Chapter 12: Pharmacy

Uncertainty in Pharmacy

The pharmacy profession has undergone significant evolution since the soda fountain era of the 1920s (Urick & Meggs, 2019). While the historic technical functions of pharmacy are rooted in medication stewardship, safe dispensing of prescribed medications, and compounding based on physician directives, pharmacists today are involved in more diverse activities focussed on medication therapy management (Ferreri et al., 2020). Medication therapy management is a pharmacy term that encompasses practice philosophy, activity, and function that focus on ensuring medication therapies are optimised to people’s individual and unique needs (Bluml, 2005). It leverages pharmacists’ specialised and expert knowledge related to medications and health technologies. The correlate in other health professions might be clinical, clinician, or person-facing practice. Depending upon the jurisdiction or country, medication therapy management also reflects an evolving needs-based pharmacist scope of practice facilitating independent prescribing; renewal, adaptation, modification, or substitutions of prescriptions; attendance at medical emergencies; provision of clinical guidance on optimal prescribing options; and deprescribing of medications no longer needed (Marupuru et al., 2022). As a result of this evolution, pharmacists now encounter significantly more opportunities to directly and positively impact the care and outcomes of patients, to assume direct responsibility for pharmacotherapeutic decision-making, and to collaborate as full partners in healthcare teams.

Medication therapy management has amplified circumstances under which uncertainty and ambiguity exist in the day-to-day work of pharmacists. When the main role of pharmacists involved safe compounding and dispensing of medications, accurate calculations and items dispensed were clear yes-or-no actions. Today, as clinical decision-making in information-imperfect and person-specific situations occurs more frequently, pharmacists are faced with many different forms of uncertainty (Mackintosh & Armstrong, 2020). In this contemporary context, pharmacists experience uncertainty around their evolving healthcare roles and the complexities of healthcare environments.

Two distinct forms of uncertainty are common within pharmacy practice: interpersonal uncertainty and decisional uncertainty. Interpersonal uncertainty occurs when pharmacists feel unsure of the most appropriate response when communicating and working with a client. These situations typically involve ‘difficult conversations’ touching on sociocultural taboos or topics like lifestyle risk-factor modification or the use of harmful and/or illegal substances, especially when they may interact with medications. One example of a potentially difficult conversation is a client describing a sexual health problem that will require the pharmacist to teach them to inject medication directly into the penis. Another example is advising a client about quitting smoking/tobacco despite it being legally available. A final example is talking with a client about potential interactions between prescription medicines and illicit substances like cocaine. Depending on the pharmacist’s experience and sociocultural norms, these situations may cause them to experience a feeling of awkwardness, fear that their advice may be received as judgemental, or a lack of confidence in providing the best possible advice. Decisional uncertainty occurs in situations when there is conflicting or non-existent clinical evidence to guide therapeutic decision-making about medicines, devices, or technologies. This may arise when no one right answer is possible and only least bad options are available, causing the pharmacist to feel a lack of adequate resolution. One example is where an off-label or unapproved indication for a medication being prescribed must be processed by the pharmacist.

In part, both interpersonal uncertainty and decisional uncertainty are functions of the ambiguity in pharmacists’ evolving role, as mentioned above. Of late, the role has had to turn towards a more complex clinical orientation (Toklu & Hussain, 2013). Today, pharmacists are involved in activities such as vaccination administration, laboratory test interpretation, consultation on wearable devices, independent prescribing and deprescribing, public health screening, and other primary care activities historically associated with other health professions. These new activities mean that pharmacists are experiencing the same kinds of uncertainty issues that are associated with other clinical, person-facing forms of healthcare practice. Furthermore, this expansion of pharmacists’ roles and responsibilities can create tension with other healthcare professionals unaccustomed to the clinical decision-making activities foundational to interprofessional practice. Such uncertainty and tension add another layer of cognitive and emotional load.

Priorities to Prepare Learners for Uncertainty in Pharmacy

Helping pharmacy learners to anticipate the interpersonal and decisional uncertainties that are now commonplace in practice is a complex and essential task. A central priority is in supporting pharmacists’ professional identity formation in ways that prioritise the healthcare they provide, their clinical contributions, and an interprofessional collaborative orientation rather than a business management, technical support, or background orientation (Noble et al., 2019). To this end, pharmacist socialisation to the more person-facing clinician identity needed for medication therapy management requires a profession-wide, collaborative approach involving educators, employers, professional associations and advocacy groups, and regulators (Noble et al., 2014). Learners who view their roles solely as order-followers, unquestioningly adhering to prescriptions from established prescribers like physicians, midwives, and nurse practitioners, may face substantial challenges meeting the societal mandate for health. This view may also lead to practice that exposes patients to unnecessary risks (Johnson et al., 2023).

Independence in decision-making is crucial for those entering the field. Qualifying pharmacists who struggle with making independent choices and communicating these clearly to patients and other healthcare professionals will encounter difficulties. Yet many learners select pharmacy as a field of study not fully aware of its evolving scope of practice and clinical responsibilities associated with independent decision-making and activities such as vaccination administration and laboratory test interpretation (Kellar et al., 2021). Their prior socialisation and educational experiences may reinforce a view of their professional role as recommenders instead of decision-makers, finding comfort in the notion that another healthcare professional will ultimately be responsible for enacting their recommendations. Thus, pharmacy learners need to be engaged in activities in which they practise decision-making and interpersonal skills in situations that involve uncertainty.

Fostering Uncertainty Tolerance in Pharmacy Learners

Clinical simulation has emerged as an important tool in pharmacy education. The use of trained actors to portray the roles of patients, customers, or other healthcare professionals has been widely used in pharmacy education as a way of preparing learners for real-world practice in a safe and standardised manner. The actors, sometimes called standardised patients, follow structured scripts providing them with important details regarding the situation they are portraying as well as psycho-demographic details to help them understand the possible motivations, interests, concerns, and agendas of the person they are playing. This is essential to create authentic portrayals. The goals of the approach are to simulate real-world experiences without exposing real people to any potential risks or harms (moderator: uncertainty dress rehearsal) and to achieve standardisation for the purposes of performance comparisons across a cohort of learners.

Clinical simulations can be used for both formative and summative assessment purposes. When used for formative assessment, they provide opportunities for learning by doing (moderator: uncertainty dress rehearsal) and reflecting on action (moderator: reflective learning). Use of stop-start and take-two simulations allows learners to experiment with different approaches to situations (moderator: open pedagogy) and helps them build confidence, acquire new skills, and see the impacts of different responses to challenging situations. When used for summative assessment, clinical simulations allow educators to establish minimum competency expectations, use standardised assessment instruments, and apply psychometrically defensible approaches to evaluating readiness to practise.

To counteract the prevailing socialising influences described in the previous section and to highlight the central role of clinician professional identity, pharmacy educators can use clinical simulation activities such as role play exercises, destabilisation activities, case-based problem-solving, and critical incident discussions. These learning activities should reflect the complex nature of healthcare and its related interpersonal and decisional uncertainties. Simulations can let learners visualise how a pharmacist with a clinician professional identity may behave and think differently from one with a technical or business orientation. The pharmacist acting as a clinician must maintain composure in the face of emotional stress while acting in a decisive, reflective, and adaptive manner. These qualities are necessary for pharmacists leading medication therapy management practices.

The two exemplar activities described below can be adapted for use in a variety of pharmacy education formats. They illustrate how educational strategies focussed on reframing professional identity among pharmacy learners can help support interpersonal and decisional uncertainty. While there are challenges to be addressed in these activities, the problems are embedded within contexts that helps learners differentiate a clinician pharmacist’s behaviour from that of a technically oriented pharmacist or businessperson. The objectives of the activities are to:

• introduce learners to the realities of clinician-oriented practice
• give learners practice in managing the uncertainties associated with the clinician orientation
• support professional identity formation and socialisation into this contemporary model of pharmacy practice.

In the authors’ context, academic staff typically performed the assessments in the in-person clinical simulations involving standardised patients outlined below. Immediate verbal feedback was provided to learners at the time of the simulations (moderator: expert guidance), followed by more formal feedback and assessment (moderator: assessments). Where technological infrastructure permitted, the sessions were videotaped and archived for learners to review later as part of their own learning portfolios (moderator: capacity for reflection). A global assessment instrument (Table 12.1) was used to provide learners with feedback regarding their overall communication and interpersonal skills and to create a standardised vocabulary for identifying competent and exemplary behaviours demonstrated during the assessments (moderator: setting clear expectations). The local context within which the scenarios were developed required high reliability, and given their nuances, they were not used for summative purposes; instead, they were implemented for personal and professional development and learning purposes only (moderator: reflective learning). However, if summative assessment were required for academic purposes, a grading scale could be added, an example of which is provided.

Table 12.1 Global Communications Assessment

	Does Not Meet Expectations	Minimally Meets Expectations	Clearly Meets Expectations
Verbal expression	Communicates in a manner that interferes with and/or prevents understanding by audience	Exhibits sufficient control of expression to be understood by an active listener	Demonstrates command of expression (fluency, grammar, vocabulary, tone, volume, and modulation of voice, rate of speech, and pronunciation)
Non-verbal expression	Fails to engage, or frustrates and antagonises patient	Shows enough control of non-verbal expression to engage a patient willing to overlook deficiencies such as passivity or self-consciousness	Displays finesse and command of non-verbal expression (eye contact, gesture, posture, and use of silence)
Response to patient’s feelings and needs	Does not respond to obvious patient cues	Responds to patient cues in a formulaic or ineffective manner	Responds to patient cues perceptively, genuinely, and appropriately
Degree of focus, logic, and coherence	Displays no recognition of the problem and no plan or approach to tackling it	Shows appropriate response to the context, but organisational approach is formulaic and minimally flexible	Demonstrates superior judgement and organisation, and focus and flexibility regarding the context
Overall presentation	Responds inappropriately and ineffectively to the task	Applies some logic and comprehension to the task, but not consistently	Responds precisely, logically, and perceptively to the task, integrating all components

Exemplar Activity 1: Clinical Simulation – “I Don’t Know What to Say”

Activity Origin

This case was developed, implemented, and evaluated at the Leslie Dan Faculty of Pharmacy at the University of Toronto.

Sources of Uncertainty

The case provides learners with an example of interpersonal uncertainty faced by pharmacists. It requires individuals to demonstrate high levels of communicative competency and cultural literacy to respond appropriately and confidently to the scenario. There are no pharmacotherapeutic challenges in this case (moderator: scaffolding uncertainty), and the scenario involves a relatively simple pharmacy law related to not recycling medications to other patients once they have left the security of a pharmacy (moderator: subject mastery).

Facilitator Guide

Motivation and Context

Community pharmacists work in busy, for-profit retail settings and must balance the responsibilities of registered healthcare professionals providing patient care with the customer service requirements of shopkeepers. The time-pressured, intense nature of this twin role, with its associated uncertainties and ambiguities, introduces a high degree of cognitive and emotional load, leaving most pharmacists with relatively little capacity to manage unexpected and interpersonally challenging situations. One method that many pharmacists have developed to manage their workload is to emphasise and rely upon routines, algorithms, and highly structured workflows governed by rules and flowcharts.

The Case

The case is a role play clinical simulation completed by one learner at a time. It has been used primarily for formative teaching purposes and as a tool for exploring cognitively and emotionally difficult situations in pharmacy practice, but it may be suitable for learners in other health professions. The case requires facilitated debrief (moderators: expert guidance, reflective learning) and opportunities for guided reflection (moderator: reflective learning). In some cases it can provoke strong negative reactions. It may also create psychological tension that must be addressed through supportive feedback and facilitation by the instructor (moderator: pastoral care). The value of the learning opportunity presented by this case can only be realised within a supportive, non-judgemental, educationally focussed context (moderator: psychological safety).

Key Facilitation Points

Facilitators should prioritise the following learning points and techniques in the case:

• guided self-reflection to identify and articulate sources of, and reasons for, interpersonal uncertainty
• clarity around legal considerations to apply a non-negotiable legal requirement within an emotionally intense environment
• use of communication skills to manage both internal concerns and external patient–pharmacist relationship issues.

Facilitation Notes

In the authors’ context, learners have frequently claimed that they are not sure what is expected of them in this case, either from an interpersonal, authentic patient care perspective or from an academic grade perspective (moderator: merit minded). They have tended to understand that the situation presented requires empathy and demands attention, but they have been uncertain how to achieve this with a stranger in a professional work environment (moderator: low subject proficiency). Facilitation should focus on reflective questioning (e.g., ‘How would you like the pharmacist to respond if you were the patient?’, ‘Imagine your parent in this situation: how would you want the healthcare professional to respond?’) (moderator: expert guidance). An important element of the case also involves truth-telling and how to be truthful in a difficult situation while avoiding emotional escalation. Facilitation should focus on alternative ways to present difficult information and how much information to give beyond what is necessary.

The emotional intensity of the scenario can be uncomfortable for some learners, particularly those who have experienced a recent death of a family member or friend. Before the scenario is used, a content warning should be provided to all learners, standardised patients, and instructional staff, to inform them that death will be discussed (moderator: pastoral care). Facilitators and standardised patients must be attentive to signs of extreme distress, such as tearfulness, during the clinical simulation. If this occurs, they can adjust the intensity level, take a break, or, if necessary, stop the simulation (moderator: pastoral care). However, some discomfort, in the form of interpersonal uncertainty, is an important part of the learning for the case. Helping learners explore why they feel uncomfortable and what techniques they can use to manage this for the patient’s benefit and for their own mental health is an important part of the debrief (moderator: reflective learning). Ensuring that learners know they should neither suppress nor deny their emotional response to the case but should acknowledge and accept emotional discomfort is also vital. There should be discussion about how to articulate one’s own discomfort and to develop pathways to manage emotional discomfort – for example, by having a private space within the pharmacy to share a challenging experience once the patient leaves. Discussion related to boundaries and boundary protection in a community

Activity

Download Word (.docx, 25kb) version of the case

Impact

This activity has been evaluated experientially. Educators’ observations suggested that this was one of the most challenging simulations learners had faced. It deals with an extremely complex and delicate psychosocial situation and requires communication skills which include empathy, reflective listening, and cultural literacy. Learners frequently ‘froze up’ in the simulation, struggling to find an appropriate verbal response. Some learners, out of overwhelming uncertainty, emphasised inappropriately the pharmacy law dimensions of the case rather than interact authentically with the patient. The combination of uncertainty (how to proceed) and discomfort (the emotional weight of the situation) provides a purposeful opportunity for teaching, reflection, and professional growth.

Adaptations and Summary

This case has been used for many years, as its core learning principles continue to be relevant, though social, professional, and contextual changes have allowed continual evolution of the details. For example, adjustments can be made to introduce elements of cultural literacy depending upon the level of the learners and the skills of the facilitators. The patient could be framed to explore how culturally literate communication adapts to the individual patient’s needs and how uncertainty and discomfort on the part of the pharmacist are also functions of this context. Variations may include the following:

• Pat is Indigenous and lives in an urban setting with limited access to Indigenous healing and support systems.
• Pat is a member of an ethnocultural marginalised group with limited access to culturally supportive grieving groups.
• Pat and Sam were a same-sex couple who experienced discrimination in the past.

Exemplar Activity 2: Case Study Seminar and Clinical Simulation – “But What If They Have An Allergic Reaction?”

Activity Origin

This case was developed, implemented, and evaluated at the Leslie Dan Faculty of Pharmacy at the University of Toronto.

Source of Uncertainty

The case study seminar and role play clinical simulation gives learners an example of decisional uncertainty faced by pharmacists. In the scenario, there is limited available pharmacological evidence to guide decision-making, and learners need to consider diverse, context-specific factors to reach a clinical decision. The case was designed to ensure that decision deferral or referral to another healthcare professional (such as a physician) is not an option.

Facilitator Guide

Motivation and Context

Drug shortages in community pharmacy have become not only commonplace but worrisome for those needing medications and for the healthcare professionals who supply them. When preferred medications are not available, pharmacists are required to select a best possible alternative. Frequently, such recommendations are made by community pharmacists who know what is in stock and available for dispensing from their shelves. Wherever possible, pharmacists usually provide prescribers with options and choices; however, when severe drug shortages limit availability of options and choices or involve over-the-counter medications, the decision-making responsibility falls on the pharmacist. The need to make such decisions in the face of uncertainties can cause significant cognitive and emotional stress.

The Case

The activity uses a case study seminar format in which a small group of six to eight learners and a facilitator role play and discuss a case in detail, relying upon evidence and practice experience to make decisions (moderator: subject proficiency). The objective of the activity is to engage learners in peer benchmarking around their decision-making processes (moderator: diverse teamwork). It is facilitated by debriefing focussed on how the complex problem was analysed and resolved. Wherever possible, the facilitator engages in a Socratic model of instruction (moderator: expert guidance), an approach used by the philosopher Socrates to define broad ideas and underlying complexities. In this approach, rather than stating facts or answers (moderator: didactic teaching), the facilitator guides the conversation by asking open-ended questions, reflecting learners’ comments back to them, engaging all learners in discussion and debate, and emphasising the clinical problem-solving process itself rather than the specific pharmacotherapeutic issue that happens to be the raised in this case (moderator: uncertainty dress rehearsals).

Key Facilitation Points

Facilitators should prioritise the following learning points and techniques in the case:

• guided self-reflection to identify and articulate sources of, and reasons for, decisional uncertainty
• clarity around legal considerations to support independent therapeutic decision-making by a pharmacist without consultation to another healthcare professional and taking responsibility for this decision
• understanding of the importance of monitoring and following up once a decision is made, to remain connected to the patient and able to manage any issues that emerge because of the decision.

Facilitation Notes

This case represents an increasingly common drug-shortage problem and may be recognisable to learners who have evening, weekend, or summer jobs in pharmacies. As a case study seminar, the primary focus is not on communication skills or interpersonal interactions per se, but on a pharmacotherapeutic problem-solving process. By design, there is no right answer to this case (moderator: flexible assessments); instead, learners need to evaluate and consider a range of alternatives and to apply professional judgement in identifying and justifying one preferred least bad option. In the authors’ context, learners frequently wanted to avoid making a final decision in this case, preferring to offer the patient options from which to select. Facilitators need to press learners to declare and justify their one preferred option and help them defend their decision with their peers (moderator: expert guidance). Learners who are accustomed to adhering strictly to guidelines or algorithms to solve clinical problems need to use alternative problem-solving strategies. The decisional uncertainty in the case may be uncomfortable for them.

The case hinges on the concept of risk-balancing. All possible decisions in the case are associated with some risk of negative events. Some negative events are more likely to occur, and some may be more impactful. The goal is to minimise, mitigate, and manage risks rather than to eliminate them entirely. Facilitators can use reflective questioning techniques to help learners explore their decisional uncertainty (moderator: expert guidance) and to practise reviewing the likelihood and impact of specific negative events versus the benefits of a particular decision (moderator: uncertainty dress rehearsals). This will support their ability to take required action in times of decisional uncertainty. Because there is nowhere to look up the right answer and no other person (like a physician) who can provide reassurance of the right answer, this activity requires learners to accept complex feelings and thoughts while making the most patient-centred decision.

The cognitive and emotional load associated with this case can trigger psychological discomfort and decisional paralysis, particularly as decision-making and problem-solving are occurring within a peer-based social learning environment, where risks of embarrassment in front of other learners and friends can require skills to manage. This was a deliberate design choice for the activity, as it starts to alert learners to the public nature of their decision-making in practice. Techniques for mitigating psychological discomfort can include a talk-aloud strategy in which learners are encouraged to talk through their decision points and thinking processes (moderator: capacity for reflection), use of checklists to determine potential risks and benefits (moderator: scaffolding uncertainty), and what if? projections that allow them to forecast and think through the implications of their decisions. These cognitively oriented approaches to mitigating psychological distress can serve as useful templates for future decision-making situations in practice.

Activity

Download Word (.docx, 27 kb) version of the case

Impact

This activity has been evaluated experientially. Learners frequently demonstrated decisional paralysis and ‘froze up’ while working through the case. Sometimes, learners appeared to want others to make decisions first, so they could better conform with the general thinking and feeling of their peers. This social comparison can have positive or negative outcomes. Alternatively, when faced with decisional uncertainty, some learners emphasised inappropriately the pharmacy law dimensions of the case rather than exercise clinical judgement to solve the problem. The combination of decisional uncertainty (how to proceed) and discomfort (the emotional weight of the situation) provides a special opportunity for teaching, reflection, and professional growth.

Adaptations and Summary

The case considers the notion of situations in which there is no right answer and only least bad options are available. Over time, it has evolved to incorporate discussion around balancing risks. Typical questions include, ‘What is the risk of overdosing on epinephrine compared to the risk of underdosing?’ ‘What is the risk of improper storage conditions for an EpiPen® compromising its effectiveness compared to the risk of not having any epinephrine available?’ Framing the discussion of uncertainty around the balancing of risks and probabilities of harm provides learners with important opportunities for reflection and comparison with other learners in terms of the weighting they give to different context-specific factors in clinical decision-making.

Conclusion

The evolution of the pharmacy profession has led to a significant reorientation of pharmacy practice. The role of the pharmacist has moved away from technically oriented actions like supportive and reactive dispensing and compounding and towards clinically oriented actions which are more person facing, requiring independent and interprofessional collaborative decision-making. This shift has introduced or increased interpersonal and decisional uncertainty in daily pharmacy practice.

Role play clinical simulation and case-based seminar discussions can be used to prepare future pharmacists for person-facing, clinical roles in practice, supporting professional identity formation and signposting effective problem-solving strategies for when absolute certainty is not possible. The two exemplar activities presented were designed to teach, practise, and provide feedback on responses to situations that contain interpersonal and decisional uncertainty. Providing educational opportunities for future pharmacists to simulate, discuss, and reflect on their experiences with the uncertainty inherent in clinically oriented practice is important for ensuring safe, effective, and valuable care.

Acknowledgements

The authors acknowledge the support of Thao Vu, PhD, in designing the online version of the exemplar activities.

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References

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