Abstract
Background:
Physical assessment in pharmacy practice is not a new concept, yet the idea is still unfamiliar to many people. Canadian pharmacy graduates are expected to be trained in physical examination as it relates to drug therapy. However, standard delivery of course content in this area has not been clearly established, and previous publications have reported low uptake of this practice despite formal training. To aid the future development of a physical assessment course for pharmacists that is relevant to practice and will contribute to patient care, it is important to gather insight from practising pharmacists, health care providers and the public.
Objective:
To determine the type of physical assessment skills that would be of value to pharmacy practice and the benefits and barriers of these skills in practice from the perspectives of pharmacists, health care providers and the public.
Methods:
This was a cross-sectional online survey of pharmacists, nonpharmacist health care providers and the public. Descriptive statistics and thematic analysis were used to describe data.
Results:
A total of 348 respondents (98 pharmacists, 154 nonpharmacist health care providers, 96 public) completed the survey. Most (64%) nonpharmacist providers were physiotherapists or occupational therapists (only 6.5% physicians). Most respondents felt that performing basic vital signs was relevant to pharmacy practice (79% pharmacists, 69% other providers, 79% public) and felt confident and comfortable about pharmacists using these skills. Palpation, percussion and auscultation were rated less favourably (<50% for most respondents). Nonpharmacist providers tended to be less favourable than pharmacist and public respondents. Seven themes related to benefits and 13 themes related to disadvantages of pharmacists performing physical assessment were identified.
Conclusion:
These findings provide insight into opinions about the value of pharmacists performing physical assessments. Consensus recommendations on performance expectations to improve recognition of pharmacists in this area is needed in the future. Can Pharm J (Ott) 2021;154:xx-xx.
Knowledge Into Practice
Physical assessment in pharmacy practice is not a new concept, yet uptake of this practice is low.
This study provides insight from the perspectives of pharmacists, nonpharmacist health care providers and the public about the value and feasibility of performing physical assessment in pharmacy practice.
Consensus recommendations on the performance expectations of pharmacists conducting physical assessments will help guide pharmacy educators and increase recognition and confidence among pharmacists, health care providers and the public about this practice.
Mise En Pratique Des Connaissances
L’évaluation physique dans la pratique pharmaceutique n’est pas un concept nouveau, mais son adoption est faible.
Cette étude a fourni un aperçu du point de vue des pharmaciens, des fournisseurs de soins de santé non-pharmaciens et du public sur la valeur et la faisabilité d’effectuer une évaluation physique dans la pratique pharmaceutique.
Des recommandations consensuelles sur les attentes en matière de rendement des pharmaciens effectuant des évaluations physiques permettront de guider les formateurs en pharmacie et d’accroître la reconnaissance et la confiance des pharmaciens, des prestataires de soins de santé et du public à l’égard de cette procédure.
Background
Pharmacists are responsible for ensuring the safe use of medications to the public. They play an important role in evaluating the appropriateness of medications based on their indication, efficacy, safety and convenience for a patient. Some pharmacists now have prescribing authority and are able to administer medications by injection. 1 All of these services require pharmacists to thoroughly assess patients. This includes physical assessment. Performing physical assessments on a patient for the purpose of detecting medication-related problems early and to monitor ongoing or newly prescribed medications would provide useful information for improving patient care.2-5 However, the uptake of integrating these skills into practice is low.5-7 Canadian pharmacy graduates are expected to be trained in the performance and interpretation of physical examination findings as they relate to drug therapy.8,9 However, standard recommendations for developing course content in this area have not been clearly established, and the extent of variation across Canada is not known.
One of the challenges of developing a program on physical assessment for pharmacists and pharmacy students is identifying the specific skills that would be meaningful for pharmacists to incorporate into their practice routinely. Pharmacy practice is a diverse profession. One publication described how 3 clinical pharmacists working in different specialties (intensive care, oncology, family medicine) incorporated physical assessment into their practices. 10 The types of skills used in these practices ranged from measuring blood pressure with a manual cuff to auscultating blood pressure and respiratory crackles. 10 The primary concerns that were raised with incorporating physical assessment skills in pharmacy practice included limited opportunities to practice and fine-tune these skills, resistance from other health care providers who provide similar services (including physicians, physician assistants, nurses), level of comfort of the patient in having a pharmacist perform these skills and time to incorporate these assessments in a busy practice.10-12 The literature on the incorporation of physical assessment in community pharmacy practice is limited.
Physical assessment was introduced into the pharmacy curriculum at the University of Manitoba in 2013. 13 This program currently teaches students the performance and interpretation of vital signs (blood pressure, pulse rate, respiratory rate, temperature), respiratory assessment and electrocardiograms. Future topics in development include diabetic foot examination and skin conditions. Practising pharmacists who have graduated prior to the introduction of this program have expressed an interest in a continuing education program in physical assessment to keep up with the demands of their profession and to be able to supervise students who are able to demonstrate these skills on rotation. To ensure that future developments of the physical assessment course for pharmacy students and practising pharmacists are relevant to pharmacy practice and will contribute to patient care, it is important to gather insight from practising pharmacists, health care providers and the public. This will provide some direction in developing a physical assessment program that will teach skills that are feasible to incorporate into practice and will allow for improved interprofessional collaboration. Accordingly, we aimed to carry out a survey study to determine the type of physical assessment skills that would be of value to pharmacy practice from the perspectives of pharmacists, health care providers and the public.
Methods
Design
The was a cross-sectional survey study to understand the perspectives of pharmacists, other health care providers and the public about the performance of physical assessment in pharmacy practice. Ethics approval for this project was received from the University of Manitoba Human Research Ethics Board (Registry No. H2018:255 [HS21934]).
Population
This study involved 3 surveys, which were open to 3 different populations in Manitoba: 1) pharmacists, 2) nonpharmacist health care providers (this included physicians, nurses, nurse practitioners, physician assistants, physiotherapists, respiratory therapists and dentists) and 3) the public, aged 18 years and older. Participants were recruited through paper and online advertisements. An online advertisement was sent by email directly to the pharmacy and other health care education programs and regulating bodies in Manitoba. Paper advertisements for public engagement were posted at community pharmacies and clinics. An advertisement also appeared in the local newspaper.
Data collection
The survey was administered using an online service (SurveyMonkey). Data were collected over a 6-month period (September 2018 to February 2019). The survey collected demographic information and information on the level of comfort, confidence and knowledge about pharmacists performing specific skills in physical assessment, identifying the specific types of physical assessment skills that would add value to practice and identifying educational needs and access to resources that would ensure pharmacists can continue to practice these skills competently. Questions were formatted using diverse formats to capture responses, including the use of Likert scales, ranking and open-ended comments (see Appendix 1, available in the online version of the article, for survey questions). Before the final administration of the survey, it was piloted to a small sample (3 physicians, 3 pharmacists and 3 non–health care providers) to ensure the survey questions were understood by respondents and to ensure the survey captured information as it pertains to the study objectives.
Data analysis
Descriptive statistics were used to describe demographic information of the respondents and responses to questions using Microsoft Excel software. Qualitative thematic analysis was used to analyze open-text comments from the survey. 14 Two investigators (L.S. and C.L.) reviewed all open-text comments, and line-by-line coding was applied using Microsoft Excel to analyze the comments, moving iteratively between data to identify themes. Major themes and supporting quotes from open-ended comments were identified by examining coded segments of the comments to note the most frequent or important information reported by respondents. All refinements to codes and organization of coded segments into themes were done through discussion and critical reflection between 2 investigators (L.S. and C.L.). Information from the survey was then used to guide course content for physical assessment for pharmacy students and pharmacists.
Results
A total of 348 individuals responded to the survey. Ninety-eight of the respondents were pharmacists, 96 were from the public and 154 were other health care providers. Demographic and practice characteristics are shown in Table 1. The large majority of nonpharmacist health care providers (92/98, 93.9%) and public respondents (59/64, 92.2%) had not observed a pharmacist perform a physical assessment. In those who had seen a pharmacist perform a physical assessment, basic vital signs (3 health care providers, 5 public) and inspection (6 health care providers and 1 public) were the most common areas of physical assessment observed. More than half (53.2%) of pharmacists reported that they have performed a physical assessment (Table 2). Basic vital signs (66.7%) and inspection (81.5%) were the most common categories of physical assessment performed by a pharmacist. Skin (e.g., skin rash; 85.7%) and cardiovascular system (e.g., blood pressure, heart rate; 53.6%) were the most common areas in which physical assessment was performed by a pharmacist. The physical assessment that was performed often resulted in referral to a family doctor (e.g., “referred to doctor because heart rate was low and patient was on a beta-blocker”) or other health care provider (65.4%) or resulted in a positive or actionable outcome (e.g., “recommended treatment for a stye”; 65.4%).
Demographic and practice characteristics (N=348; n, %)
Pharmacists’ personal experiences in having performed physical assessments, n (%)
Most pharmacist respondents felt the performance of basic vital signs and inspection was relevant to pharmacy practice (78.7% and 86.6%, for basic vital signs and inspection, respectively) and felt confident (78.9% and 62.0%) and comfortable (80.0% and 60.5%) with pharmacists using these skills (Figures 1a-c). Likewise, most nonpharmacist health care providers and the public felt that performing basic vital signs and inspection is relevant to pharmacy practice (nonpharmacist providers 69.1% and 69.3%, respectively; compared with public 79.2% and 75.0%). The public rated their level of confidence higher than nonpharmacist providers for these skills (public 70.1% and 52.9%, for basic vital signs and inspection, respectively; compared with nonpharmacist providers, 64.7% and 46.5%). About 64.0% and 54.7% of nonpharmacist health care providers and 68.8% and 67.6% of the public felt comfortable with pharmacists performing basic vital signs and inspection, respectively.
(a) Proportion of respondents who agree or strongly agree with the relevance of physical assessment in pharmacy practice
Palpation, percussion and auscultation were rated less favourably by respondents in terms of relevance, confidence and comfort of pharmacists using these skills (Figures 1a-c). The public rated these skills higher than the pharmacists did (public-reported relevance of 48.5%, 41.8% and 50.7% compared with pharmacist-reported relevance of 40.5%, 32.1% and 33.8% for palpation, percussion and auscultation, respectively). In contrast, nonpharmacist health care professionals rated the relevance of these skills lower than pharmacists did (32.3%, 16.9% and 28.2% for palpation, percussion and auscultation, respectively).
Skin (e.g., skin rash, burns, fungus), general survey (e.g., weight/height) and the respiratory system (e.g., breathing) were areas in which most respondents felt pharmacists could be expected to perform physical assessment on a patient (Figure 2). The least common included neurology (e.g., tremors), abdominal (e.g., bowel sounds) and musculoskeletal (e.g., muscle strength) systems. About 24.2%, 22.7% and 27.3% of pharmacists felt physical assessment of neurology, abdominal and musculoskeletal systems, respectively, could be expected to be performed by a pharmacist, compared with 12%, 19% and 9% of nonpharmacist providers and 23.3%, 31.7% and 28.3% of the public. Nonpharmacist health care providers tended to respond less favourably than pharmacists and the public with regard to performing physical assessment skills for all body systems, with the exception of skin, general survey and peripheral vascular system (e.g., pulses on feet, diabetic foot inspection). The public reported higher ratings for head, eyes, ears, neck and throat (HEENT) and abdominal than pharmacists and nonpharmacist health care providers did.
Areas that you would expect a pharmacist to perform physical assessment skills on a patient
Figures 3a to 3e show the average ranking that was reported by pharmacists and nonpharmacist health care providers on the value of physical assessment performed by a pharmacist on a scale ranging from 1 (no value) to 10 (very valuable). The ranking was for the purpose of 1) determining drug indication, 2) monitoring drug therapy, 3) determining urgency, 4) providing general screening and 5) improving communication between health care providers. Pharmacists ranked the value of the role of physical assessment in these areas higher than other health care providers did.
Average rankings reported by pharmacists and nonpharmacist health care providers*
The opinions of pharmacists, nonpharmacist health professionals and the public on conducting physical assessment in pharmacy practice were divided (Appendix 2, available in the online version of the article). Themes that related to the benefits of pharmacists performing physical assessment in practice included 1) improving the monitoring of medication efficacy and/or safety for early intervention, 2) patient convenience with regard to triaging conditions and managing common ambulatory conditions, 3) increasing access to health care services for the public, 4) strengthening the ability of pharmacists to provide and communicate recommendations, 5) reduced burden to the health care system, 6) potential for new opportunities for pharmacists and 7) increasing patient confidence. Themes that related to the disadvantages and/or barriers of pharmacists performing physical assessment in practice included 1) the need for adequate training; 2) increased workload for pharmacists; 3) concerns with infrastructure, including lack of remuneration, lack of time and physical layout of pharmacy; 4) distraction to traditional pharmacist roles; 5) potential for errors in performance and interpretation of physical assessment; 6) infrequent use of these skills to maintain competency; 7) redundancy of services; 8) reduced patient care or public confusion or inconveniencing the patient; 9) liability; 10) conflicts with other health care providers; 11) out of scope, 12) documentation and communication of findings; and 13) conflict of interest.
Discussion
This study provides insight into the opinions of pharmacists, nonpharmacist health care providers and the public on pharmacists incorporating physical assessment into their practice. Although the concept of physical assessments performed by a pharmacist is not new, 15 it remains an unusual concept to many. It was therefore not surprising that most nonpharmacist health care providers and the public have not observed pharmacists using these skills.
Most of the respondents considered basic vital signs, skin assessment (e.g., rash), general survey (weight/height) and the peripheral vascular system (e.g., edema, diabetic foot inspection) as areas in which physical assessment could be performed in a community pharmacy setting. While abdominal and neurology systems were considered less applicable to pharmacy practice, exposing pharmacy students to components of these areas (e.g., drug-induced tremors) has the potential to be of value for providing a baseline understanding of patient care, with the caveat that these assessments may need to be taken where continued exposure, training and competency can be evaluated. Moreover, further training could be sought for specialized pharmacists. For instance, the identification of jugular venous distension in the hospital setting for patients receiving furosemide for heart failure might be appropriate for a pharmacist working in this setting.
This study provided diverse perspectives on the benefits and limitations of pharmacists performing physical assessments on patients. The ability to detect drug-related problems early, triage conditions and provide increased access to a service were identified most commonly as the benefits of pharmacists performing physical assessment. However, the need for adequate training, the added workload for pharmacists and the lack of infrastructure to allow pharmacists to carry out these assessments were of upmost concern. Other valid areas of concern that were raised included limited opportunities to perform these skills in practice to maintain competency. A few respondents noted that these skills take practice and good mentoring to become competent at performing and interpreting findings. Moreover, concerns were raised regarding the overlap in health care providers who are able to perform these skills and the need for open communication between health care providers to avoid duplication of physical assessments. Physical assessment is only one component of the entire picture, and without access to electronic charts or lab findings, certain physical assessments would not be enough to guide recommendations in isolation. Rather than seeing the potential added value, some respondents felt that pharmacists were trying to take on new roles that simulate physicians. The public was most concerned with how this would affect wait times for receiving their prescriptions if pharmacists are occupied with performing these assessments. Other health care providers were concerned with whether patients would be less inclined to seek their physician for needed care and the inability to access findings obtained by the pharmacist. Of note, the lower ranking by nonpharmacist health care providers on the value of pharmacists performing physical assessments is not interpreted as a lack of “permission” but rather speaks to the need for increased awareness and education of other health care professionals on how pharmacists would be able to contribute to patient care with the ability to carry out these assessments.
These findings must be taken into consideration with a few study limitations. First, it is important to note that most nonpharmacist health care providers were from rehabilitation medicine (e.g., physiotherapy, occupational therapy). It is unclear why this was the case, but all colleges in the health sciences faculty were invited to participate, and it could be a matter of dissemination, interest and time to respond to the survey. This profession may also have the least regular interaction with pharmacists in practice. Of note, only 8.4%, 6.5% and 3.3% of respondents were physician assistants, physicians and nurse practitioners, respectively. As a result, the sample of nonpharmacist health care providers may not be a representative sample of prescribers of medications in which interaction with pharmacists may be more meaningful. Moreover, the survey may be more likely to attract nonpharmacist health care providers with strong negative opinions about pharmacists performing physical exams (and who may be concerned with protecting their professional turf). While this is a limitation, it was also important to be inclusive in our sample of nonpharmacist health care providers to capture a diversity of health provider perspectives. In this study, more than half of the pharmacists who responded had performed a physical assessment. It is unclear if this is representative of the entire Manitoba pharmacist population or if the subject of the survey itself attracted more pharmacists who have these skills to share their opinions on the topic. One publication reported that 38.2% (13/34) of pharmacists who participated in a professional development program in Alberta and Ontario have performed physical assessment in practice. 5 Another study reported that 49% (39/79) of pharmacists performed physical assessment on a real patient before taking a physical assessment course in British Columbia. 11 Since physical assessment in pharmacy practice is a relatively unfamiliar concept for many nonpharmacists, it is expected that many of the respondents who are not pharmacists are not aware of the level of training that pharmacists receive in this area. This may contribute to the lower reported rankings of value with regard to pharmacists performing physical assessment among nonpharmacist health care providers compared with pharmacists. This is important to note, as there is potential for added value for training pharmacists on physical assessment in many areas that may not have been recognized by all participants of this study. For instance, many felt neurology was not an important area in which pharmacists could perform a physical examination. However, pharmacists could be trained in the early detection of drug-induced movement disorders, which can have important implications for patients.12,16 It is also important to be clear that the opinions of nonpharmacists should not drive pharmacy practice, but rather should be used to understand where resistance might occur.
Despite these limitations, this study provided added insight to help guide pharmacy educators to move forward with building physical assessment content for pharmacy students and pharmacists. Based on these findings, the next step is to prioritize physical assessment skills based on expected skill level. One way to systematically achieve this is to use the “Novice, Functional, Competent” framework to assign performance expectations for specific physical assessment skills.17,18 This could help frame consensus recommendations, which should be revised over time and adapted based on practice setting, to guide pharmacy educators in building physical assessment content into the pharmacy curriculum. Input from pharmacists, physicians, nurse practitioners and patient representatives from across Canada would be important in the development of these recommendations. Such recommendations have the potential to improve the recognition and confidence of pharmacists, other health care providers and the public about the pharmacist’s ability to perform these skills and to clarify which skills they received adequate training in.
Conclusion
To develop a physical assessment program in pharmacy that is meaningful, it is important to consider the lay of the land in pharmacy practice (with most Canadian graduates working in community practice 19 ) and how these settings interact with other health care providers and the public. It is clear that there needs to be a mechanism to allow for time, space and monitoring of competency of physical assessment in community pharmacy practice. Developing a consensus recommendation based on performance expectations is a logical next step to improve the recognition and confidence of pharmacy skill level in this area and contribution to practice.
Supplemental Material
sj-pdf-1-cph-10.1177_17151635211004975 – Supplemental material for Physical assessment in pharmacy practice: Perspectives from pharmacists, nonpharmacist health care providers and the public
Supplemental material, sj-pdf-1-cph-10.1177_17151635211004975 for Physical assessment in pharmacy practice: Perspectives from pharmacists, nonpharmacist health care providers and the public by Christine Leong and Leila Soufi in Canadian Pharmacists Journal / Revue des Pharmaciens du Canada
Supplemental Material
sj-pdf-2-cph-10.1177_17151635211004975 – Supplemental material for Physical assessment in pharmacy practice: Perspectives from pharmacists, nonpharmacist health care providers and the public
Supplemental material, sj-pdf-2-cph-10.1177_17151635211004975 for Physical assessment in pharmacy practice: Perspectives from pharmacists, nonpharmacist health care providers and the public by Christine Leong and Leila Soufi in Canadian Pharmacists Journal / Revue des Pharmaciens du Canada
Footnotes
Acknowledgements
The authors would like to acknowledge Kara Lipski, who was a fourth-year pharmacy student and research assistant at the time of this study, for her help in piloting the surveys.
Funding:
This study was funded by the District Five National Association of Boards of Pharmacy (NABP)/American Association of Colleges of Pharmacy (AACP) Study Grant 2018.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
