A conceptual framework toward identifying and analyzing challenges to the advancement of pharmacy

Abstract

Background

Pharmacists and health care professionals are faced with increasing and changing health care needs around the world. To meet these demands, they are required to continuously upgrade and develop their professions. Reprofessionalization is therefore crucial to the successful delivery of health services, but traditional theories might provide little practical guidance to evaluating the overall status of a profession.

Objective

This study proposes a new conceptual framework of three interrelated professional sectors: education, regulation and practice, and uses it to identify and analyze challenges facing the pharmacy profession in Jordan.

Methods

A multiple-method qualitative study comprised of semi-structured interviews and focus groups was conducted in Amman, Jordan. To explore and identify the challenges, a purposively recruited cross-sector sample of 53 key informants, stakeholders and pharmacists were interviewed. Interview transcripts were translated and analyzed using QSR NVivo 10. Thematic analysis identified eight main challenges facing pharmacy in Jordan. The original participants were then invited to participate in focus groups, the purpose of which was to validate the interview findings, map them against the conceptual framework and discuss recommendations for development.

Results

The eight validated challenges span the following areas: graduates preparedness for practice, pharmacy education accreditation and quality assurance, pre-registration requirements, workforce development, workforce planning, remuneration and wage rate, pharmacy assistants, and Pharm.D. pharmacists. Focus group participants used the framework to map each of the challenges to the primary sector-to-sector disconnect that they perceived to explain it. A list of recommendations addressing each of the challenges was also devised.

Conclusions

The framework was found to offer valuable insight as an explanatory and diagnostic tool in policy-relevant research. By emphasizing the processual and contextual nature of reprofessionalization, the framework presents an alternative approach to traditional theories. This study also raises important questions regarding the status of pharmacy in Jordan and aims to provide guidance for local development and much-needed reprofessionalization drives.

Introduction

Sociological theorists have long been interested in the theory of professions and what distinguishes them from other occupations. According to an early idealistic ‘normative’ approach to defining a profession, values and ethical codes give the professions their key stabilizing function in society1, 2; but this categorization of an occupation – largely based on unsubstantiated privilege granted by society – was not deemed a sufficient measure for discriminating between occupations.3, 4 The argument was therefore further expanded by the ‘trait’ approach to include, in addition to a code of ethics, a combined range of defining characteristics or traits (e.g. self-regulation, training, licensing, examinations, and professional associations)5, 6; the varied interpretations of the trait approach and its arbitrarily set lists of criteria explain its failure to produce a consensus.⁴ Interactionist views, on the other hand, examine the dynamics of professionalism as a form of service provision rather than a set of traits; this ‘occupational control’ approach argues that professionals deploy exclusive services to exert market control over their occupation.3, 7, 8 Freidson proposed that in addition to this occupational control or ‘dominance,’ ‘autonomy’– or the ability to control one's work activities – is also needed to give professional power to an occupational group.⁹ Sceptics, however, attribute the narrowing of knowledge gaps and the rise of new and highly-specialized occupations to the decline of these professional powers.10, 11 Within the theories of professions, there appears to be no unified holistic approach to what constitutes the professionalization of an occupation – or the process of it becoming a profession.

Throughout these ongoing disagreements, debates and theoretical evolutions, the profession of medicine – firmly rooted in the historic Hippocratic Oath – has always been “the example of choice when sociological theories about the professions were discussed.”¹² As the division of health care labor progressed, the professionalization of pharmacy and other health care occupations began to increasingly feature in such discussions.3, 13, 14 The professionalization of pharmacists is set within the evolutionary stages of pharmacy practice models. Manufacturing, compounding and distributing medicines were key features of practice in the 19th century; the establishment of sale and supply restriction laws, pharmacy schools and representative associations across Europe, the U.S and Asia signaled the start of professional regulation, official representation, and organized education of pharmacy.¹⁵ The large loss of pharmacists' manufacturing and compounding roles to the advent of the 20th century pharmaceutical industry was coupled with the consequential loss of their social purpose as compounders and distributers; hospital pharmacists had more varied activities but as in community practice, the emphasis shifted to the ‘product.’¹⁶ These events coincided with pharmacy beginning to feature in discussions – albeit with negative connotations – on sociological theories of the professions.

Despite pharmacists gaining occupational control over their service through preventing the unqualified from dispensing medicines, the pharmacy profession has historically been considered subordinate to the medical profession and its professional status has often been questioned. In his 1964 essay ‘The Professionalization of Everyone?,’ Wilensky critically examines the “heroic struggles” of some occupations to join the rank of “clearly recognized and organized” professions and describes pharmacy as a “borderline” profession ancillary to medicine.¹³ Medical sociologists Denzin and Mettlin similarly argued for the “incomplete professionalization” of pharmacists and partly owed their allegedly failed “attempt to turn themselves from ordinary occupations into the prestigious groupings called professions” because of their lack of control on medicine, their social object.¹⁷ Freidson also agreed by concluding that pharmacy is “firmly subordinated to medicine” due to the inability of pharmacists to diagnose diseases and prescribe medicines, which compromises their professional ‘autonomy’ according to him.⁹ However, the provision of drug information and medication counseling by community pharmacists and the addition of clinical pharmacy to hospital settings would eventually redefine the essence of practice and somewhat neutralize the negative effects of the manufacturing industry.¹⁶ These developments formed the backdrop to the introduction of Hepler and Strand's concept of pharmaceutical care.¹⁸ Shortly after, Dingwall and Wilson firmly reject Denzin and Mettlin's claims, counter-arguing that pharmacy's social object is not the medicine itself but rather its median role for social change.¹⁹ Despite these developments, the ‘quasi’-status of pharmacy as a profession – as defined by the traditional sense of the word – still holds in contemporary literature.20, 21

The field of health professions is not static and shifts continuously as health care systems and the role of health care professionals develop and adapt over time; and many of the assumptions underlying the traditional professions theories do not survive the dynamic climate of health care.⁴ Pharmacists are continuously faced with increasingly demanding and complex health care needs and advancing technologies, forcing them to constantly re-evaluate their current practice models and envision future ones.²² According to Birenbaum,²³ these continuous efforts to upgrade and develop the status of pharmacy within changing health care environments is referred to as reprofessionalization. Reform drives in the name of reprofessionalization have become a recurring feature in the literature; the topic is examined through several lenses such as extending practice roles,20, 24, 25 advancing educational models,26, 27, 28 and reviewing existing regulatory systems.29, 30 Birenbaum concedes that theoretical frameworks “fail to recognize the interactive and contextual nature of the development of the professions.”²³ According to Annandale,³¹ the relationship between theory and research is also reciprocal where “extant theories gradually fall out of fit with societies as they change and new approaches are called for.” This presents a structural problem for research aiming to identify challenges affecting the advancement of a profession and to assess if it's time to reprofessionalize an occupation, without relying on or associating with ephemeral definitions that supposedly determines its professionalization. This paper presents an alternative approach to the traditional theories of the professions and professionalization. It describes a simple conceptual framework that redefines what constitutes a professional arena and tests it in a case study conducted on pharmacy in Jordan.

The conceptual framework describes that in any professional arena, there is a dynamic and complex interplay between the education, regulation and practice sectors. The framework was developed by Rouse in his work with the Accreditation Council for Pharmacy Education (ACPE), the U.S. national accreditation agency for pharmacy education. The conceptual framework, used widely in presentations, was intended to depict the separation of the entities responsible for education, practice and regulation, but at the same time the dynamic relationships that exist between the sectors, working in collaboration to advance the profession. It was first published in Version 1 of the Global Framework for Quality Assurance of Pharmacy Education – adopted by the International Pharmaceutical Federation (FIP) in 2008. FIP is the largest global body representing pharmacy and pharmaceutical sciences and whose goal is to support the development of the pharmacy profession. Fig. 1 illustrates the relationship between the three principal components of the framework. ‘Practice’ refers to the sector of the profession that provides a broad range of services to society in and from a variety of settings. ‘Regulation’ refers to the sector – within and/or outside the profession – that determines and enforces the statutory requirements for the organization and practice of pharmacy. ‘Education’ refers to the sector of the profession that prepares the members of the pharmacy workforce for practice; i.e. both pre-service education and continuing education (CE)/continuing professional development (CPD).

The framework depicts that there should exist a dynamic relationship between its components or sectors – even a ‘tension’– constantly driving change and advancement. The separation also provides for ‘checks and balances’ whereby a ‘push’ from one side can be checked (even opposed) by the other sector, with some positioning back and forth until something that works in the best interests of the profession and the public becomes the agreed ‘end point.’ The possible negative impact of a lack of separation (the absence of checks and balances) between these three sectors may lead to stagnation or conflict of interest; ‘self-regulation,’ for example, can be used to illustrate this effect and will be discussed in this paper. At the same time, however, it is important to ensure that at no stage do any of the separations depicted get too wide, thereby creating a disconnect, which may lead to dissatisfaction or frustration. If, for example, pharmacy educators teach for a model that is not supported by practitioners and/or regulators, graduates may become disillusioned if the practice or regulatory environment does not allow them to practice in the manner conveyed by the academic program. Developments and innovations in any of these professional domains may lead, drive or require an appropriately measured response from another, but there must always be that dynamic interplay of ‘checks and balances.’ Failure to make needed changes by one sector can – and should be – challenged by the other sectors in the profession. For example, changes in practice needs may force appropriate changes to be made in education, and new regulations will impose new effects on the practice environment. A proper push–pull fit between these professional domains is crucial to not only maintaining the integrity of the profession, but to also advancing it. Similarly, any disconnect between them destabilizes their harmony and may prove, to varying degrees, detrimental to the overall state of the profession. Existing challenges hindering the advancement of a profession may also be better understood by tracing them back to their corresponding ‘disconnected’ axes; for instance, noncompliance to dispensing laws can be traced to a primary disconnect between ‘regulation’ and ‘practice’ owed to the weak implementation of dispensing regulations in community practice. This additional diagnostic or formative feature of the framework allows it to be a practical analytical tool in policy-relevant prescriptive studies.

Modern pharmacy practice in the Hashemite Kingdom of Jordan – or Jordan – can be traced to the 1930s, and the first independent community pharmacy opened in 1946.³² The Jordan Pharmaceutical Association (JPA) was established in 1957 but the JPA Law 1972 was the primary legislation that enabled its present role as a statutory regulatory and registration body; in addition, the JPA also acts as the principal professional body representing, promoting and developing the pharmacy profession in Jordan. The regulation of pharmacy in Jordan is a complex amalgam of statutory frameworks carried out by separate entities but one that can be broadly categorized as state-sanctioned self-regulation.³ Pharmacy practice is governed by the JPA's Drug and Pharmacy Law 2001 and the Ministry of Health's Public Health Act 2008, Narcotic Drugs and Psychotropic Substances Law 1988 and various sets of statutory rules. The registration of pharmacy premises and the inspection of medicines and medical devices are the administrative responsibilities of the Ministry of Health and Jordan Food and Drug Administration, respectively. The JPA defines the pharmacist as “any person holding a degree in pharmacy from an accredited university in the Kingdom, and registered in the pharmacists register with the Association, and authorized by the Ministry to practice this profession.”³³ Registration with the JPA is thus mandatory and pre-registration requirements include the successful completion of an accredited pharmacy degree, 1440 h of training and the JPA's licensing examination. There are currently 15 universities in Jordan that offer the five-year Bachelor of Science (B.Sc.) in Pharmacy and two of them also offer a six-year Doctor of Pharmacy (Pharm.D.) degree; the B.Sc. is considered the main national program, but both degrees qualify as an entry requirement and are accredited by the Higher Education Accreditation Commission (HEAC).³⁴ To maintain their registration status, pharmacists are required to pay annual fees to the JPA. There are no mandatory CE or CPD requirements of pharmacists, nor are there any post-licensure revalidation mechanisms in place. The majority of pharmacists work in the private sector,³⁵ and the various practice settings in Jordan include community pharmacy, hospital pharmacy, the manufacturing industry, pharmaceutical wholesalers and distributers (locally referred to as drugstores), academic institutions, professional and regulatory bodies, research and consultancy companies as well as other governmental and intergovernmental organizations.

At face value, pharmacy in Jordan is thriving: (1) Jordan is a leading global pharmaceutical industry exporter and regional medical tourism destination36, 37; and (2) in the decade leading up to 2015, the number of community pharmacies increased by 50%, exceeding 2200 pharmacies, (3) the total number of licensed pharmacy schools have doubled bringing the total to 15 (5 public and 10 private), and (4) the active workforce has also nearly doubled to about 12,000 pharmacists.32, 38 Underlying these quantitative growths, concurrently published literature on pharmacy practice paints a less bright picture and reports a number of challenges. Despite community pharmacies being considered the most accessible health care facility,³² pharmaceutical care provision in Jordan continues to suffer from limitations.32, 39 Community pharmacists fully support the concept of pharmaceutical care, but a number of barriers to its implementation have been reported such as inadequacies in pharmaceutical care training and poor physician-pharmacist communication.⁴⁰ Despite the introduction of the patient care-oriented Pharm.D. program in 2000, these concerns are also echoed in the hospital setting where the importance of the role of pharmacists in hospital settings is still questioned among physicians in Jordan who view pharmacists within the traditional role and resist accepting or recognizing newer pharmacy clinical services.⁴¹ The negative dynamics of the pharmacist-physician relationship have also been identified as a factor resulting in stress and low job satisfaction among a cross-sector sample of pharmacists; other factors were reported to be the lack of formal career progression and development due in part to the absence of CPD/CE.⁴² Additionally, a poor public image of the pharmacist,³² limited pharmacist–patient interactions,⁴³ and deficiencies in pharmacists' communication and patient counseling skills have been found.⁴⁴ The non-strict enforcement of regulations in pharmacy practice has also been documented; existing classification and dispensing laws are not strictly enforced and, as such, patients can buy any medication without prescription – with the exception of controlled narcotics and major tranquilizers.³² One study also reported that it is not uncommon to find unsupervised pharmacy assistants unlawfully running pharmacies and supplying medications to patients.⁴⁵ This absence of strict enforcement of dispensing laws not only sheds light on a regulations problem, but also means that pharmacists and pharmacy assistants are entrusted with an unofficial but common responsibility of ‘prescribing’ that is outside of the realm of their expertise.⁴⁶ This example demonstrates that these and other unknown problems found in pharmacy in Jordan are not merely a professional and status concern, but are potentially detrimental to the health and safety of the public. Therefore, understanding the underlying patterns leading to these issues as well as identifying any other challenges in Jordan is a priority area for investigation.

The present study is the first attempt at filling the gaps by identifying the key challenges that are currently hampering the advancement of the pharmacy profession. With Jordan as the case example, the authors incorporated the conceptual framework into the study's design and analysis, and examined its value as an explanatory and formative tool for understanding the uncovered challenges and devising needs-based strategies to address them. The authors use the experiences from their multi-method, participant-centric research approach to discuss the framework's benefits and implications for reprofessionalization drives by researchers and stakeholders.