Abstract
Introduction
The role of the community pharmacist in the United States (US) and other countries has been transitioning from primarily medication dispensing to providing more clinical services.1,2 The severe acute respiratory syndrome coronavirus-2 (COVID-19) pandemic has highlighted the public-facing role of pharmacists in the health system. They have played a key role in communicating trustworthy health recommendations (e.g., clarifying information about COVID-19 treatments) 3 and promoting precautionary measures to reduce disease transmission (e.g., hand hygiene, social distancing, self-isolation), along with promoting continued adherence to treatments for pre-existing medical conditions. 4 As the pandemic has demonstrated, community pharmacists may also alleviate pressure in saturated areas of the health system (e.g., general practice and emergency departments) and be an invaluable resource in meeting the demand for access to vaccines. 2
As health care moves away from fee-for-service to value-based reimbursement models, pharmacist services have expanded immensely. Pharmacists provide medication management and reconciliation, transitions of care, education and behavioral counseling, collaborative care with physicians, and preventative care services such as health screenings and immunizations. 5 Pharmacists have long been recognized as one of the most trusted and accessible health care professionals who can help improve public health as advocates for preventive health services. 6 One way they can achieve this is through screening patients for recommended vaccines and administering immunizations, as allowed by state law.
Vaccinations are considered to be one of the most economical and practical methods to decrease morbidity and mortality of preventable diseases. The US Office of Disease Prevention and Health Promotion estimates that if each birth cohort is vaccinated with the recommended immunization schedule, up to 14 million cases of diseases can be prevented and over $43 billion in direct and indirect health care costs can be saved. 7 Data from the Centers for Disease Control and Prevention showed substantial progress in the number of influenza vaccine doses distributed in the US by season, from 12.4 million in 1980-1981 to 169.1 million in 2018-2019 8 ; yet only 45.3% of noninstitutionalized adults over 18 years old were vaccinated against seasonal influenza in 2018-2019, 9 which remains below the targeted goal of 70%. 10 Some ways to address the suboptimal vaccination rates in the general population include increasing the scope of pharmacy practice and providing patients with additional non-traditional settings in which to obtain immunizations. 11
There are over 67,000 community pharmacies in the US which have the capacity to help increase the vaccinated population. 12 Data from the Centers for Disease Control and Prevention displayed that the most common place for a flu vaccination among vaccinated adults 18 years and older was the pharmacy/store. 13 However, according to a Canadian study, approximately one-third of pharmacists report not having enough time to administer vaccinations to adult patients, 14 and US pharmacists are likely to experience similar time constraints. Student pharmacists who are qualified as interns are in a position to help improve immunization rates and public health efforts through vaccination privileges. 15 Hess et al recently highlighted the potential role of intern pharmacists in community pharmacies to help increase public access to new vaccines in response to the COVID-19 pandemic. 16 A literature review of the impact of pharmacy students on immunization initiatives described increases in vaccination capacity, patient education, and patient satisfaction from student involvement in university campaigns, community outreach events, hospital programs, and community pharmacies. 17 These immunization opportunities for student interns help patients and also help student immunizers refine their skills. At the University of Oklahoma College of Pharmacy, influenza immunization clinics were incorporated into introductory and advanced pharmacy practice experiences (IPPE and APPE, respectively) and resulted in improvement in knowledge, perceptions, and attitudes of student pharmacists administering immunizations. 18
As of 2018, New York (NY) was 1 of only 3 states in the US that did not allow student pharmacists to provide immunizations. The 2017-2018 influenza season resulted in the highest percentage of influenza-like illness since the 2009 flu pandemic, with preliminary estimates of 45 million cases of influenza illness and 61,000 deaths in the US. 19 High influenza rates along with low vaccination rates contributed to the passing of legislation (bill A2857-D/S1043-D) on December 7, 2018, to allow student pharmacists in NY to provide immunizations. 20 The bill was signed into law to help increase awareness of and access to immunizations for the public and ensure that NY retains a qualified healthy workforce.
Previous studies have evaluated pharmacy students’ perceptions of immunizations but most have surveyed students after recently completing their immunization training. For example, Welch et al found that student confidence in providing immunizations increased through an influenza vaccine administration IPPE which required students to complete an APhA certification, an immunization-based simulation, and practical experience in influenza immunization clinics. 21 Kubli et al evaluated students at the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences after their immunization course and found they had increased knowledge regarding immunization facts as well as the perceived importance of immunizations yet a substantial portion of students retained apprehension about needle injections; there was no follow-up to examine if students used this knowledge in practice and what impact that had on students. 22
Assessing student feedback from real-world practices, such as rotations and work experiences, allows faculty to identify which sites students are making the largest impact in providing vaccinations. This helps to determine the number of students that have the opportunity to practice at the top of their license through vaccinating patients. Our study contributes to previous literature as the survey was administered nearly one year after students completed the training and asked questions regarding their vaccination experience and comfort. Further, the survey instrument used in our study asked questions regarding the specific areas of knowledge/confidence related to vaccine administration. Thus, we explored student perceptions of the individual components of the immunization process, such as confidence in providing intramuscular (IM) and subcutaneous (SC) injections, completing the screening and consent process with patients, obtaining reimbursement for providing adult immunizations, and managing vaccine adverse reactions. This level of detail allows for the early identification of knowledge gaps. Identifying gaps in knowledge can assist in improving the vaccination training received by students. It can also identify barriers to students providing immunizations when they become licensed pharmacists.
The primary objective was to measure the perceived capability and confidence of first-time immunization-certified student pharmacists to provide vaccinations, obtain reimbursement for providing immunizations, and manage vaccine adverse reactions. Secondary objectives were to determine how often only student pharmacists provide vaccinations in clinical practice and at which practice sites student pharmacists are making the largest impact providing vaccinations. This is relevant to practicing pharmacists because 1) immunizations can be delegated to student pharmacists while pharmacists focus on other duties and, 2) pharmacist preceptors can fill common knowledge gaps to help student pharmacists refine their immunization skills.
Methods
After review and exemption were obtained from the University Institutional Review Board, this study was conducted during the fall 2019 semester, within the first calendar year that pharmacy students were authorized by NY state law to provide immunizations under certified pharmacist supervision. In January 2019, first-, second-, and third-year doctor of pharmacy students at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences were required to participate in the American Pharmacists Association (APhA) Pharmacy-Based Immunization Delivery certificate training program 23 during their IPPE course. During the training, each student was required to perform a saline IM injection and a saline SC injection. Students were also educated about NY state law, documentation, and management of adverse reactions involving vaccinations. Based on the completion of the training, these pharmacy students were eligible for study participation.
During the months of November and December 2019 (nearly one year after completing the vaccination training), a non-validated questionnaire created as a Google Forms survey was distributed via email to second-, third-, and fourth-year pharmacy students through the administration office of the School. The survey tool was shaped by an interdisciplinary team including two pharmacists with a Master’s in Business Administration and a researcher with previous survey methodology experience. Published literature was examined for a validated survey tool related to the current study, but no suitable tools were found. The questionnaire was pilot tested among first-, second-, and third-year pharmacy students for readability, length, and relevance of specific items.
To protect the privacy of students during the recruitment process, the survey was voluntary and anonymous. Students desiring to participate were required to actively respond to the invitation. No incentives were offered for participation. Students were asked to complete the Google Forms survey by clicking on the link provided in the email. By clicking on the submit button to finish the survey, consent was assumed. To screen out ineligible participants, the first question of the survey asked if they had received immunization certification.
The first section of the survey contained questions about general demographics such as gender, the highest level of education completed, and work setting. The second section consisted of questions that assessed student perceptions related to providing vaccinations. These included 14 questions using a 5‐point Likert scale for responses: strongly disagree (1), disagree (2), not sure (3), agree (4), strongly agree (5), and two questions (“Reasons for not getting a flu shot before pharmacy school?” and “How many immunizations have you given?”) with multiple response options. At the end of December 2019, the survey link was deactivated and student responses were analyzed during January 2020. Descriptive statistics were used to evaluate the data and were summarized by frequencies.
Results
Demographics of survey respondents.
Responses to survey questions measuring perceptions of student pharmacist immunizers.
One hundred eleven students (58.7%) indicated they had not administered an immunization in the nine months after they had completed their APhA immunization training (Figure 1). When presented with the statement, “My workplace does not allow me to provide vaccinations,” 67 students (35.4%) responded with agree or strongly agree. Of those 67 respondents, chain community pharmacy was the most frequent work setting, selected by 31 students (46.3%). The majority of pharmacy students (n = 143; 75.7%) received a flu shot every year before enrolling in their first year of pharmacy school and indicated no barriers to obtaining their influenza vaccination. Of the remainder that indicated a barrier to receiving their influenza vaccination before starting pharmacy school (n = 46; 24.3%), the most frequent barrier cited was cost, or the vaccination not being covered by insurance (Figure 2). Number of immunizations administered since completing training. Self-reported barriers to students receiving vaccines.
Discussion
Understanding student pharmacists’ perceptions as immunizers is an important step to better prepare them for their future as practitioners that are capable and confident to perform clinical services. Pharmacy students are the future of the profession and will be responsible for working together with other health professionals to improve patient health outcomes. The results of this study suggest that, overall, first-time certified pharmacy student immunizers have positive perceptions of their ability to provide vaccinations. The APhA immunization training program was also perceived positively by the students. This is similar to the results from a survey performed at the Thomas J. Long School of Pharmacy and Health Sciences in Stockton, California where the majority of respondents had a positive perception of the APhA training program. 24
The vast majority of pharmacy students that participated in this study felt comfortable administering IM injections while fewer were confident in their SC injection skills. This difference is likely due to the fact that most immunizations that pharmacists and interns have been allowed to administer in NY are via the IM route. As such, this cohort of students was not able to practice their SC injection skills.
Of the respondents that indicated that their workplace did not allow them to provide vaccinations, the majority worked in chain community pharmacies. During the time of the survey, chain community pharmacies in Western New York, such as Rite Aid and Tops Friendly Markets, did not allow their interns to provide immunizations. Since the majority of respondents worked for chain pharmacies, the inability to administer immunizations at these sites likely contributed to nearly 60% of students indicating that they had not administered vaccinations in the 9 months after they received the APhA training, and prior to the survey. Less than half the respondents (45%) agreed or strongly agreed that they felt capable of successfully obtaining reimbursement for providing immunizations. This may be an area for additional training that could be incorporated into experiential education components of the curriculum.
Pharmacists in NY have been on the front lines helping to save lives and reduce health expenditures since the passing of legislation allowing them to administer authorized and approved vaccines for COVID-19. 25 Further research related to pharmacy students providing vaccines should be undertaken. This could include: 1) a more detailed follow-up evaluation of the training program to identify potential areas for improvement, 2) follow-up assessment of the knowledge retained from the training once students graduate and become licensed pharmacists, and 3) continued evaluation of uptake of and barriers to student pharmacists as immunizers in various pharmacy practice settings.
The global impact of pharmacists as immunizers is being recognized as well, especially in low-and middle-income countries where there is an unmet need for vaccination services. 26 A recent benefit-risk analysis in Africa demonstrated that the benefit of receiving childhood immunizations for other infectious diseases (e.g., diphtheria, tetanus, pertussis, hepatitis B, Haemophiles influenzae type B, Streptococcus pneumoniae, rotavirus, measles, meningitis A, rubella, and yellow fever) far outweighs the risk of household death resulting from exposure to COVID-19 at a vaccination clinic. 27 Researchers concluded that routine immunizations must be continued as an essential service during the pandemic. Pharmacist immunizers around the world are vital to filling the gaps in providing vaccination services.
Limitations
A limitation of this study is that only 51.8% of eligible students completed the survey, and the perceptions of the non-respondents may be different. Another limitation is the absence of knowledge-based assessments to allow for comparison with student confidence scores. However, in order to obtain immunization certification, students must show competency in both IM and SC injection administration and pass a knowledge-based examination. Additionally, even though student confidence does not necessarily equate to competence, graduates who are confident in their immunization knowledge and skills will become graduates that are more likely to provide immunization services. 28 Furthermore, in our survey, several questions highlight the knowledge of each component that is part of the overall student immunization process. Of those who agreed or strongly agreed with all five statements in these questions, 83.3% agreed or strongly agreed with having the confidence to administer SC injections and 92.6% agreed or strongly agreed with having the confidence to administer IM injections, which was greater than the overall student population that completed the survey (58.2% and 91.5%, respectively). This indicates that more knowledge regarding immunizations leads to higher confidence. Regardless, student pharmacists’ knowledge-based assessments of immunization should be an area of future research as it is a critical skill for their career.
Moreover, even though the surveys were anonymous, voluntary, and administered with no incentives, a potential bias may have been introduced by students desiring to rate their abilities in a positive manner. The responses from the subjects at three different academic levels might have introduced some bias as the third-year student pharmacists attained more pharmacy learning experiences and patient encounters than first- or second-year student pharmacists. The survey tool was developed based on in-depth interviews with experts, a thorough literature review, and was pre-tested with a group of student pharmacists. However, it was not a previously validated tool nor was it tested for validity, thus limiting the confidence afforded by the results.
Conclusions
Student pharmacists’ perceptions about their ability to provide immunizations and the impact of APhA immunization training are positive, overall; however, more emphasis on SC vaccinations and methods of reimbursement may be needed. As the role of pharmacists as health care providers continues to evolve, so does the role of the student pharmacist. Student pharmacists should be able to take full advantage of the knowledge and skills that come with their clinical training. Continual evaluation and improvement of training along with legislative advocacy for student pharmacists are essential as the scope of pharmacy practice expands to improve patient outcomes.
Footnotes
Acknowledgments
We would like to thank all the student pharmacists who participated in the study.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors do not have a financial interest or affiliation with any organization that could be perceived as a conflict of interest in the content of this study.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
