Staying strong under pressure

Building autonomy and resilience when pushed by patients, colleagues or personal contacts.

The journey of an early career pharmacist – from student to intern to junior pharmacist – is one that everyone in the profession recalls.

Building professional confidence, independence and autonomy continues throughout a pharmacist’s career.

AP spoke to three pharmacists about the challenges they faced and how they developed professional autonomy during their early years of pharmacy practice.

Colleen Niland BPharm, Grad Cert DE, MSHP, MPS, Danila Dilba Health Service, Darwin, NT    

Confronting angry customers, patients and other health professionals was daunting for Colleen Niland as a newly registered pharmacist more than a decade ago.

‘At some stage of every pharmacist’s career, we’ve all been in the position of customer hostility,’ Ms Niland, 34, says. ‘Whether it be to supply an over-the-counter product we don’t believe is appropriate, dispense a prescription we have reservations about, or get raked over the coals for asking a few health-related questions.’

Ms Niland says some consumers see early career pharmacists as targets that can be easily intimidated. Providing safe and effective pharmacist care to agitated consumers can be ‘scary’ or even ‘overwhelming’. But concurrently navigating patient emotion and patient safety is a skill that builds over time.

‘What drives our decision to refuse a sale, not dispense a script or say no to unethical practice?’ Ms Niland asks.

‘It’s the reason we became pharmacists! My role is to ensure safe, appropriate, and quality use of medicines. This line is one of my “go-tos” when speaking to customers, patients on the ward, and other health professionals. It’s the basis for my reasoning on decisions. Simple yet effective.’

When Ms Niland was an intern 12 years ago, one of her mentors asked a question which stayed with her.

‘She said, “Could you stand up for yourself in a court of law?” It’s a terrifying thought, and one I certainly hope not many pharmacists experience, but it does allow some perspective for potential decisions you make in day-to-day practice. There are differences between legal and ethical dilemmas, and the ethical ones are often harder to navigate.’

It is critical, she says, to understand pharmacists’ professional codes and practices. They provide necessary insight on the expectations of pharmacists and consumers.

‘Ethical dilemmas are seldom simple conundrums. Each year when new interns start at my workplace, I make sure to discuss and review the Code of Conduct, the Code of Ethics, the National Competency Standards, and the Professional Practice Standards,’ she says.

‘As pharmacists, we all know of these documents, but do you understand them? Are you aware of what their contents include? No-one is expected to recite them word for word, but understanding their purpose and contents instils a quiet confidence in our professional boundaries, allowing for the constraints we apply to our own practice . . . they guide the decisions we make as health professionals.’

Confidence also comes with time, Ms Niland says, and it is normal for some level of professional anxiety. The best remedy is to find a mentor, someone to bounce ideas off and discuss difficult scenarios. A knowledgeable, trusted colleague has most likely encountered
the same situation.

‘Having a mentor, close or a phone call away, also reminds us that professionally we are not alone. It’s perfectly acceptable to seek advice when needed, and admit you are out of your comfort zone.

‘I was lucky enough to have two fantastic mentors when I was an ECP. I still turn to them for advice, and credit them with the professional confidence I have today.’

Arnav Chug BPharm (Hons), AACPA, MPS, Master’s candidate, Melbourne, VIC

Arnav Chug, 27, is a pharmacist with 4 years’ experience in community, aged care, advocacy and consultancy practice who believes that challenging the status quo is imperative in a dynamic pharmacy landscape.

He is currently completing a Master of Public Health, and is a member of the PSA’s ECP Working Group after previously serving on the Victorian Branch Committee.

Mr Chug says his first teacher once quoted to him Friedrich Nietzsche: ‘A moral system valid for all is basically immoral’. And with daily diverse legal and ethical dilemmas to face, he also recalls the words of one of his mentors: ‘The law governs what you can and can’t do, and your values determine how the interaction unfolds.’

‘Real growth takes place when you are left on your own with no-one to refer to,’ he says. Constant changing regulations during the pandemic last year were challenging, especially restrictions on salbutamol supply, which involved ‘some very tough conversations’ with those in ‘desperate need’ as well as with suspected stockpilers.

‘At times, there have been scenarios where the introduced legislation is simply too rigorous and doesn’t allow for much interpretation. There will be times where you might need to intervene with doctors and other more experienced pharmacists. I have had doctors simply be unaware of self-prescribing laws. In other instances, there have been pharmacists unaware of regulations around supply of medications off medication charts alone.

‘Remember, experience doesn’t equal expertise, and simply taking a subordinate position in that scenario wouldn’t serve the right purpose,’ he says.

‘As recent graduates, early career pharmacists have the most up-to-date clinical and professional knowledge, so it is about harnessing this in a proactive manner, being non-judgemental and not compromising your own standards.’    

To ensure better outcomes for both the patient and himself, while maintaining professional standards, Mr Chug undertook assertiveness training and has felt more resilient in challenging situations since.

Recalling another tricky situation, he says: ‘I once worked for a pharmacy where the retail staff were filling online orders for Schedule 3 medicine delivery without pharmacist intervention. There were online terms and conditions which were cautiously circumventing the law, however I wasn’t comfortable with how easily they were bypassing my professional responsibility. How could I carry all the risk despite not having any input?’

Although he was told no other pharmacist had complained about this, the pharmacy ‘ultimately revamped the process. It was a little win’.

Mr Chug says pharmacists should let experiences guide their moral compass, not redefine their identity: ‘Remember, you are the health professional and you control the room. Your actions today could influence the customers of tomorrow.’

Deanna Mill BPharm (Hons), GradCertAppPharmPrac, MSHP, MPS, PhD candidate, University of Western Australia

Since her early years as a student, Deanna Mill has worked in many hospital and community pharmacies. Now 26, even in recent experience, and during her current research as a PhD candidate exploring professional behaviour and professionalism among pharmacists, Ms Mill is constantly faced with situations where she is uncertain of how to proceed.

‘I know what the legal and ethical answer is to most situations, but applying them when faced with patients, prescribers, employers or other people in situations that may be highly emotive is incredibly difficult for pharmacists every day,’ she says.

‘When faced with challenges or uncertainties in practice, if I feel uncomfortable, I have always drawn on my gut, my body telling my brain there’s something I need to address.

‘And I’ve relied on my support network, which includes other pharmacists, managers, family, friends, professional organisations and a range of other health professionals, or even professional support services.’

If it’s illegal, maintains Ms Mill, don’t do it. There must be another way. If the law is impacting your practice and preventing you from providing patient-centred care, she urges reporting this to professional organisations, politicians and other people who can act to change the relevant laws.

Remember, Ms Mill says, that you’re there to help the patient.

‘If harm may come from your actions, your decision to dispense something, then don’t do it and explain why. You do not have to do anything because someone else wants you to. Just make sure you explain why and make a plan with the patient to address the issue.’

Ms Mill has been asked numerous times to dispense large amounts of opioids for patients just discharged from hospital after acute surgeries – even after discussions with the prescriber that have cited current evidence and concerns about opioid overuse, misuse and accidental overdose in the community.

‘Having confidence in my knowledge of the risk of opioid medicines and best practice considerations in this area, I choose to have a discussion with the patient themselves,’ she says.

‘I’ve found that by discussing the risk and devising a pain management regimen appropriate for the patient considering the use of other pain management options, I am able to empower the patient to make their own decisions about the appropriate amount of opioid medications to supply them, and a plan for any pain escalation.

‘In these cases, I dispensed lesser quantities than had been prescribed to the patient, with the patient’s permission, fulfilling my responsibility to ensure safe, responsible use of these medicines – and good patient care,’ she adds.

Like most pharmacists, Ms Mill has also been asked for an ‘owing’ prescription without the prescriber’s knowledge or direction. In these cases, she engages the patient in a conversation about the particular medicine and their options for obtaining it.

‘I take the approach of never directly saying ‘no’ but instead investigating why they’ve run out of the medicine and assisting them to devise a plan to get it. This may include engaging the doctor to send them a prescription, or to make an appointment, or using legal emergency supply regulations – including temporary COVID-19 emergency supply provisions to support ongoing patient health.’

Ms Mill has been asked ‘countless times’ to supply Pharmacist Only Medicines without question. When she has tried to ascertain need and engage the patient in a conversation, she says she has received flippant replies such as ‘I’ve used it before’ , ‘I know what I’m doing’, or ‘They always just give it to me’.

‘This is particularly challenging, especially when the presenting person has preconceived notions about you supplying them the medicine,’ she says.

‘One example is that I was recently asked by a lady to supply chloramphenicol for her baby. The baby, who was not with her, had not been assessed by a doctor or an optometrist, and she couldn’t describe the symptoms to me. She was rude and said she always just gets it for her family whenever she needs it.’

This response was concerning to Ms Mill, because she could not determine if it would be safe to supply for the baby, and so it was not within her professional responsibility to do so. Rather than say ‘no’, she explained that it was difficult for her to know if it was the right treatment for the baby, and that children under two years really should be assessed by a professional – in case there was something else wrong with their eyesight.

‘She was angry and left the store exclaiming that she would just get it elsewhere. And she might well have done just that. But I was considering what was best for the baby, and in my opinion that was to seek further help.’

• Know your worth. Negative interactions are few. Most are rewarding and worth our demonstrated integrity and professionalism.
• Review professional codes and practice standards. Understand their purpose.
• Let go when you can’t influence someone’s actions.
• Strive to be better with assertiveness training. Forge an environment where you treat staff with integrity, then they will stand up for you in tricky situations.
• Trust your instincts. If something doesn’t feel right, investigate it further.
• Take time to assess and resolve difficult situations. Rarely is a situation an emergency, even if someone is making a scene or creating a life-or-death scenario. Call emergency services if necessary. If not, ask for the time necessary to consult resources or your support networks.
• Don’t forget your role in healthcare, individually and community-wide. Ensure safe, appropriate, and quality use of medicines, whether through supply or refusal.
• Don’t forget you are not alone. Use mentors, work colleagues or PSA’s ECP Facebook page.
• Don’t let the usual ‘the other pharmacist always does it for me’ guide decision-making. Learn to practise with autonomy; don’t desert your values.
• Don’t risk your registration to appease employers, angry patients or uncooperative prescribers.
• If it’s illegal, don’t do it – there must be another way. If the law is impacting your practice and preventing the provision of patient-centred care, report it to professional organisations, politicians and others who can act to change those laws.