Pharmacists’ perceived role in supporting diabetes education and self-management in Ireland: a qualitative study

The role of pharmacists

One HCP group with a potential role in supporting SDE attendance and diabetes self-management are pharmacists. An evolution of the pharmacist role from a singular focus on medication dispensing to more patient-centred, collaborative care is evident in the literature^11–13. Concerns about the sustainability of healthcare expenditure and increasing demands on primary care physicians have fuelled this movement¹⁴. Several countries have expanded the role of pharmacists to facilitate coordinated care delivery, such as provision of emergency prescription refills and administration of vaccinations¹⁴, and in the guidance, education, and support of people with chronic disease¹⁵. Community pharmacists play a vital role in the primary healthcare system in Ireland. Some of the health services provided by pharmacists include administration of the flu vaccine, blood pressure measurement, cholesterol testing, smoking cessation, and provision of emergency contraception. However, services such as medicine use reviews, minor ailment schemes, and chronic disease management services are currently not provided in a pharmacy setting. A recent review found that pharmacists see people between 1.5 and 10 times more frequently than general practitioners (GPs)¹⁶. In Ireland, it is estimated that 2 million people visit a community pharmacy each month¹⁷. People with diabetes have regular contact with their pharmacist, identifying it as a condition in which pharmacists could assume a greater role in care^18,19.

Evidence from meta-analyses has highlighted the effectiveness of diabetes self-management support delivered by pharmacists in improving adherence, glycaemic control and diabetes knowledge when compared to usual care^20,21. There is also said to be considerable cost savings from greater utilisation of pharmacists in diabetes support²². However, the same authors highlight the issue of inadequate reimbursement mechanisms for clinical pharmacy services. Lack of resources has also been identified as a challenge to pharmacists assuming a more active role in diabetes care^11,12.

In Ireland, national frameworks highlight the need to provide self-management support for chronic illness within routine care²³ and Irish research on Type 2 diabetes SDE attendance identified the need to look beyond the attitudes of people with diabetes, to explore the role of HCPs in supporting SDE attendance¹⁰. Existing qualitative research has explored the role of pharmacists in diabetes self-management support from the perspective of people with diabetes^12,18 but there is a paucity of research regarding pharmacists’ own views on the topic.

Aim of the study

The current study aims to develop a greater understanding of the potential role of pharmacists in supporting people with Type 1 and Type 2 diabetes. Specifically, this study will explore pharmacists’ knowledge of SDE and their perceived role in diabetes education and self-management in Ireland.

Ethics approval

Ethical approval was granted by the National University of Ireland Galway (NUIG) School of Psychology Research Ethics Committee in January 2019 (SREC 24/01/2019).

Participants and recruitment

Community pharmacists currently working in Ireland were eligible for this study. Invitations to participate were circulated through the Irish Pharmacy Union (IPU, the representative and professional body for community pharmacists in Ireland) and PharmaBuddy (an online pharmacist support group) initially, followed by ongoing recruitment via Facebook and invitations delivered to pharmacies in the West and Midlands of Ireland. All invitations included an overview of the study and an email address to express interest in participation and to receive an information sheet and consent form. Convenience sampling was utilised, and all interested participants were interviewed. Data collection occurred alongside recruitment (via Facebook and pharmacy letters). The data collected was judged to reach saturation by the research team, defined as data being adequate in both amount and variety to answer the research question²⁷, and recruitment efforts concluded at this point

Data collection

Semi-structured interviews were conducted by EC, a female student health psychologist (B.A Psychology), between February and June 2019. EC worked with an experienced qualitative supervisor (JMS) in completing the study. EC communicated with participants prior to the interview to inform them about the study, receive written informed consent for their participation and to arrange an interview time. There was no previous relationship between the interviewer and participants, participants were informed that the study was being carried out for a MSc dissertation, but no other researcher characteristics were provided.

Interviews were held face-to-face and over the phone, with only the interviewer and participant present. EC conducted phone interviews (n = 8) in a private room while interviews held in person (n = 2) were conducted in an office and pharmacy consultation room. A topic guide of open-ended questions (see Extended data²⁴) focused on the pharmacist role in supporting Type 1 and Type 2 diabetes self-management behaviours and SDE attendance was used flexibly to guide each interview. No field notes were taken as interviews were primarily held by phone and were audio recorded. Prompts were included to probe answers where necessary. This guide was developed based on previous literature on pharmacists’ roles in patient care¹³, diabetes self-management and SDE attendance¹⁰.

All interviews were audio-recorded, transcribed verbatim and checked for accuracy by EC. Following the first two interviews, the transcripts were reviewed by EC and JMS. The validation technique of member checking was offered to all participants; however, this was declined. Transcripts were anonymised and imported to the software package NVivo 12 to facilitate data organisation, management and analysis.

Data analysis

Interviews were coded alongside data collection. Data were analysed following an inductive reflexive thematic analysis approach²⁸ and according to a critical realist framework as posited by Maxwell²⁹.

Line by line coding was carried out using NVivo by EC. Initial conceptual themes and codes were identified and applied to subsequent transcripts and were modified and developed as necessary. Data saturation was reached at analysis of the final two interviews. Draft themes were reviewed by JMS alongside transcripts and discussed with EC. A selection of extracts were chosen to illustrate each theme. Extracts were edited for clarity³⁰ and identified by a participant number. Participants were not involved in the analysis process. A summary of findings was sent to all participants following analysis.

Patient or customer: the nature of the pharmacist relationship

The nature of the pharmacists’ relationship with, and the terms used to describe, the people who use their services depends on the transaction type, but pharmacists primarily used the term patients. As such, this term is used to refer to people with diabetes within the results section.

Pharmacists highlighted their accessibility compared to other HCPs as they are available in the evenings and at the weekend. With no need to make an appointment they tend to be the “first port of call” (Participant 3, 6 & 8). Pharmacists believed that they had more contact with people with diabetes than other HCPs and described themselves as being “the only person in the whole system that knows the full picture” (Participant 8). This frequency of contact facilitates a level of familiarity and honesty within the relationship.

Pharmacists positioned themselves as having a close and caring relationship with their patients, emphasising the importance of a personal connection. However, one pharmacist believed it was not the familiarity but the profession which garners this respect.

Pharmacists believed that patients’ perception of the pharmacist role within the wider healthcare team also influences their relationship. Pharmacists explained that some patients believe that the pharmacist role is solely medication dispensing and consequently will not engage beyond this.

Beyond medication: pharmacists current and potential roles in diabetes management

Pharmacists emphasised their role in medication dispensing as the “gatekeepers of medicines” (Participant 8), but also acknowledged a wider and “strong community based healthcare role” (Participant 4). There were two aspects in pharmacists’ discussion of their role in wider diabetes care: what they currently do and what they could do. As such, two sub-themes were identified: pharmacists’ current role and pharmacists “not being utilised as best they should be”.

Pharmacists’ current role. The level of involvement in wider diabetes care varied across pharmacists interviewed. There was a belief that people with diabetes are “not just there to be given the medication ... but also to be educated on their disease so that they themselves are able to manage their disease better” (Participant 1). The presence of the pharmacist as a source of motivational support for patients was also described:

While pharmacists would engage in advice on diabetes self-management, some would not do so unprompted.

It appeared that there is no standardisation or structure in place for engagement with patients on the wider management of their conditions.

This lack of structure may underlie the differences in opinion across pharmacists regarding the support of diabetes self-management. One pharmacist perceived no role in supporting diabetes’ self-management, “Generally, I think most of that goes through the diabetic clinics and the doctor” (Participant 9), describing their role as sourcing and supplying medication rather than informing.

Pharmacists not “utilised as best they should be”. Pharmacists felt that they are limited in what they can currently do and are not “being utilised as best as they should be.” (Participant 3). The primary area in which pharmacists described the potential to assume a greater role was in advising on and adjusting medication. Referring to the precedent set by their counterparts in other jurisdictions, pharmacists proposed that they could enhance patient care and reduce the need to visit a GP, freeing up services in certain scenarios:

One pharmacist also believed there was scope for developing specific lifestyle support, “like diet plans or weight management that would all fall in under the broad umbrella of diabetes” (Participant 5). However, pharmacists noted that patients may not take advantage of the expertise of pharmacists beyond medication: “When you start to talk about lifestyle and exercise you sort of get a ‘yeah, yeah grand’” (Participant 10).

Need for diabetes education

Pharmacists were clear in their belief that education is a key component of diabetes management. Two sub-themes were identified: the importance of patient knowledge and the availability of patient education.

The importance of patient knowledge. Pharmacists described that patients differed in their knowledge about diabetes. Several issues are apparent when knowledge is insufficient, with one pharmacist describing patients who fail to “realise that they’re diabetic or would think that things [anti-inflammatory medication] had caused diabetes” (Participant 3). A lack of patient knowledge on how lifestyle interacts with diabetes was also noted by pharmacists: “people are not aware of how their lifestyle ... especially where diet is concerned, it can contribute to the worsening of the condition” (Participant 1). Pharmacists believed that some people with diabetes do not realise the severity of their condition and thus are slow to adjust their lifestyle, relying instead on increasing medication.

Pharmacists suggested that diabetes medication non-adherence and misunderstanding regarding its function, or a perceived lack of benefits, may also result from a lack of knowledge.

However, the potential to educate patients and the benefits of this were evident. Pharmacists acknowledged the growing emphasis on education for management: “Definitely the education around the carbohydrate counting and stuff is where it’s going in terms of management” (Participant 6), and in empowering and motivating patients: “once they feel more educated, they feel more involved, which is definitely beneficial” (Participant 10).

Availability of patient education. Closely linked to the importance of diabetes knowledge was the availability of education for people with diabetes. Pharmacists discussed various sources of patient education. One pharmacist suggested that patients often seek advice on patient-driven forums: “a lot of it is ill informed, patient driven, more so than healthcare driven” (Participant 4). Another described educating patients about aspects of their care because the wait for a diabetic clinic appointment is “...just ridiculous. By the time they get an appointment with the diabetic clinic they could be up to three tablets” (Participant 3). Further, one pharmacist holds information days to supplement their patients’ diabetes care:

Pharmacists referenced several established services for diabetes, but SDE was only mentioned unprompted by one pharmacist and most were unaware of the existence of SDE programmes.

Those who had heard of SDE had limited knowledge: “well I know that they exist somewhere but if someone asked me to refer them, I’d have to google it” (Participant 2). However, there was interest in the programmes and a view that pharmacists could promote SDE to their patients, “because it’s just such an ease of access, it makes sense to have something there that you could just keep reminding them” (Participant 10), with suggestions such as inclusion of a leaflet with their prescriptions “to bring awareness that there are education classes available” (Participant 1).

Barriers “all the stuff that gets in the way”

Despite pharmacists’ interest in engaging in discussions around diabetes self-management, several barriers were described. The predominant barrier was resources; time, pharmacists and finance, all of which were closely linked. Time constraints were mentioned by several pharmacists due to an increase in paperwork and administration.

Time to engage in patient consultation was also compromised by “pressure to supervise other services in the pharmacy” (Participant 1), highlighting the issue of staffing. However, the cost of having a second pharmacist often cannot be sustained because the “numbers of prescriptions doesn’t constitute enough for a second pharmacist” (Participant 5). This reflects the structure of pharmacy services and what the pharmacists are paid for.

Underlying data

There are no quantitative data associated with this article. The audio files and transcripts generated during the current study are confidential. In the consent document signed by participants it stated that ‘no-one but the research team would hear the recordings’.

As a result, researchers seeking to access the underlying data (i.e. audio files and transcripts) will need to apply directly to the NUI Galway Research Ethics Committee for approval. The Committee can be contacted at ethics@nuigalway.ie. Should approval be granted, the authors are happy to facilitate access. Quotes reflecting the transcripts are available in the article itself.

Extended data

Open Science Framework: Pharmacists’ perceived role in supporting diabetes education and self-management in Ireland: a qualitative study, https://doi.org/10.17605/OSF.IO/B289U²⁴.

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).