A qualitative study of pharmacy nurse providers of community based post-birth care in Queensland, Australia

Recruitment of sample

In the non-metropolitan sites with pharmacy nurse clinics, we contacted pharmacies employing nurses directly by telephone. The study was described to the pharmacy manager or equivalent, who was then asked to pass on details of the study and researcher contact details to the pharmacy nurses. Pharmacy nurses were asked to call us if they wished to participate in the study. Both of the two pharmacy nurses in one site, and three of six in the other regional case study site were recruited to the study.

A more complex sampling and recruitment strategy was required for the city of Brisbane. Brisbane is the capital of Queensland, with a population of 1,079,392 within the Brisbane City Council (BCC) local government area in June 2011. Prior to this research, no systematic attempt had been made to enumerate the proportion of pharmacies offering a ‘pharmacy nurse’ baby clinic within the city, nor to map their geographic distribution. As a first step in building an appropriate information base, researchers mapped the distribution of all pharmacies in the BCC area through listings in http://www.yellowpages.com.au and http://www.truelocal.com.au. Secondly, all 301 pharmacies listed in the BCC catchment area were telephoned, and asked whether they employed a pharmacy nurse to provide a ‘baby clinic’. Of the 56 pharmacies (18.6%) employing a pharmacy nurse, 40 were randomly selected and contacted by telephone to request participation in the study, and 14 participants were recruited in the Brisbane city area. In total 19 pharmacy nurses working in city and regional centres were interviewed, primarily through face-to-face interviews (N = 15), although 4 nurses were interviewed by telephone or completed an online survey.

GPs with an interest in postpartum care were purposefully recruited through contacts of one of the research team.

Semi-structured interviews lasting between half an hour and an hour were conducted at mutually convenient locations, including pharmacies, GP clinics and other public venues. Respondents were asked about a variety of aspects of their work experience, their credentials and their perceptions of their roles. A summary of the topic guide can be provided by request to the author. Following consent, interviews were audio-recorded and transcribed verbatim.

In addition to the qualitative interviews, researchers also mapped the prevalence and geographic distribution of pharmacy clinics with publicly provided CFHCs in the case study sites. In the BCC, mapping compared the accessibility and availability of pharmacy clinics with CFHCs using information publicly available through the Queensland Health website. Opportunistic observation of 10 of the pharmacies where pharmacy nurses worked took place at the time of interview.

The majority of data collection took place between June and November 2011, although some interviews took place between Jan 2011 and June 2012.

Data analysis

Qualitative data gathered through interviews were analysed using thematic analysis with Nvivo 9 software. Coding of data was initially conducted independently by several of the researchers involved in data collection; subsequently the themes identified were further explored in consultation, with high degree of consensus regarding the reliability of thematic interpretations [23].

The attributes and qualifications of pharmacy nurses

Our all-female sample were all registered nurses (N = 19), and most (N = 16) had qualifications in midwifery, while a significant proportion were also credentialed in child health (N = 10). Only a minority were qualified as lactation consultants (N = 4) with a few holding other relevant qualifications such as paediatric nursing or child development. All had experience in providing care to mothers and babies prior to working in the pharmacy. Most recounted extensive work histories of 15 years or more in nursing, and most had practised primarily in midwifery and child health. Seventeen of the 19 respondents worked in the pharmacy for less than 15 hours per week, with six to ten hours per week the modal category, generally in one or two clinics of three to four hours duration per week. Almost all interviewees held one other part-time job as a nurse in a hospital or General Practice clinic. In the pharmacies they were employed as part-time or casual staff on hourly pay rates. Our respondents, especially those caring for families, were attracted to work in the clinics because of the predictable, part-time work within school hours.

“…the hours here are very suitable here for me and my family.” RESP 6

“Before I became a pharmacy nurse, I used to work for Child Health as a Child Health Nurse, and then I had my own children and the hours in the Child Health service were very inflexible so I really couldn’t work you know like just four hours a day sort of thing, so the pharmacy allowed me to do that.” RESP 11

This well qualified and experienced group of nurses provided considerable insight into their motivations, duties, sources of job satisfaction, working relationships with other primary care providers and concerns with their work. In the next part of the paper, we report on the major themes that emerged from the interviews with pharmacy nurses and GPs. These included the strong sense that the work of pharmacy nurses fills a gap in the public provision of maternal and child health services. Pharmacy nurses felt that they provided an accessible, convenient service and that they could provide flexible, responsive care. They were also able to articulate a number of limitations and concerns about their conditions of practice.

The genesis of pharmacy nursing in Queensland

“Filling a gap”

For both the GPs and the pharmacy nurses in our sample, the lack of sufficient public CFHC services was a significant problem, which contributed to the genesis of pharmacy nurse clinics. For example, one of the GPs in our sample said:

“..one of the reasons for not referring to early childhood nurses [CFHNs] more is there just isn’t capacity.....Fund it properly… If I said to all of my new mums go along and meet the early childhood nurses, talk to them about breastfeeding…the unsettled baby…get your baby weighed and measured every week for the first six weeks, they would be overwhelmed, they can’t actually deliver, so all I do is set women up with an unrealistic expectation on an overloaded and already stretched service…” GPBR1

The pharmacy nurses themselves overwhelmingly described their services as ‘filling a gap’ in the public provision of care in the context of the retrenchment of public services. While one of our respondents simply indicated that pharmacy nurse clinics:

“ fill a gap that is not provided by the public system.” RESP 4

Others elaborated extensively, for example:

“I just think that pharmacy nurses probably evolved because of the poor quality of the child health service that was there for women, and that there was a need in the community for women to be able to have easy to access Child Health Nurses. When I started doing Child Health twenty years ago there were centres in every suburb, women found it very accessible they’d come every week, and then … closed them down … and eventually they only had big major centres ……so people would have to drive there … so they’ve actually closed so many of them now that women find it really difficult to access them there is obviously now a big wait for them too, like four weeks to get in and so I think out of that evolved pharmacy nurses.” RESP 11

“Thirty years ago there were so many government provided clinics, a mum could almost walk in at any time and get helped. But the government has moved away from that type of provision.” RESP 9

The nurses were well aware that publicly provided services have become increasingly targeted towards ‘at-risk’ mothers, with the result that sometimes “…normal mums get forgotten” RESP 9.

One of the nurses put this in terms of a ‘zero-sum’ situation:

“There used to be child health, equivalent down the street. I used to work there myself… [now] it’s not funded because all of the funding goes into the at risk mothers who are in the community and get home visited.” RESP 5

Our examination of the geographic distribution and availability of pharmacy nurse clinics and publicly provided CFHCs concurs with the notion that pharmacy nurses ‘fill a gap’ created by the retrenchment and re-orientation (to ‘targeting’) of publicly provided maternal and child health services. Across our case study sites, for example, the number and distribution of pharmacies employing nurses varied widely. Two of the four regional and rural sites which had reasonably well integrated and comprehensive community based maternal and child health services, did not have pharmacy nurses at all, whereas one of the case study sites in which post-hospital discharge services were poorly integrated and coordinated, two pharmacy nurses provided clinics at four different pharmacies. In the BCC area, we identified a large disparity in the prevalence of pharmacy nurse clinics (n = 56), compared with CFHCs (n = 13). There were other significant differences in availability and access between the two types of clinics. Seven of the 13 CFHCs were open every weekday, and the remainder open once or twice per week; most of the public clinics operated on an appointment only basis with average waiting times of between 2 and 4 weeks for an appointment. In contrast, the larger number of pharmacy clinics were open shorter hours (generally open for half or whole days once or twice per week), but almost all were available on a drop-in basis, so parents did not have to wait for an appointment.

Quality of service provision: responsive, flexible, continuity of carer

In addition to ‘filling a gap’, pharmacy nurses also emphasised a number of key features which distinguished their work from CFHNs working in public CFHCs. As mentioned, most of the pharmacy nurses ran their clinics on a ‘drop in’ rather than appointment basis, and hence perceived their services as more responsive to client needs and demands than public (primarily appointment only) centres.

Pharmacy nurses, many of whom had previously worked in CFHCs, perceived their practice as more autonomous and flexible than nurses working in CFHCs. They described their work in pharmacies as free of the bureaucratic and organisational constraints governing the practice of CFHNs. They also articulated their capacity to work without oversight from their employers and hence to be able to practice autonomously.

“I probably think that [public] Child Health is very inflexible in that it seems to go a lot on what books say.” RESP 11

In relation to infant feeding, a number of pharmacy nurses talked about their capacity to support the mother in her decisions, rather than ‘rigidly’ promoting breast feeding, for example:

“….if a woman walks in and says I'm giving my baby a bottle - … I [don’t] say to her ‘you're doing the wrong thing’ - I like that it's more flexible [here than at CFHC]. I'm aware of the [promotion of breastfeeding] guidelines, I support them but you're dealing with real people. I'm allowed to do … that. I get the reverse of it where people come to me and say, ‘they're too pushy [at CFHC] and I like you because you're not”. RESPR1

Pharmacy nurses were positive about their capacity to respond to the individual needs of their clients and provide ‘woman centred’ care:

“I just say, I'm available as much or as little as you want to come - whatever you feel you need.” RESPR1

The pharmacy nurses in our sample also valued the fact that they provided continuity of care by virtue of being the one care provider in a pharmacy clinic. They indicated that most of the parents they saw were ‘regulars’, and they spoke of this continuity as an intrinsic source of job satisfaction:

“…enormous satisfaction, particularly when I have parents coming back with second and third babies.” RESP 7

Another said:

“I've been here for ten years and I'll see people that have had four kids so you know all their kids.” RESPR1

This kind of continuity enabled pharmacy nurses to provide personalised care, even when ‘off duty’ as the following shows:

“But I'll tell them if they're having problems and they need to, I am over here on Tuesday if you need me. They can ring me up here. If I know them and I'm really comfortable, I'll tell them they can ring me at home if they're really stuck.” RESPR1

Most pharmacy clinics are located in shopping centres, and as such are convenient to their clients:

“Well I think it’s an excellent service to the mother, drop-in at a shopping centre I think is a very important service, rather than her going to some little building in the middle of woop-woop, where you know there’s no shelter, and if it’s raining they get wet coming from their car to the building.” RESP 8

Most pharmacy nurses reported high demand for their services, with some reporting extremely busy clinic sessions where they might see up to 25 mothers in a single clinic of three to four hours.

Services provided by pharmacy nurses

Pharmacy nurses reported two main types of care provision: first, practical and emotional support to parents (particularly mothers), and second, health surveillance of babies. They perceived that they were able to provide meaningful emotional support, reassurance, and empowerment in a flexible, responsive clinic environment:

“I think that women need somewhere they can go to for support and can come and feel comfortable that someone will listen to them … the most important thing is basically empowering the mothers and basically offering support for them.” RESP 11

“…reassurance plays a big part in what I do because sometimes they just want to be told that what they’re doing and the baby…is thriving.” RESP 6

“ weighing; a lot of advice and support. I find a big part is just counselling mothers because they're coping with something completely new. To me that's the big thing.” RESPR1

Infant checks including weight, other measurements and general parenting advice were among the other most frequently cited types of services provided. A much smaller proportion, about one quarter of our sample, reported providing advice and information about infant and other products for purchase.

Constraints, concerns and limitations

Pharmacy nurses were also asked to comment on any constraints or concerns they had with their practice in pharmacies. The key concerns they listed were professional isolation in their practice, lack of opportunities for professional development, lack of privacy for consultations, inadequate facilities for bare weighing of babies or providing breast feeding advice and support, and ad hoc or non-existent mechanisms for record keeping or client follow up. The nurses themselves and the GPs also provided insight into the existing mechanisms for the integration of care through referrals, and for how these might be improved.

Pharmacy nurses practise on their own, albeit with some contact with the staff of the pharmacies in which they work. They do not work alongside peers, nor do they have back up when they are sick. They do not have a professional association to provide support, peer contact or professional development. As we have seen, most are well qualified in areas relevant to their practice, but many expressed concerns about the difficulties of keeping up to date with developments in practice, especially when informational seminars run by formula companies were amongst the few opportunities available to them.

“we’re very isolated in the community as nurses so it’s up to myself to keep myself updated with information, what’s the latest and if I’m sick there’s no one to back me up....I try to go to as many seminars as we’re invited to. They would be run by the formula companies and even though they’re sponsored by formula companies, the information they give at seminars are usually by paediatricians or specialists in whatever field may be applicable to us so it’s not about formula. So we get to meet other nurses that way.” RESPW1

As well as isolation and lack of opportunities for professional development, pharmacy nurses work in a context that poses several other impediments to the provision of high quality care. Most reported lack of facilities and space to undress and assess babies, resulting in the common practice of weighing babies dressed. Similarly, pharmacy nurses reported feeling constrained in their ability to provide mothers with breastfeeding support because of lack of privacy and to some extent the lack of time. One of the pharmacy nurses who is also qualified as a lactation consultant expressed her concerns about this limitation in capacity to support new mothers. This pharmacy nurse also expressed concern about her proximity to infant formulas in the pharmacy, which she felt implicitly endorsed these feeding products.

Another widespread concern was with record taking and keeping. The relatively isolated, autonomous and unregulated practice of pharmacy nurses meant that there is no consistent approach to record keeping. Information collected was quite variable (infant weighs notwithstanding). Whether they kept records at all, and if so what and where, was even more varied. Most respondents indicated limited capacity to store records, and few had access to a computer. One of the interviewees expressed concern that she had no capacity to follow up clients if they did not make a return visit.

At the present time, pharmacy nurse practice is essentially unregulated in Queensland; there is no statutory body that provides oversight or regulation, and pharmacy nurses themselves do not have a professional association. As already discussed, our sample of pharmacy nurses are experienced and well qualified for the work they undertake in pharmacies, but without some form of regulatory oversight by a professional association or statutory body, there is no assurance that all nurses working in pharmacies will be appropriately qualified. This has implications for primary care coordination and integration, as discussed in the next part of the paper.

Primary care coordination and integration

One of the important indicators of primary care coordination and integration is the existence and use of referral pathways. Very few of our sample of pharmacy nurses - less than one fifth - explicitly mentioned referrals to other health care practitioners as part of their routine practice. They also reported few mechanisms or structures that might facilitate the integration of care with other primary care providers, apart from one exception: in Queensland, all new parents are issued with a child health record ‘book’ (commonly known as the ‘red book’) by the birthing facility at which the birth took place. The book is intended for the documentation of routine health surveillance and immunisations, and provides information about the infant’s birth, weight and condition at birth. If the parents brought the ‘red book’ to the pharmacy, most of our respondents indicated they would refer to it. Some also used it to record infant weight or other measures, or to make notes in the back of the book. However, there was no systematic use of the child health record by pharmacy nurses, and therefore no consistent formal mechanism for communicating information to other primary care providers.

Informal referrals, particularly word of mouth recommendations, were much more commonly used, but patterns of recommendation to or from pharmacy nurses varied substantially, and tended to reflect relationships based on personal knowledge of individuals. This is not surprising given the lack of certainty about the credentials and qualifications of pharmacy nurses. One of the GPs in our sample summarised this clearly by saying

“Some pharmacies have nurses who do weighs and measures of baby, although that can be hit and miss in terms of what is their training and their background, and certainly some of the advice that women have received from them has been quite inappropriate in my experience, and others of them seem pure gold, so it’s just that you don’t have that control over them, and well my understanding is there isn’t any sort of rigorous system in place to make sure [about] the information they are giving women…” GPBR1

Of course, these kinds of variations in the quality of care provided can be seen across a range of practitioners; the problem for pharmacy nurses is, as noted earlier, the lack of clear and consistent credentials required for the job, since the occupation is currently unregulated.

Working relations with CFHNs tended to be particularly problematic for different reasons. A number of pharmacy nurses had previously worked in public CFHCs, and were critical of what they described as their bureaucratic, inflexible, unresponsive and intrusive aspects. They rarely recommended the CFHCs, although some informed their clients about specific services at Child and Family Health, such as

“the little [six week] course for mums if you make your appointment.” RESPR1

One pharmacy nurse referred mothers to the CFHC because of the limitations of the facilities she had access to at the pharmacy. Some of the limitations included lack of space for private consultations, and inappropriate facilities for bare weighing babies.

Conversely, pharmacy nurses rarely had women referred to them by public CFHCs. Only one pharmacy nurse indicated that some mothers of ‘well babies’ were told of her services by the local CFHC. More frequently, pharmacy nurses spoke of a difficult relationship with public providers of child and family health, and mentioned feeling somewhat denigrated by staff in publicly provided CFHCs. For example, one nurse told us “I don’t think Community Health would send anybody to us. I’ve had women’s feedback....that [pharmacy nurses] aren’t ‘proper’ Child Health nurses” RESPR1.

Our respondents were cognisant of their inability to make formal referrals to other health care providers, and would advise women to seek a formal referral from a doctor if necessary. The patterns of relationship and referral with GPs, obstetricians, paediatricians, pharmacists and hospital midwives were quite variable, and depended very much on personal knowledge of particular practitioners. For example, in several cases, pharmacy nurses either worked for GPs, or in clinics with midwives in private hospitals. These relationships, based on personal knowledge and experience of a particular individual, facilitated informal referrals between them. For example,

“....where I work [in a General Practice], particularly one of the doctors - initially I just worked for her - she would certainly tell women go and see me. I think when they know you [they refer on to you].” RESPR 1

On the other hand, when these relationships were not present, GPs expressed concerns about ensuring consistency in the quality of care offered by pharmacy nurses as noted above.

Most of the pharmacy nurses indicated that they would informally suggest that parents seek the advice of a GP where necessary, although some expressed hesitation because of the time and cost involved in seeing a doctor. In addition, decisions about ‘necessity’ are potentially subjective, and may be dealt with differently depending on the health care provider involved, as the following interview excerpt demonstrates:

Interviewee: But the people who need - they need to talk to you about something - then they are going to persist. Because what are they going to do? Go and sit down at a doctor's surgery - because some doctors take an hour-and-a-half to see you? Then they've got to pay for that too, don't they?

Facilitator: Yes.

Interviewee: So that side of things - as an alternative to a doctor's advice. I do get some people who say, they've got this and this - what do you reckon?

Facilitator: That puts you in an awkward position.

Interviewee: It does but a lot of it's basic stuff. You know, if they have a bit of a temperature and viral things I will say, this is how viruses work, this is what happens. But again you've got to say, if you are worried, as you know, you go to the doctor.

So a lot of it's just basic little things. A little bit of stuff gets a bit hard because you can buy cortisone over the counter, you can buy DermAid. With some of those little dermatitises, I know very well they're going to go to the doctor and that's exactly what they're going to give them and they're going to pay $65 for a consult and that. For some people, I will tell them they can have that over the counter if they want. Sometimes I'll take them and get the pharmacist to have a look at stuff and see if they're happy to recommend something they can buy over the counter. Sometimes they won't, they can't give them something over the counter. So I do use the pharmacist as well.

The direct referral to a pharmacist noted above was not mentioned often by our respondents, but it is important in its implications for the provision of primary health care, especially if pharmacy nurses feel pressured to promote products within the pharmacy. Only one of our respondents indicated that she had been asked to do this. All said that they would not promote products simply to achieve a sale, although four of the pharmacy nurses said they promoted products because they believed in the quality of the product sold by the pharmacy. Overall the nurses were positive about the pharmacists who employed them and respected their professional integrity. All nurses explicitly referred to the fact that endorsing products was not a formal condition of their employment. However, more subtle implicit pressure, expressed by one nurse as the need to ‘cover my wage’, was clearly a concern for some pharmacy nurses.

Overall, coordination with other primary care providers of postnatal or early parenting care was ad hoc and variable at best. Several of the pharmacy nurses referred clients to lactation consultants, and some older infants were referred to allied health professionals (physiotherapists or podiatrists). In sum, the views of our sample about working with other primary care providers indicated that few used systematic channels for referring to GPs, pharmacists, or CFHCs, and some interviewees recounted a ‘hostile’ relationship between the CFHCs and the pharmacy nurse services. Apart from particularistic relationships with employing pharmacists or GPs, pharmacy nurses generally practise in isolation, with no systematic avenues or mechanisms for service coordination or integration with other primary care providers.

Limitations

This study provides important preliminary findings about an under-researched form of maternal and child health care provision in Australia. The study provides new knowledge about the prevalence of pharmacy clinics within the BCC. However, little is known about their prevalence in the remainder of the State, or in other parts of Australia. Descriptive data which could provide a more definitive picture of the prevalence of pharmacy based baby clinics is needed to contribute to an understanding of this form of care in the context of publically funded child and family health nursing services.

One of the major limitations of the study is its reliance on a small number of pharmacy nurses and GPs. The interviews comprise a small scale, qualitative study. A larger study which could establish the representativeness of the sample to the population would further contribute to the body of knowledge in this area.

Another limitation is its reliance on only two types of health care providers. The inclusion of other key stakeholders in any further research would be an important next step. The insights and experiences of pharmacy owners, employees in the public sector providing community maternal and child health care, and newly parenting mothers in Queensland would contribute to a fuller understanding of the genesis and role of pharmacy nurse clinics, and what it means for the overall provision of care.