This study has identified factors that influenced the implementation of paediatric CPS in Hong Kong by exploring physicians’ and nurses’ views. It has provided evidence to stakeholders that with appropriate strategies, the involvement of clinical pharmacists could help to improve the paediatric healthcare in Hong Kong’s public hospitals. Our results have helped to fill in a gap in research by the use of a rigorous qualitative methodology, thus promoting the systematic uptake of research findings into practice.
The results of this study needed to be interpreted with caution in light of some limitations. The difficulty in recruiting additional participants across more study sites due to resource limitation and the difficulty in nominating PIs from other cluster as per local research ethics committee protocol might affect the generalisability of this study. Additionally, the inability to read non-verbal language with telephone interviews may have an impact on the interpretation of the data.
The factors that were identified in this study are coherent with a parallel study conducted with clinical pharmacists as part of a series of the PI’s doctoral portfolio, thus reflecting the consistency and reliability of the findings [13].
Both medical and nursing professionals concurred that clinical pharmacists have improved patient outcomes with their involvement in medicine management, and this is concordant with the evidence across literature, whether quantitative or qualitative [19–21]. Additionally, participants demonstrated trust in clinical pharmacists, as they believe that the expert knowledge of clinical pharmacists has helped facilitate the clinical service as a whole. Certainly, a high level of trust from physicians and nurses toward the CPS aided its successful implementation [22, 23]. Our results demonstrate that both the medical and nursing professions display a high level of trust in clinical pharmacists’ work, and this was a result of the experience that they had with the paediatric CPS.
The involvement of clinical pharmacists improves interprofessional communication and is a prerequisite for collaborative practice [24, 25]. Clinical pharmacists significantly contribute to multidisciplinary teams and create a sense of belonging among their members in partnership, coordination, cooperation, decision making, and therapeutic outcomes [26]. Members of both disciplines interviewed in this study believed that the provision of a CPS helps provide relief for the counselling aspect of clinical work, thereby allowing physicians and nurses to focus on other aspects of their work. Participants also believed that clinical pharmacists were in a better position to provide medication counselling to patients, parents, or caregivers due to their expertise in this highly specialised area, and studies have shown that counselling provided by clinical pharmacists improves patient outcomes and also results in better adherence to medications [27].
Several participants pointed out that the public in Hong Kong does not understand the role of clinical pharmacists and is not aware of their existence. This problem is not only limited to Hong Kong, but is also prevalent in other countries as they have reported similar findings [16]. The public perception of the professional role of pharmacists is expressed through patients’ attitudes, trust, and expectations of them as healthcare professionals, and these often influence policymakers’ decisions on healthcare legislation that determines the functionality of professional services [28]. The understanding and recognition of the pharmacists’ role, therefore, is a driving factor in how a new healthcare service can be successfully implemented in an existing healthcare system. Studies have revealed that people in Hong Kong have a low acceptance of pharmacist-led self-care management in the community, due to the unfamiliarity of the general public with the role of pharmacists [29]. Therefore, pharmacists should make an effort to empower the public through medication education, and this could be initiated by professional bodies or societies as a starting point.
Another associated factor that affects the implementation of paediatric CPSs related to the public is the culture of medical dominance. This barrier is consistent with our interview findings and has been highlighted by Schoeb [30]. Participants from both healthcare professions confirmed that there is medical dominance issue, as both types of professionals explained that traditional and cultural values place physicians at the top of the professional hierarchy. The situation in Hong Kong is demonstrated by the unfair allocation of resources, power, and even legislation. For example, Chap. 359 of the Supplementary Medical Profession Ordinance stipulates that the chairman of the Supplementary Medical Profession Council must be a registered medical professional, such as the Pharmacy & Poisons Board, a regulatory body responsible for the registration of pharmacists. One study reported a striking dominance of hierarchical culture in Hong Kong’s public hospitals [31].
Participants reflected that the role of clinical pharmacists was unclear within the organisation, although guidelines on standards of practice for paediatric CPSs are in place within organisations, providing an unabridged definition of the role of clinical pharmacists. Certainly, studies have found that clarification of clinical pharmacists’ roles within multidisciplinary teams enhanced the effectiveness of patient care, thus indicating that a better understanding of the CPS by physicians and nurses is needed to implement the service more successfully [32, 33]. Several parameters were identified to facilitate clinical pharmaceutical practice [34]. First, advanced degrees, which are compatible with the skills required for the practice of clinical pharmacy, can help other healthcare professionals acknowledge the skills and knowledge that paediatric clinical pharmacists possess to perform their clinical tasks competently. A higher education program with significant experiential and clinical education components at advanced levels could promote the safe and effective use of medicines, thus helping other healthcare professionals or the public recognise how clinical pharmacists contribute to the healthcare system [35]. The second parameter is credentialing. Credentialing has a positive effect on the quality of care and patient outcomes by presenting the clinical practice to the credential’s standards, and it helps to standardise practice across organisations [36].
One of Hong Kong’s prevailing problems is its shortage of healthcare professionals, due to the lack of registered physicians and the loss of staff to the private sector resulting from the pressure of overloaded public hospitals and financial reasons [37, 38]. Although the availability of clinical pharmacists is also limited, the reason behind this shortage is not the turnover of these professionals, but rather their engagement in operational duties in medication supply. Hospital pharmacists in Hong Kong have always been heavily involved in medical supply, and a survey conducted in 2008 found that drug distribution constituted about 55.5% of hospital pharmacist activities in the public sector [11]. Although that survey was conducted some years ago, the lack of separation between the two roles was still present in our data, thus showing the need for improvement in this area.
The healthcare system in Hong Kong suffers from underinvestment with a lower percentage of GDP in health spending (6.8%) than in other developed countries, such as the USA (16.7%) and the UK (10.2%) [39]. With most of hospital pharmacists are required to perform dispensing duties as explained above, the resource left to deliver CPSs is scarce. An increase in resources for recruiting paediatric clinical pharmacists would be ideal, but with the shortcomings of the current healthcare system, clinical pharmacists must determine the most cost-effective way to deliver their services. Hohmeier et al. pointed out that given the increasing demand for CPSs and the increasing workload of clinical pharmacists, successful clinical service implementation is dependent on both the practitioner’s clinical knowledge and their ability to manage their clinical tasks in addition to other competing workload priorities [40]. The authors proposed that a paradigm shift in clinical service research and education in pharmacy may be needed to place focus not on ‘what’ to do, but on ‘how’ to do it. As suggested by the participants of our interview, one way to improve the service implementation of CPSs in Hong Kong is to have them engage in more direct patient care activities. The need to adopt a consistent process of direct patient care was reiterated by the American College of Clinical Pharmacy (ACCP). In its white paper, the ACCP described four essential elements that serve as the cornerstones of a clinical pharmacist’s direct patient care process, regardless of the type of practice, the clinical setting, or the medication conditions. These include assessing the patient and his or her medications, developing a plan of care, implementing this plan, and evaluating their outcomes [41]. The implementation of a successful direct patient care service not only helps achieve better patient-related outcomes but could also improve the public’s and other healthcare professionals’ recognition of clinical pharmacists as healthcare providers, thus establishing their unique role within the healthcare system in Hong Kong.