Introduction
The coronavirus pandemic caused by the COVID-19 virus has reshaped how frontline healthcare workers are perceived. The pandemic has highlighted the vital role pharmacists and pharmacy interns can play during public health emergencies while also providing insight into the challenges they encounter to meet public health needs. Not all Americans have direct access to healthcare facilities; however, nine out of ten live within five miles of a pharmacy, making pharmacists the most accessible healthcare workers in America (Berenbrok et al., 2022). During the pandemic, pharmacists provided over-the-counter recommendations and consultations to help patients manage their symptoms (Strand et al., 2020). Pharmacists also supply and administer COVID-19 tests and vaccines. In December 2021, the FDA initially granted an Emergency Use Authorization (EUA) for Paxlovid for patients 12 years or older (weighing at least 88 pounds). Paxlovid is an oral medication made of two antiviral active ingredients, nirmatrelvir and ritonavir. Once pharmacists were authorized to furnish Paxlovid under the revised EUA in July 2022, they could dispense and furnish this antiviral medication, further expanding their scope of practice (FDA, 2024). In May 2023, the FDA approved Paxlovid for the treatment of mild to moderate COVID-19 viral infection in adults.
Challenges in Pharmacy Practice
Adequate resources, such as electronic health records, are necessary for pharmacists to fulfill their expanded scope of practice and care for their communities. Access to a patient’s complete history, including recent lab results, allows pharmacists to prevent drug-drug interactions and maintain accurate documentation. While this type of access has the potential to expand the role of pharmacists and pharmacy interns, fill gaps in medical care, and improve patient safety, there are concerns regarding reimbursement, patient consent, and liability, which must be addressed (Hayden & Parkin, 2020).
During the pandemic, many other challenges arose for pharmacists and pharmacy interns, including cuts in workday hours, understaffed pharmacies, and an increase in workload due to surges in telephone and electronic prescriptions. In their study, Hayden and Parkin found that community pharmacists have implemented various measures to ensure safety, including social distancing within pharmacies and introducing medication delivery while addressing heightened workloads, stress, and patient aggression (Hayden & Parkin, 2020). Following the COVID-19 pandemic, the scope of a pharmacist, particularly in mental health, medication management, and public health, has room for expansion. This reinforces the need to advocate for further legislation that expands the role of pharmacists and collaboration with other healthcare providers.
The current literature suggests that pharmacists and pharmacy interns have broadened their scope of practice while simultaneously adapting to new challenges within the pharmacy industry. What is less known is the extent to which they feel prepared to handle these challenges. The present study seeks to examine how pharmacists and pharmacy interns perceived their impact during the COVID-19 pandemic, with a focus on non-vaccine treatments and services. In addition, this study examines the challenges and barriers they encountered, providing a deeper understanding of the factors that shaped their ability to deliver care. By capturing these perspectives, this research aims to contribute to evidence regarding the pharmacist’s role in patient care and the additional support they need to fulfil their role.
Methods
Study Design
This study used a cross-sectional survey design to assess the knowledge, attitudes, and practices of pharmacists and pharmacy interns regarding non-vaccine-related COVID-19 care. The study was conducted from July 1, 2023, to October 31, 2023.
Participants and Setting
The final sample comprised 219 respondents who were recruited via snowball sampling. Eligible participants included licensed pharmacists and pharmacy interns actively engaged in pharmacy practice within the United States. Inclusion criteria specified current licensure or internship status in pharmacy practice. Participants who failed to provide informed consent were excluded in accordance with institutional ethical guidelines governing human subject research.
Data collection was conducted electronically using Microsoft Forms. To optimize participant recruitment and enhance sample diversity, the survey link was disseminated through multiple digital channels. Distribution platforms included professional social networking sites (e.g., LinkedIn), institutional outreach via the West Coast University School of Pharmacy email system—targeting current pharmacy interns—and professional pharmacy organizations such as the California Society of Health-System Pharmacists (CSHP) and the California Pharmacists Association (CPhA). This multi-modal dissemination strategy facilitated access to a broad sample of pharmacists and pharmacy interns. Participation in the survey was both voluntary and anonymous, in accordance with ethical research standards. The collected data was saved within a SharePoint drive accessible only by the research group members.
Procedures
The participants received the Microsoft Forms through a QR code or a link to the survey. The data received from Microsoft Forms was exported to Microsoft Excel for analysis.
Measures
The research team designed a four-section survey, which was developed by the authors and shared via Microsoft Forms, comprising a total of 11 closed-ended questions and one open-ended question. Section one included demographic data and work environment, where the respondents were asked about their work setting and daily prescription volume. The second section assessed COVID-19-specific training and education, asking participants if they received specific COVID-19 training and assessed their preparedness to assist with non-vaccine services during the COVID-19 pandemic. The third section inquired about practice and the frequency with which pharmacists furnished/dispensed antiviral medications to treat COVID-19. The final section inquired about barriers and resources, such as difficulty accessing medical records, insufficient education amongst pharmacists, lack of trust from patients, and limited availability of treatment options. A short free-response question asked participants what the greatest barrier they faced was and what resources pharmacists and pharmacy interns needed to improve their services.
The survey was pre-tested with a small sample of pharmacy interns (n=6) to ensure clarity and reliability. Survey modifications were made according to recommendations prior to distribution.
Statistical Analysis
Data were analyzed in Microsoft Excel sheets. Descriptive statistics (means, standard deviation, frequencies, and percentages) were used to summarize demographic characteristics and survey responses. All numerical value results were rounded appropriately to the nearest tenth or whole number to enhance readability and simplify the presentation of data.
Ethical Consideration
The study was IRB-approved with an exempt status (IRB #06292023) by the West Coast University Institutional Review Board on June 29, 2023. Informed consent was obtained electronically from all participants before they could access the survey.
Results
The study included 219 respondents, comprised of 122 pharmacy interns and 97 pharmacists. Table 1 provides further elaboration on the respondents’ workplace settings. The survey was distributed via snowball sampling; therefore, the number of pharmacists and pharmacy interns the survey reached cannot be accurately reported. Most participants were licensed intern pharmacists (56%) and worked in an outpatient setting (64%). Forty percent of participants had a “medium-sized” prescription workload.
Table 1 shows that the average daily prescription workloads varied across survey respondents, ranging from less than 250 to more than 750 prescriptions. This study found that 68% of respondents reported that they rarely (not often’) or never (not at all’) furnished antiviral medication, such as Paxlovid, to treat COVID-19.
Pharmacists and pharmacy interns have provided a variety of other services to combat COVID-19. These services include over the counter (OTC) or self-care recommendations (67%), medication therapy management (58%), non-pharmacological counseling (59%), and dispensing Remdesivir (3%). It should be noted that Remdesivir was not an answer option in the survey but was mentioned in the explanation of the “other” option by six respondents.
Table 2 shows that 89% perceived a major or moderate role in delivering non-vaccine COVID-19 services, while 11% perceived a minor or no role. Survey respondents were asked how much they agreed with the following statement: “I felt prepared to treat COVID-19 patients during the pandemic.” Table 2 shows that of all the respondents, 45% strongly agreed/agreed with the statement, 20% strongly disagreed/ disagreed with the statement, and the remaining 35% felt neutral to the statement.
Respondents most often cited limited access to medical records as the greatest barrier (38%), followed by insufficient stock to deliver care (22%), insufficient education about COVID-19 (16%), lack of patient trust in pharmacist expertise (12%), and other barriers (12%). ‘Other’ was a closed response without a free-text option. Overall, 62% reported receiving COVID-19–specific training, while 38% did not.
The respondents were also asked about the resources needed to deliver better outcomes when providing non-vaccine COVID-19 services. According to the respondents, 83% needed adequate staffing, 69% needed electronic access to medical records, 43% lacked advanced technology, 51% admitted needing adequate consultation space, 50% wanted payment for their services, and 5% of the responders needed other resources besides those that were stated in the questionnaire. These numbers are expected to exceed 100% as more than one answer could be selected.
The respondents had the option to provide additional comments regarding their perception of the pharmacists’ and pharmacy interns’ roles in non-vaccine services provided during the pandemic. The question stated, “Please provide any additional comments regarding your perspective on the impact of pharmacists in COVID-19 non-vaccine treatments.” Most respondents left no comment, except for eight. Based on a thematic analysis of the free responses, the most prominent themes highlighted the increased reliance on pharmacists for non-vaccine treatment access, systemic barriers to prescribing, and the need for improved infrastructure (billing, training, and access) to support expanded roles. A summary of the themes is illustrated in Table 3.
These qualitative themes are consistent with the quantitative findings. Specifically, perceived importance of pharmacists’ roles in the quantitative findings aligns with qualitative feedback regarding the reliance on pharmacists for information. The stated need for EMR access in the qualitative findings mirrors the top barrier pharmacists chose in the quantitative results. The stated emphasis on training in the qualitative findings corresponds to the quantitative findings that 38% reported they had no COVID-19–specific training and 16% cited insufficient education as a barrier. A unique qualitative finding was that some were unaware pharmacists were prescribing COVID-19 treatments, underscoring needs for both additional training and broader outreach/communication about pharmacists’ scope.
Discussion
This study sought to explore pharmacists’ and intern pharmacists’ perceptions of their impact on COVID-19 treatments beyond vaccine administration. Although the FDA authorized pharmacists to furnish Paxlovid in July 2022, 68% were not actively doing so and utilizing their expanded scope due to barriers, such as difficulty accessing medical records, insufficient education amongst pharmacists, lack of trust from patients, and limited availability of treatment options. The resources necessary for pharmacists and pharmacy interns to fully utilize their expanded scope of practice were also identified. Of the survey respondents, 83% expressed the need for adequate staffing, and 69% expressed the need for electronic medical record (EMR) access (Table 2). Despite barriers, limited resources, and variations in training or frequency of furnishing, 89% of pharmacists and pharmacy interns across all settings perceived that they played a major or moderate role in treating COVID-19 patients.
While 89% of respondents perceived their role as at least moderately important, a minor 45% agreed that they felt prepared to provide non-vaccine services to the public during the COVID-19 pandemic. Pharmacists and pharmacy interns reported focusing on supporting the community through OTC self-care treatments and providing medication therapy management services, with 62% of respondents receiving COVID-19 specific training to do so. Other studies have also revealed that the COVID-19 pandemic has heightened dependence on community pharmacies, with 50% of individuals seeking OTC medication advice from pharmacists for symptom management (Cadogan & Hughes, 2021). Additional barriers faced by pharmacists have been identified as insufficient staff size (Biddle et al., 2021), inadequate pharmacy consultation space (Strand et al., 2020), shortages of protective equipment (Cohen & Rodgers, 2020), and psychological challenges (Basheti et al., 2020), contributing to feelings of unsafety and inadequate financial incentives. Notably, qualitative comments indicated some respondents were unaware that pharmacists could prescribe COVID-19 treatments, underscoring the need for clearer communication in times of health crises and additional training for essential frontline workers, such as pharmacists.
While pharmacists and pharmacy interns made significant contributions to patient care during the pandemic, implementing expanded services such as furnishing Paxlovid requires additional support and resources. As of October 2022, Medi-Cal reimburses pharmacies for both dispensing and the clinical service of furnishing Paxlovid (Policy Update and Billing Guidance for COVID-19 Oral Antiviral, Paxlovid, 2022). To safely furnish medications like Paxlovid, pharmacists expressed the need for access to EMRs (69%), adequate consultation space, and sufficient staffing, highlighting the importance of infrastructure and resources in enabling their expanded role.
A critical finding from this survey demonstrated the need for pharmacists to have access to EMRs to dispense medications safely and accurately. This coincides with other case studies detailing the importance of pharmacists having access to EMRs to allow them to provide appropriate care via collaborative decision-making to improve patient care and outcomes (Biddle et al., 2021). The implementation of a universal platform that provides all healthcare teams, including pharmacists, with a patient’s complete medical history, will enable more accurate record-keeping and tracking of drug-drug interactions. This will also aid the transition of care and medication reconciliation in an accurate and timely manner, which is vital to patient safety. To optimize patient care, all providers caring for the same patient should have access to their complete records. While this type of access can expand the role of pharmacists and improve patient safety, it raises concerns about patient confidentiality as health records would be shared universally among multiple healthcare settings, resulting in increased liability. These potential challenges associated with a future universal EMR system highlight factors that should be considered when interpreting the study’s findings and limitations.
Limitations
The limitations of this study must be acknowledged and considered when developing similar studies in the future. Although this study did reach power, the sample size was still relatively small. Furthermore, the risk of survey error, time constraints, and the possibility of non-responsiveness may impact the comprehensiveness and accuracy of the data. There is also sampling bias, as the study was unintentionally tailored to the outpatient pharmacy setting. The survey was distributed to anyone fitting the description of a licensed pharmacist or intern pharmacist, without taking into consideration that only pharmacists in community settings would be furnishing Paxlovid and providing OTC/self-care recommendations. This resulted in some questions not being applicable to all responders. These limitations suggest caution in generalizing the findings across different pharmacy settings and populations. To mitigate these limitations, future studies can offer incentives to increase response rates and collaborate with national pharmacy organizations to recruit participants to enhance generalizability.
Conclusions
Based on the results of this study, pharmacists and pharmacy interns perceived their profession as playing a major role in COVID-19 treatments and related services, with the majority acknowledging a significant impact in providing non-vaccine services. Despite this, there has been limited research on the perceptions of pharmacists and pharmacy interns regarding their roles and the barriers they face in providing services. Future studies should strive to expand participant diversity to include pharmacists and pharmacy interns from different healthcare settings. By addressing these gaps, we can gain a deeper understanding and provide more effective support for the evolving role of pharmacists in public health.
In conclusion, this study highlights the need for systemic changes to support pharmacists and pharmacy interns in their expanded roles during public health emergencies. By addressing barriers such as staffing shortages and lack of access to EMRs, ensuring appropriate compensation, and improving pharmacy infrastructure through technology integration, pharmacists and pharmacy interns can significantly enhance their impact on patient care and public health. These findings are instrumental in shaping policies and practices that will better prepare the healthcare system for future challenges.