assistance and program development Benefits of CDE certification Personal and professional satisfaction Improved patient outcomes Collaboration, respect and recognition Clinical knowledge and skills Challenges in practice Lack of pharmacist motivation Lake of awareness Resistance from other healthcare providers Infrastructure and resources Prescriptive authority Patient-related issues Strategies to overcome challenges Relationship building Time and reimbursement issues Increasing public awareness Enhancing patient motivation CDE, certified diabetes educator.
primary responsibilities was helping patients understand each diabetes medication. Further, 1 participant, who practises in an urban setting, indicated involvement with insulin-pump training: I do work with pump training, insulin pump starts, so I currently do some independent training so I’ll get referred a patient who’s interested in a pump and I’ll get them trained. (CDE3, community pharmacist) The majority of participants indicated that they were frequently involved with insulin starts and insulin dose titrations. One participant who practiced in an urban community pharmacy setting stated: Many times we’ll identify someone who could benefit from insulin. We’ll talk about it with the patient and then I’ll offer to obtain a prescription for them to start insulin and then I’ll fax the doctor and ask if I can have the prescription along with the authority to make adjustments to try to titrate them up. (CDE1, community pharmacist) Almost all participants indicated that they provide counselling on both acute and chronic complications of diabetes as well as related medical conditions. One participant from a rural community practice stated: And counselling on.medications for their blood glucose control as well as lipid and blood pressure control or you know, depression, smoking cessation, whatever other issues may be going on in relation to their diabetes. (CDE4, community pharmacist) All participants indicated that they provide education concerning lifestyle modifications. Particularly, they all indicated that they provide some degree of basic dietary advice, such as healthful eating, following Canada’s Food Guide and carbohydrate counting. Although several participants indicated that they might suggest increased physical activity, they were much less comfortable and active in discussing this than in discussing dietary measures. Participants also indicated that follow up and monitoring of patients are large components of the job, particularly with new medication and insulin starts. Consequently, all participants indicated that they were active in helping their patients interpret selfmonitoring of blood glucose (SMBG) results. Theme 2: Benefits of CDE certification Participants were asked whether they found value in obtaining the CDE designation. Most participants indicated both increased
personal and professional satisfaction after attaining the CDE designation. Furthermore, the majority of participants also indicated an increased confidence in being able to provide diabetes management. Participants indicated that the greatest personal benefit came from improved job satisfaction and a sense of workplace empowerment. One participant, who practiced in an urban community pharmacy setting, indicated: Since I got my CDE, I now have more hours to devote towards specific hours that are meant towards that patient consult and I’ve been able to remove myself from that daily traditional dispensing to allow that and had I not had my CDE, that opportunity probably would not have been there. So, it’s completely changed the work I’m doing on a day-to-day basis. (CDE1, community pharmacy) Another benefit of becoming a CDE that was expressed by almost all participants was increased knowledge and skills in diabetes management. Several pharmacists indicated that they now deal with more complex issues when treating patients with diabetes and are often consulted by other healthcare professionals (HCPs) for such purposes. Furthermore, almost all participants indicated that their relationships with other HCPs improved as a result of becoming CDEs; most felt an increased sense of respect and credibility from their colleagues. Those who indicated there was no improvement stated that it was because they already had strong, established relationships with the physicians in their communities. Some participants also indicated that their relationships with patients had improved as well, and many believed that becoming a CDE led to improved patient outcomes and satisfaction (although this outcome was not measured). Some also felt a sense of responsibility in mentoring other pharmacists who were interested in becoming CDEs. Of significant interest, one participant indicated that becoming a CDE led to a collaborative prescribing agreement with a physician that allowed for various diabetes-related activities normally permitted only to a physician (e.g. prescribing a new antihyperglycemic agent) to be performed by the pharmacist. Similarly, another pharmacist indicated that a “transfer of function” was set up with a physician to allow greater responsibility and flexibility in managing patients with diabetes. Overall, all of the participants indicated they were happy with their decisions to become CDEs, and all indicated that they planned to recertify when the time arises. Theme 3: Challenges in practice As expected, all participants identified certain challenges in the workplace that they felt hindered them from putting their knowledge and skills in diabetes management to full use. The 5 main challenges were identified as lack of motivation; lack of awareness; lack of infrastructure and resources; resistance from other HCPs and patient-specific issues. Regarding lack of motivation on the pharmacists’ part, several participants indicated that they had had difficulty in altering the ways in which they normally function in the workplace. This was expressed as being personally challenging and that changing roles from what was comfortable was difficult. Second, study participants frequently reported lack of external awareness (of their being CDEs) as a challenge to delivering diabetes management services; this applied to both the public and the other HCPs. All participants indicated that they were trying different strategies (e.g. calling physicians or handing out pamphlets) to try to increase awareness. Some participants felt that not all HCPs were receptive to their roles as a CDEs. Most indicated that they encountered “turf protection” at one point or another, in particular from nurses. This may
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have occurred as isolated events and, overall, most participants described this situation as being not particularly troublesome and generally described positive support from other HCPs. All study participants described at least 1 challenge under the subheading of infrastructure and resources. Lack of time to deliver diabetes-related services was the most commonly cited challenge, followed closely by a shortage in funding for them to provide diabetes education and services. One participant working in a rural community pharmacy stated: Well, there’s a lot of different reasons [for providing free services], particularly, nobody has ever in Canada.paid for these things before. Because it’s a public healthcare system funded by the government, a lot of people wouldn’t really have an appetite for that [paying for diabetes services] and partly I would feel way too guilty. (CDE14, community pharmacist) Many participants indicated a lack of access to electronic health records and laboratory results as being a challenge; it is difficult to make decisions without a full health history, and tracking down this information takes time. Participants also indicated a lack of prescribing authority (i.e. pharmacists’ being able to prescribe medications in certain conditions after signing an agreement with a physician) as a challenge. Last, many participants in rural settings felt staffing shortages (pharmacists and pharmacy technicians) greatly impeded their abilities to provide the diabetes management they would like to provide. The ultimate challenges faced by many study participants related to patient-specific issues. Many participants mentioned that it was difficult to deliver diabetes care to patients who are not motivated or interested in what you have to say. Furthermore, patients’ actual capacities to access pharmacists’ services (for various reasons) were listed as challenges for some participants. Two reasons cited were: A huge problem with our First Nations people is being able to access healthcare in general. Whether that be to get to a regular physician, to get to a regular pharmacy, to be able to show up for an appointment that you have scheduled, to get to any place that is providing help, because they have huge transportation issues, they have huge issues with social support. (CDE4, community pharmacist) For the most part, when you start talking about nutrition and proper nutrition.a lot of people really can’t afford, unfortunately, you know what I mean? (CDE14, community pharmacist). Theme 4: Strategies to overcome challenges Participants were asked to describe strategies they have used to help overcome challenges encountered when trying to deliver diabetes services and capitalize on the CDE designation. Building relationships was one of the common subthemes that emerged. Physicians were identified as the primary HCPs to try to connect with. A variety of other strategies to overcome challenges were also listed by participants. Regarding lack of awareness of their being CDEs, various examples of trying to overcome this were provided, from giving public presentations, to building relationships with pharmaceutical representatives, to basic promotional materials such as posters and newspaper ads. One participant suggested a mechanism that might overcome the lack of funding and the reimbursement issuesdto charge the patient for the services provideddyet they did not actually do so. Making patients adhere to booked appointments and utilizing technology (e.g. text messaging the SMBG’s results) were reported as strategies to overcome time barriers, but by and large, time and reimbursement were challenges most participants had not yet found answers for. Regarding
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strategies used to increase patient motivation, some participants indicated using motivational interviewing to help build rapport with their patients and to learn what was important to them. Discussion Although pharmacists have become increasingly involved in diabetes management in recent years, pharmacists’ functioning as CDEs in their natural work environment is relatively new. Certification in any area has the potential to affect roles and responsibilities. As such, this study aimed to determine the practice experiences of CDE pharmacists through a qualitative assessment. The 4 major themes have helped to provide an understanding of CDE pharmacists’ experiences in delivering diabetes-related activities. Based on the interview responses, it appears that all participating CDE pharmacists are engaged in various levels of diabetes management, and this level of involvement has increased since they became CDEs. As expected, these pharmacists felt their primary responsibility was to educate patients about appropriate medication use. Many of these pharmacists are very comfortable with and involved in insulin management, interpretation of SMBG results and insulin dose titration. This aligns somewhat with previous literature, which found non-CDE pharmacists are not comfortable counselling on insulin use (20). Most participants also thought it was their responsibility to counsel patients about related chronic conditions and both the acute and the chronic complications of diabetes, regardless of the work setting. All participants indicated that they provide some degree of nutritional counselling and were comfortable in doing so, which has not always been the case for pharmacists (17). These participants did not spend a great deal of time discussing physical-activity interventions, and some suggested this to be the responsibility of other HCPs, although they did not provide any examples of who these HCPs may be. Given the number of interactions pharmacists have with these patients and the opportunities to discuss introducing physical activity, this remains a significant gap, and pharmacists may require additional training to improve their comfort levels in this area. All participants interviewed felt that becoming a CDE had benefited them personally and professionally. They described becoming a CDE as being beneficial with respect to their job duties, relationships with other healthcare professionals, job satisfaction and delivery of information as it relates to diabetes management. A few pharmacists indicated that their jobs had changed as a result of becoming CDEs; the changes ranged from obtaining prescribing agreements or transfers of function with physicians to more work time devoted strictly to diabetes education away from the dispensary. The majority of participants indicated increased confidence as a result of becoming CDEs and increased recognition by their colleagues, which is consistent with previous literature and certification in other instances (7,21). All participants were happy with their decisions to become CDEs and would encourage others to do so as well. These findings support previously published studies investigating the value of certification among pharmacists (17,22). In addition, several other studies have indicated the benefits of professional certification for other healthcare professionals (23,24). The challenges identified by participants in this study are consistent with previous studies of pharmacy practice in general, such as lack of recourse, lack of funding, increased demands on pharmacists’ time and patient barriers (18,25e27). Participants reported facing several complex problems when trying to provide diabetes-related education and clinical services, similar to those of most other practising pharmacists in general. Although participants described increased engagement in diabetes management since becoming CDEs, the majority still reported that these challenges
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(e.g. time, funding) prevented them from practising to the full scope of their abilities. Similar to previous literature, lack of awareness was also cited as a major challenge (28), although it appears that these participants are engaged in various strategies to try to overcome this lack. It is interesting that some participants mentioned that the absence of a collaborative prescribing agreement with a physician hindered their abilities to practice to their full scope. This is in contrast to previous literature (29,30) in that it indicates these participants are seeking more responsibility for the provision of patient care, further demonstrating the increased confidence these pharmacists have. Limitations As with other qualitative approaches, a number of essential limitations are relevant, such as researchers’ biases, their abilities to generalize the findings and time consumption. Although the results reported provide rich explanations of the practice experiences of CDE pharmacists in Saskatchewan, these findings may not be generalizable to a wider population of CDE pharmacists across Canada or even within Saskatchewan for those CDE pharmacists who chose not to participate. A sample size of 14 may seem low, but in qualitative design the focus is on the value and richness of information achieved from participants (6), and that endeavour is not associated with the number of participants. The majority of participants were from community pharmacies, and the results could vary substantially across practice settings. It is always possible that those participants who chose to participate were motivated and may not be representative of the larger sample. Finally, this study did not evaluate the differences in patient outcomes realized by having a CDE pharmacist involved in their care. Conclusion This is the first study to obtain an in-depth qualitative description of CDE pharmacists’ activities and to evaluate the effects of becoming CDEs have on pharmacists. It appears from all accounts that the pharmacists interviewed are putting their CDE designations to use and are finding ways to harness this designation. All of the pharmacists interviewed indicated that becoming CDEs has been beneficial to them for a variety of reasons. Although challenges exist in providing diabetes-related services, these pharmacists are engaging in a broad variety of diabetes management-related activities. A larger, cross-country study is necessary to determine whether these results are consistent amongst all pharmacists in Canada as well as a study to determine the impact of CDE pharmacists’ roles in patient outcomes. Acknowledgements The authors acknowledge the contribution of the pharmacists who participated in this study, and we sincerely thank them for allowing us to share their experiences. The authors also thank Scarlett Ewan for proofreading the findings in the final stages. The authors also thank the Saudi Arabian Cultural Bureau in Canada for helping fund a portion of this research.
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