An estimated one-third of Australia’s population resides in rural areas. The isolation and decreased access to services have been associated with lower levels of health and wellbeing among the rural population. Sub-optimal medication supply and management have been reported in rural communities lacking healthcare services and skilled workforce support. This PhD research explored the involvement of pharmacists, as advocates of Quality Use of Medicines (QUM), to support medication management in rural areas. The research comprised two qualitative research phases, exploring (1) medication management gaps and issues in a rural community (Phase 1), and (2) a strategy to address one of the identified gaps and issues (Phase 2). Action research is applied throughout this PhD research, by reflecting on existing practices and needs, and pursuing practical strategies and solutions to address these needs in participation with others.
The first research stage required a geographical mapping exercise to identify a suitable rural study community in Queensland. Literature review and semi-structured interviews with 12 key informants external to this community informed the research topics. These topics were then explored in face-to-face, semi-structured interviews with 49 healthcare providers and 69 consumers within the study community. Thematically-analysed interview data revealed the need for pharmacist-mediated support to assist healthcare providers who had to undertake extended medication-related roles, particularly in non-pharmacist hospitals. Data around medication support requirements identified some lack of familiarity amongst nurses in the logistics of ordering and/or issue of medications, and associated legislation. Insights were also provided into the lack of clinical pharmacy support to provide therapeutic review and recommendations to healthcare providers, and medicines information to patients. Potential service delivery models for pharmacists to provide enhanced medication support included sessional (cross-sector) employment from within the community, and outreach and virtual support (via tele- or videoconferencing) from regional or metropolitan centres. Other data identified the potential for extended roles for various health professionals to ensure timely access to medications, particularly for continuing therapy, and to address inefficient transfer of medication information impeding timely medication supply and administration.
Recommendations were proposed in response to the issues identified in the Phase 1 study. These recommendations were screened and discussed with relevant key informants, researchers and health administrators to determine priorities and feasible strategies. As a result of this round of consultations, the subsequent research phase was designed to explore the potential for sessional employment of rural pharmacists as a practical service delivery model to provide medication support to rural areas, specifically to non-pharmacist hospitals.
The second research phase extended nationally and to New Zealand, focussing on scopes of practice for sessional pharmacists, and drivers and challenges to implement a workable model. Semi-structured interviews were undertaken via telephone or Skype™ with 17 pharmacist-participants. The 17 interviewees either were formerly employed sessionally (two models had expanded into full-time appointments; three models had been discontinued), had ongoing sessional contracts (n=8) or were working towards support arrangements for non-pharmacist hospitals (n=4). Thematic analysis identified the key outcomes of sessional employment as enhanced pharmacist support, resulting in improved QUM, and reduction in workload and stress of other healthcare providers involved in the medication management process. Roles performed by these pharmacists encompassed inpatient consultation services, dispensing, pharmaceutical distribution and clinical governance support. These services and associated service hours were aligned to the community’s needs and adapted to the pharmacist workforce capacity and funding availability in the community.
Healthcare providers’ recognition of the value of pharmacists’ involvement in medication management was identified as a driver in the establishment and continuity of sessional services. Prolonged rapport building assisted pharmacists’ efforts to promote their services, particularly amongst hospital staff who had no experience working with a pharmacist. Lack of funding for services was a challenge to implement these services. However, further exploration revealed that autonomy for funding allocation at the local level and ‘funds pooling’ from other sources enabled sessional employment. Hospital experience was considered valuable and ideal; those with a community pharmacy background recommended self-directed learning, mentoring, hospital induction and district or regional support. The limited rural pharmacist workforce capacity hindered participants from providing more comprehensive services. Despite this, participants highlighted that sessional contracts enhanced employment opportunities in rural areas, resulting in increased workforce capacity and created an opportunity to provide pharmacist support.
While the sessional models varied, the Phase 2 study shows potential to address the deficit in hospital pharmacy services in rural areas to some extent. Functionality of the sessional employment model is largely dependent on community engagement at the local level, collegial collaboration and support, funding, and flexibility to adapt to the local setting and demographics. Prospective sessional models are advised to invest in these foundations. Future research could consider a trial of sessional employment within the Queensland study community or in other rural communities seeking additional pharmacist support, with consideration of the identified enablers and challenges.