Attitudes of Community Pharmacists towards Expanding their Prescribing Role: A Cross-sectional study

There is a growing international development in community pharmacists’ and authority prescribing role. Objective: The study assess the attitudes of community pharmacists toward expanding their prescribing role and to identify any contributing factors. This cross-sectional study was conducted in Jordan. A validated self-administered questionnaire addressing participants’ attitudes toward expanding the prescribing role of community pharmacists, the preferred model, barriers and training need was used. In general, 62.3% of community pharmacists exhibited neutral attitudes toward expanding their prescribing role, and 79.4% favored the supplementary prescribing model. The key drivers for expanding prescribing were a better use of community pharmacists’ skills (88.7%) and drug knowledge (79.4%). However, the most perceived barriers were inadequate training in patient assessment and monitoring (75%) and diagnosis of disease (73%). Female respondents had higher mean attitude scores (65.5± 6.79) than males (63.1± 7.89),(p= 0.021, t=2.321). Respondents with a Pharm .D degree had higher mean attitude scores (68.0 ±9.19) than those with a postgraduate degree (66.3±7.59) or those with bachelor of pharmacy (63.6±6.88, p= 0.010, F=4.709). Although overall attitudes of community pharmacists toward prescribing role were neutral, there were some gaps in their knowledge and skills. Community pharmacists, therefore, require further and urgent training in certain areas together with addressing the identified barriers.

Community pharmacists (CPs) have a unique position in the healthcare system, and their role is shaped by organizational, economic, and regulatory factors that may appear different worldwide 1-3 . Despite the differences in the pharmacists' responsibilities in different contexts, their primary duties include ensuring that a patient's drug therapy is managed appropriately and effectively, dispensing of drugs, and patient counseling 4, 5 .
A considerable body of evidence shows that pharmacists are moving from the traditional roles of only dispensing and counseling the medications to more advanced services and pharmaceutical care [6][7][8][9] . It is argued that there is a need to shift the pharmacy sector from productoriented to patient-oriented through the expanding of pharmacists' active role in patient-centered care, collaborative drug therapy management, and comprehensive medication safety systems 4, 10 .
The reviewed literature calls for expanding the access of healthcare delivery to all people around the world 11 . To this end, enabling healthcare professionals groups to prescribe with doctors was seen as a future strategy 12 . That is, prescribing authority for these groups including the pharmacists was considered a significant development in the global healthcare system, especially with the growing needs of patients and increased prevalence of chronic and infectious diseases 9, 13 .
It has become clear that expanding the pharmacists' roles can benefit patients and pharmacists alike, as it is expected to improve the quality of care to patients, reduce long-term healthcare costs, optimize drug therapy, and to increase access to healthcare services, thus providing higher quality of patient-centered care [14][15][16] . For pharmacists, expanding their role is expected to improve their professional status and authority leading to better utilization of their skills and knowledge, as well as increasing job satisfaction, self-confidence, and a reduction in physicians' workload 9, 17,18 .
Expanding the role of pharmacists according to their responsibility can be practiced in three key forms. The first form is the independent prescribing (IP), in which the pharmacist, who is the clinical management decision-maker, focuses on assessing conditions of diagnosed or undiagnosed conditions and without previous permission from other medical practitioners 19 . The second form is through supplementary prescribing (SP), which includes an agreed partnership between a doctor or dentist, a patient and a supplementary prescriber who, inturn, can prescribe within the patient's specific clinical management plan [20].The third form is the collaborative prescribing model, in which "a collaborative practice agreement between one or more physicians and pharmacists, that the qualified pharmacists working among the context of a defined protocol are permitted to assume professional responsibility for performing patient assessments; ordering drug therapy related laboratory tests; administering drugs; and selecting, initiating, monitoring, continuing, and adjusting drug regimens." 9 Internationally it seems that there is a disparity in the adoption of these models. One or more of these three models was/were implemented in the United States (USA), Canada, and the United Kingdom (UK) 12, 21 . In the UK, a supplementary prescribing model including pharmacists was adopted in 2003; after that, the independent prescribing model was implemented for the supplementary prescriber within specific criteria such as training, testing, and certification 17,22 . In the USA, pharmacists are involved with doctors in a collaborative drug therapy management model 9 .
In a less developed context, significant differences in the pharmacy profession appear to present compared to the developed ones. In Jordan, as in many Arab countries, pharmacists can prescribe medications listed as Over The Counter (OTC) medications 23 . The role of pharmacists in Jordan has been expanded over the past 20 years from merely dispensing and marketing of drugs to include more clinically-oriented roles 24 . In support of this transition, Jordan has established education programs specific to the pharmacy profession, such as a 6-year Pharmacy Doctor (Pharm.D) program and Masters programs in clinical pharmacy 24 . These programs imply a great emphasis on pharmacists' clinical roles and the expansion of their duties in Jordan 4, 25 .
To date, however, the available data on the expansion of CPs role using models of prescribing have mostly came from the developed countries 26,27 . Moreover, the literature about attitudes toward pharmacists prescribing and related factors in the Arab world is limited. Thus, decision and policy makers face a dilemma of a dearth data to enhance and expand future community pharmacists' role in prescribing. Given the differences in healthcare system, education, curricula, and population characteristics, the cross applicability to the community pharmacists in Jordan might have limitations. Consequently, this study aims to explore community pharmacists' attitudes toward their role in supplementary and independent prescribing as expanded roles of pharmaceutical professional practice in Jordan, and to identify the contributing factors for their attitudes.

Methods study design, setting and participants
A descriptive cross-sectional study was conducted in Amman, the capital of Jordan, during the period from December 2019 to March 2020 using a self-administered questionnaire. The highest number of community pharmacies in Jordan is located mostly in Amman 4 . Email permission was obtained from the first author, "kreshnikHoti", to use a previously developed questionnaire and carry out any revisions needed to suit the Jordanian context. Moreover, ethical approval for the study was obtained from the Faculty of Medicine and the Faculty of Graduate Studies at [X] University and subsequently from the Jordan Pharmacists Association (JPA). Eligible participants were licensed pharmacists working in community pharmacies in Jordan. Participation in the study was voluntary and was no risk involved to the participants.

survey development
The questionnaire to measure the attitudes of CPs toward expanding their role was developed based on Hoti et al.'s (2010)'s study 28 . The study explores the pharmacists' attitudes toward expanding their prescribing role in Australia with some modifications to suit the Jordanian target population and pharmaceutical health system. The questionnaire was administered in Arabic language since Arabic is the mother tongue for the CPs in Jordan. The translation from English to Arabic was done using the guideline for the Process of Cross-Cultural Adaptation of Self-Report Measures to ensure the translation equivalency and appropriateness of the questionnaire 29 . To ensure face validity, expert panels consisting of five expertshaving previous experience in pharmacy practice revised the author's modifications on the questionnaire. Accordingly, some question adjustments were made to the questionnaire to improve the validity and answer the research questions of the study.
1-Deleting the fourth statement in section four of the questionnaire, "Pharmacists should be able to prescribe for 30-day emergency supply, rather than current 3-day limit."This regulation was found only in Australia and not in Jordan, according to Jordan Pharmaceutical Association law No.51 of 1972 and Drug and Pharmacy law No.12 of 2013 30 .
2-Deleting statement number six in section five, "Potential for increased government cost." This is because the private sectors own all the community pharmacies in Jordan, and the government only owns public pharmacies in the governmental hospital 30 .
4-Deleting statement number four in section nine, "I believe medicines prescribed from an expanded role and consultations should be claimable from Medicare" as this statement is related to the national insurance system in public and private sectors in Australia and not applicable to Jordan 31 . Then, the researcher reviewed all the suggestions and integrated them into the pre-final version of the questionnaire.
The pre-final research questionnaire was pilot tested with a random selection sample of (n=30) of community pharmacists in the nine counties in Amman. The purpose of the pilot study was to make sure that: the statements were understandable, the language was simple and straightforward, determine the time needed for data collection, length of a questionnaire, and any difficulty faced when completing the survey. All the questionnaires at this stage were excluded from the final analysis of the main study. After piloting modifications were made in the questionnaire, the researcher tested the extent of the paragraphs' internal consistency depending on the pilot sample (n=30). The Cronbach's alpha value for the whole questionnaire was satisfactory (0.81).
The final version of the questionnaire consisted of 10 sections exploring various domains related to CPs' attitudes toward expanding their roles. The participants' responses to these sections used Likert scale answers,i.e."Agree," "Neutral," "Disagree,"in addition to Yes/no questions. The first section included questions sought to obtain respondents' demographic and job characteristics. The second section covered CPs' attitude towardexpanding pharmacy professional services and pharmacists prescribing, while the third section was related the CPs' attitude to their clients' reaction towardthe expansion of their prescribing role. The fourth section was about CPs' attitude to the drivers of expanding the CPs' prescribing role. The fifth section was about prescribing models the CPs' preferred. The sixth section was about the attitude of CPs' towardthe barriers of expanding pharmacist prescribing, with the section also containing two (yes/no) questions; the first to know if they thoughtCPs should have expanded prescribing rights, and the second one to know if the CPs wished to take an expanding role in prescribing. The seventh section contained two sub-sections for expanding prescribing using the supplementary model and the independent model. Under each subsection, a number of chronic conditions were listed.
The eighth section had one (yes/no) question to know if the CPs would need further training. If answered yes, a further three subsections followed, the first regarding six therapeutic topics they might need training in. The second subsection addressed training areas and the third subsection addressed training issues such as doctors' supervision, continuing education, specializing in clinical areas, and specialist registration. The ninth section concerned the CPs' attitude toward the implications of pharmacists prescribing on pharmacy infrastructure and, finally, the tenth section focused on the CPs' attitude to expanding their roles in the management of minor ailments.

sample size
The sample size was determined using OpenEpi, based on the total number of Jordan Pharmaceutical Association registered pharmacists in Amman during the time of this study, which was 11318 4 . The minimum sample size needed was 201; this was calculated to achieve 95% level of confidence and 5% marginal error. However, the researcher added 20% (n=44) on the minimum number and distributed randomly a number of 245 questionnaires; 14 pharmacists refused to fill in the questionnaire, with a response rate of 94.3%. Additionally, 27 questionnaires which had missing data were excluded from the statistical analyses. The final number of the analyzed questionnaires without missing data was 204.

survey implementation
The capital of Jordan, Amman is divided into nine counties, and the data were collected from these in proportion to the number of community pharmacies in each county. The researcher visited the selected pharmacies in person, through working hours of the day (i.e., day shifts), and during all days of the week. Based on the covering letter, the study's purpose and instruction were presented on the front page of the questionnaire to ensure that the same information was delivered to all participants. In addition, participants were informed that all information provided by them would be kept secret and be used only for research purposes.
Once participants agreed to participate verbally, the questionnaires were distributed to them to be filled out. During data collocation, participants were recruited with the aim of heterogeneity regarding gender, years of work experience, and age. The questionnaire took about 10 to 15 minutes to complete, was collected directly or dropped, and picked up later after being completed by the pharmacists who did not have time to fill it there and then.

statistical Analysis
Statistical Package for Social Sciences (SPSS) database for Windows version 23 was used for data entry and analysis. Any missing data were excluded from the analysis. Descriptive statistical analysis was used to summarize demographic data and responses to the questionnaires (frequencies and percentage for categorical variables, means and standard deviations were also calculated). The statistical t-test was applied to compare the means of Likert scale variables where the independent variables had two categories (e.g., gender and owner of the pharmacy). Analysis of Variance (ANOVA) was used to compare the means of Likert scale variables where the independent variables had more than two categories (Age, years of experience, highest degree achieved, and type of graduation country).In addition, the appropriate post hoc test, which is the least significant difference (LSD), was applied. A total attitude score was computed out of 100 to indicate the respondents' attitudes. The attitude scores were interpreted into three categories as follows: from 0 to 33.3 indicates a negative attitude, from 33.4 to 66.6 indicates a neutral attitude and from 66.7 to 100 indicates a positive attitude.

Results
The CPs mean age was 30± 6.95 years. A little more than half of the respondents were females (53.9%). Slightly half of the respondents were registered as pharmacists for less than five years (52.9%). About 78.4% of the respondents held a Bachelor's degree in pharmacy, 12.3% had bachelor's degree of Pharm.D and 9.3% had Masters or PhD (Table 1).
The results showed that 34.4% of the CPs agreed that the pharmacy profession needs to expand its scope of professional services.  (Table 3).
The analysis revealed the driving factors that would encourage pharmacists' prescribing. More than two thirds of CPs,77.0%, perceived expanded prescribing responsibilities to be a direction that the pharmacy profession should adopt to ensure an advanced role in healthcare. Respondents also highly agreed (79.4%) that they had the required drug knowledge that qualifies them to assume more prescribing responsibilities. Furthermore, 88.7% of CPs felt that prescribing will enable better use of pharmacists' professional skills, while 78.4% of the CPs demonstrated that expanding prescribing will increase the pharmacy profit, as shown in Table 4.
Inadequate training in diseases' diagnosis (if this was the pharmacist's responsibility) was the highest reported barrier to expanded prescribing amongst the CPs (73%). Similarly, 75% of the respondents agreed that pharmacists have inadequate training to assess and monitor patients. More than half of the CPs (52%) believed that expanding prescribing can lead to confusion regarding the GPs and pharmacists' roles from the public side, while 44.1% agreed that CPs may have a commercial interest in prescribing. Inadequate  facilities in pharmacies could be a barrier for prescribing as reported by 46% of CPs, while 65.2% viewed the increased potential of litigation as another barrier for expanding prescribing for pharmacists (Table 5). In relation to the above, when respondents were asked, "Do you think pharmacists should have expanded prescribing rights?" almost all of them answered "yes", 97.1%.
T h e o v e r w h e l m i n g n u m b e r o f respondents (97.1%), who answered yes to expanding pharmacists' prescribing, reported "Pain management" as the most chronic condition in which pharmacists should have an expanded prescribing role in the form of supplementary prescribing (83.3%). Most CPs (79.2%) mainly believed that pharmacists can prescribe a limited range of antibiotics using a supplementary prescribing model. Asthma and other respiratory conditions were the third common condition reported by respondents. In the form of an independent prescribing role, CPs showed a moderate agreement on expanding prescribing for conditions of pain management and antibiotics (61.6%, 52.5%), respectively.
The majority of CPs (91.7%) highlighted the need for more training to expand their prescribing role. Three areas were highly ranked as top training needs for expanding the prescribing role by the respondents: clinical pharmacology, the pathophysiology of conditions, physiological changes and drug response in different age groups. Additionally, the CPs agreed the need to be trained in the following areas: principles of diagnosis (72.1%), evidence-based practice (72.7%), principles and methods of patient monitoring (78.0%), and public health issues (70.5%). More than a third of CPs reported no need for a specialist registration at regulation bodies (43.3%) and no need for supervision by a medical practitioner (42.7%). Moreover, only 19.7% of CPs agreed with the need for training on "Demonstration of relevant Continuing Education that ensures their prescribing skills are kept to date". The majority of CPs (84.3%) believed that the current staff arrangements in the pharmacy can support expanded pharmacist prescribing. But 81.4% of them agreed on the need to create a separate quiet consulting area for pharmacist prescribing. Furthermore, 75% focused on pharmacists' need for an additional IT resource in the pharmacy to support pharmacist prescribing. On the other hand, only 40.7% of the respondents believed that pharmacists' independent prescribing should not occur in a community pharmacy ( Table   6).The results revealed that 62.3 % (n=127) of the respondents' total attitudes scores were higher than 33.4 and less than 66.6, which represents neutral attitudes, whereas 37.7 % (n=77) of the respondents' total scores were higher than 66.7 and less than 100, which is interpreted as a positive attitude.
The overall mean of respondents' attitude towardtheir expanding role in prescribing was 64.4 ±7.39. The attitudes of community pharmacists towardthe drivers for expanding prescribinghad  The results showed that the neutral attitudes of CPs were expressed towardthe domain of the reasons they believe pharmacists should not have expanded prescribing rights (58.30±14.66). Finally, among the neutral attitudes, the least score was for the domain of the way they see the future of the pharmacy profession (53.92±22.7) ( Table 7). The analyses of the relationship between community pharmacists' attitudes towardexpanding their prescribing roles and sociodemographic factors show that female respondents had higher mean attitude scores (65.5± 6.79) than males (63.1± 7.89). This difference was statistically significant (p= 0.021, t=2.321). Respondents with a Pharm. Ddegree had higher mean attitude scores (68.0 ±9.19) than those with a postgraduate degree (66.3±7.59) or those with Bachelor of Pharmacy (63.6±6.88). This difference was statistically significant using ANOVA test (p= 0.010, F=4.709) ( Table 9). LSD test showed that respondents with a Pharm.Ddegree hada more positive attitude than counterparts having a Bachelor of Pharmacy degree (P=0.005).

discussion
The aim of this cross-sectional study was to explore the attitudes of community pharmacists toward the potential implementation of pharmacist prescribing in Jordan. Our results find that the overall attitudes of CPs toward expanding their potential role in prescribing were neutral (62.3%). These results are largely inconsistent with the existing body of literature and, thus, need to be interpreted carefully within the national and international context. The results are in particular incongruent with a recent Jordanian study where it was found that the majority of pharmacists (92.5%) had positive attitudes toward the expanded prescribing role 32 . Similarly, the current results do not resonate with those emerged from a Qataristudy which found that the overwhelming majority of pharmacists,94.4%, reinforced the idea of expanding their prescribing role 33 . However, from a wider perspective, international studies from Australia, Scotland, and Nigeria showed more positive attitudes than the current study (83.9%, 97.7% and 97.1%, respectively) 13,28,34 .
This could be due to the fact that the current study focused exclusively on community pharmacists whilesome of the previous studies did not have such focus. For instance, in Nusair et al.'s (2020) study, the results reflected the attitudes of CPs in addition to hospital pharmacists 32 . Previous research found that hospital pharmacists focus more on knowledge of drugs and areas of laboratory tests than community pharmacists 35 . In addition, it was found that hospital pharmacists have attitudinal differences from the community pharmacists regarding drivers, barriers, and models of pharmacists prescribing 36 . Given the differences between hospital and community pharmacists in terms of training and policies, their attitudes toward prescribing roles might be shaped accordingly.
Another explanation for such differences might be attributed to the early introduction of the legislation in some countries supporting pharmacist prescribing, along with the training programs for expanding prescribing 12 . Therefore, pharmacists' attitudes can vary according to the different settings, legislations of the countries, and the nature of pharmacists' training.
However, it is noteworthy to mention that, while the overall attitudes in this study were neutral, the majority of respondents (97%) answered yes to the specific question "'Do you think pharmacists should have expanded prescribing rights?"This could imply a gap in the understanding of the expansion of roles by the CPs as they agree with expansion in general, but, when attitudestowardthese expanded roles in details are examined, neutral attitudes are more shown. Nevertheless, this finding raises questions about what might be carried out in the name of perceived prescribing role of CPs and calls for further research.
The current study showed that the majority of the community pharmacists prefer the adoption of the supplementary model (79.4%). This is similar to many previous studies where pharmacists preferred the supplementary model, and in particular over the independent model 13,32,37,38 . However, to some extent, it could be challenging to make comparisons between these studies, in that the available evidence reports attitudes of combined groups of non-medical prescribers such as nurses, pharmacists and allied healthcare professionals, which could have led to different results than our findings. However, to some extent, the agreement on the supplementary model among the population of this study fits well with the overall neutral attitudes of community pharmacists regarding their prescribing role and the uncertainty they might perceive regarding their ability to be independent prescribers. In other words, community pharmacists in the current study might be more comfortable to work with a supplementary model that still depends on the doctor's shared advice as opposed to the independent prescribing model. Furthermore, the current study results are consistent with Jebara's (2019) framework for the development of pharmacists prescribing in Qatar. The study found no support to implement an independent pharmacists prescribing model in Qatar due to concerns over pharmacist diagnosis skills and the relative immaturity of pharmacy practice 39 . These results could be beneficial to the Jordanian context due to many similarities in education, culture, and people. Nevertheless, the supplementary model could be a starting point for a more advanced future independent model. For example, the successful UK model for pharmacists prescribing started with supplementary prescribing in 2003 as a foundation stone for implementing an independent model in 2006 14,40 .
It should be noted in this study that about 83.3% of CPs strongly agreed to the supplementary prescribing of chronic pain management. This postulates that CPs in the current study might be keener to expand their prescribing role to address pain management and minor infections as opposed to more severe and chronic cases. This is in line with the rules and regulations in Jordan, which emphasize that prescribing by pharmacists needs to be limited for minor conditions only, such as minor infections, cold, fever, pain, and prohibits pharmacists prescribing for more severe chronic conditions 41 In this study, CPs perceived customers to trust pharmacists as prescribers. It is worth mentioning that literature from Jordan also documents that many Jordanian patients are willing to practice self-medication and purchase medications, particularly antibiotics, from pharmacies without prescriptions due to the socioeconomic factors and to save time and cost 42,43 . These arguments are substantiated by the current results, where 65.2% of pharmacists believe that customers would have safer access to their medication if pharmacists were prescribers, which could decrease the practice of self-medication in Jordanian society.
In light of the above, and to understand how community pharmacists in Jordan can activate their prescribing role in the future, contributing barriers need to be uncovered. The majority of respondents (91.7%) expressed their needs for further training. The areas of training in expanding the prescribing role included clinical pharmacology. Previous studies in Jordan and Qatar showed similar findings 32, 33 . However, others believe that a lack of training in prescribing reflects the fact that pharmacists traditionally have no role in clinical diagnosis and treatment 12 .
The problem, as it seems in this study, is that respondents perceived inadequate training in patients' assessment skills (75%) and diagnosis of diseases (73%) as the mainbarriers for pharmacists to adopt a prescribing role, which is similar to previous researches 13,28,32 . Therefore, there is a need to focus on developing and accessing new teaching systems, including workshops and computerized simulations to match the training needs of CPs in clinical pharmacology, medical diagnosis, and assessment.
The relationship between specialized programs, training, and community pharmacists' attitudes toward prescribing was evident in our study. It was found that respondents with a 6-yearPharm.Ddegree hold more positive attitude than other counterparts who have a 5-yeardegree (Bachelor of Science in Pharmacy) (p= 0.010, F=4.709). This might be because a Pharm.D. program is more supportive for the adoption of expanding pharmacists prescribing because it fundamentally emphasizes pharmaceutical care that includes patient care and clinical pharmacy than the BSc.in Pharmacy program [44,45]. In light of the above discussions, the study showed that community pharmacists are keen to adopt a supplementary prescribing role. Enabling such a role in daily contact with the community can be seen as the first step on the ladder of pharmaceutical reform. This is, however, not a straightforward objective to achieve.
Changing policies of pharmacists prescribing by focusing on integrating community pharmacists into primary care services, developing a vision for different levels of pharmacist services, and developing new remuneration schemes for these services is required. Therefore, it would be beneficial to explore other stakeholders' attitudes toward expanding of pharmacists prescribing. Finally, qualitative research and mixed-method approach in the future is needed to uncover pharmacists' experiences toward the prescribing role in greater depth. The emerging data from the current study might be used to guide such approach.
While this study offers wide insights into how CPs perceive their future expanding role in prescribing, it suffers from some limitations. The study results are exclusively based on the perspectives of community pharmacists. The study sample was from the capital Amman, which may differ from other remote areas in Jordan in terms of sociodemographic characteristics and community pharmacies' distribution. However, Amman contains the highest density of community pharmacies in Jordan, and, thus, it is hoped that the results could be used as a springboard for guiding future prescribing policies and stimulate further international debate in this largely unexplored area.

conclusion
The study provides essential insights into community pharmacists' attitudes toward expanding prescribing role and those contributing factors. Although CPs showed strong agreement for expanding their future prescribing role, the overall attitudes were neutral. CPs were also in favor of a supplementary prescribing model compared to other models, such as an independent model. Pharmacists' competent skills and knowledge to prescribe, increasing the pharmacy profits, and the perceived trust by their clients were the main drivers for their future expanding prescribing. However, in reality, the lack of training in the diagnosis and patient assessment, increase in the likelihood of litigation, and the absence of a consultation room might inhibit adopting expanding prescribing role in Jordan. The data can provide evidence to regulatory bodies such as Jordan Pharmacists Association and Jordan Medical Association and Stakeholders of healthcare services and policies to reform pharmacies within the community toward an expanded pharmacist prescribing role. This cannot be achieved unless barriers uncovered in this study are well-understood and addressed in the future reform strategy for community pharmacists' expanded role in prescribing.