Original Article

J Oncol Pharm Practice

0(0) 1–8
Clinical pharmacy services in an ! The Author(s) 2020
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ambulatory oncology clinic: Patient sagepub.com/journals-permissions
DOI: 10.1177/1078155220950412
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Lauren Munro, Glenn Myers , Odette Gould and

Michael LeBlanc

Abstract
Introduction: Studies have shown that patients rate pharmacists more favourably when the pharmacist expresses
interest in the patient and attends to patients’ perspectives. There is limited available evidence evaluating both patient
perception and satisfaction regarding clinical pharmacy services provided in an ambulatory oncology clinic.
Methods: This was a prospective mixed methods study involving surveys and patient interviews. Consenting partic-
ipants completed a survey at their first visit evaluating their perceptions of the importance of the clinical pharmacy
services offered in the ambulatory oncology clinic. They completed a second survey 6-8 weeks later to re-evaluate their
perceptions and to measure satisfaction ratings. The final component of this study involved semi-structured one-on-one
telephone interviews to gather qualitative data regarding the study objectives.
Results: A total of 35 participants completed the survey, of which eleven completed one-on-one patient telephone
interviews. Patients perceived the clinical pharmacy services assessed as important to their care before receiving
treatment. The ratings of the importance of the pharmacist in managing patients’ nausea/vomiting significantly decreased
when remeasured, whereas the importance of meeting the pharmacist in the clinic significantly increased. The impor-
tance of the role of the pharmacist was highlighted in patient interviews as well: patients particularly valued the
pharmacist’s initiative to meet them in the clinic, the education provided by pharmacist, and the pharmacist’s accessibility
throughout treatment.
Conclusions: Overall, patients in the ambulatory oncology clinic perceived the services offered as important to their
care and they were highly satisfied.

Keywords
Oncology pharmacists, clinical pharmacy services, patient perception, patient satisfaction
Date received: 6 July 2020; accepted: 27 July 2020

Introduction care.1 In addition to meeting these standards of prac-

Cancer is a common disease with considerable morbid- tice, oncology pharmacists are increasingly providing a
ity and mortality. In 2017, an average of 565 Canadians patient-focused approach to pharmaceutical care for
were diagnosed with cancer each day. Due to the tre- individuals with cancer and it is important to under-
mendous impact of this disease, there is a substantial stand patients’ perspective of the role of an oncology
demand for cancer care resources and the complexity
of health needs for these patients requires increased
planning and development of multidisciplinary health
services.1,2 Horizon Health Network, Moncton, New Brunswick, Canada
As part of the multidisciplinary team, oncology
Corresponding author:
pharmacists are using standards of practice to guide Lauren Munro, Horizon Health Network, 700 Priestman St, Fredericton,
the provision of pharmaceutical care and to set a NB E3B 5N5, Canada.
benchmark for evaluation of services and patient Email: [email protected]
2 Journal of Oncology Pharmacy Practice 0(0)

pharmacist in order to validate and expand the services Objectives

provided.
The primary objective of this study was to evaluate
It has been shown, in a variety of oncology settings,
which clinical pharmacy services are perceived to be
that there is an association between a patient’s level of
important to patients in the ambulatory oncology
satisfaction with service quality and survival out-
clinic at the Moncton Hospital. Secondary objectives
comes.3–6 Patients who are more satisfied with their
care are also more likely to adhere to their treatment included (a) Comparisons of patients’ perception of the
plan.7 Specific to pharmacists, it has been shown that clinical pharmacy services that are most important
patients rate pharmacists more favourably when the before starting treatment to their perception after
pharmacist expresses interest in the patient, strives for receiving care and (b) Evaluations of patients’ level of
consensus on common goals, and attends to patients’ satisfaction with the clinical pharmacy services provid-
perspectives.8,9 ed through the clinic.
There is limited available evidence specifically eval-
uating patient perception and satisfaction regarding Methods
clinical pharmacy services provided in an ambulatory
This prospective mixed methods study collected quan-
oncology clinic. One recent study has shown that
titative and qualitative data over a three-month period
patients value services offered by clinical pharmacists
from December 2017 to March 2018. The research
in this setting.10 This study involved surveying patients
study was approved by the Research Ethics Board of
at their initial chemotherapy treatment regarding their
satisfaction with a face-to-face education session Horizon Health Services as well as the Mount Allison
with the pharmacist, as well as a proactive telephone University Research Ethics Board in December 2017.
follow-up call they received 3–7 days later. Another Participants provided written informed consent to par-
survey-based study showed that patients believed it take in the study.
was absolutely necessary to meet with the pharmacist Eligible participants included new patients to the
during their cancer care and that they wished to visit ambulatory oncology clinic at the Moncton Hospital
with the pharmacist regularly while undergoing who were 19 years of age and older. Patients needed to
chemotherapy.11 be starting either parenteral and/or oral anti-cancer
An important component in evaluating the quality therapy through the clinic for the first time.
of health care services is to consider the patient’s per- Surveys were available in both English and French
spective, in addition to their level of satisfaction. and included questions adapted from previous research
Patients compare their experience with their prior as well as questions designed specifically for the pur-
expectations, therefore, their level of satisfaction is poses of this study. The initial survey consisted of eight
dependent on whether the experience was superior to, patient demographic questions (age, gender, education,
inferior to, or the same as the expectations.12 type of cancer, type of cancer treatment, experience
Given the paucity of data evaluating which clinical with hospital and community pharmacists, and past
pharmacy services are important to patients in an experience with the oncology clinic). Next were 12
ambulatory oncology clinic, the present study aimed items using a visual analog scale to measure the
to assess the value patients place on the role of the patient’s expectations. The first two items measured
clinical pharmacist and the services provided both the perceived overall importance of the pharmacist in
before and after receiving oncology pharmacy services. the cancer treatment, and the importance of meeting
As recommended in the literature, a survey tool was with the pharmacist. The subsequent 10 items mea-
designed to evaluate patient satisfaction, as well as sured the perceived importance of the following phar-
patient expectations, specifically assessing the types of macy services: medication review (oncology, general,
services provided by the pharmacist.11,13 This study OTC), education (oncology medication, cancer diagno-
also incorporated one-on-one telephone interviews to sis, side-effects), follow-up (side-effects, anti-nausea
more deeply explore patients expectations and satisfac- adjustments, other side-effects), and ease of contact.
tion with the clinical pharmacy services provided in the The second survey was disseminated approximately
clinic. six to eight weeks after the first at a follow-up clinic
As the pharmacy profession continues to grow and visit. Patients were first asked whether they recalled
shape its role in the health care system, clearly under- meeting with a hospital pharmacist in the oncology
standing the role of the pharmacist from the patient’s clinic. The same visual analog scale was then used to
perspective could help optimize patient care out- re-measure patients’ perception of the importance of
comes.14 This understanding could also allow for allo- the pharmacy services. For each service, a 7-point
cation and prioritization of pharmacy services that are Likert scale was added to measure patients’ satisfaction
the most impactful from the patient’s perspective. with the services provided. When developing the
Munro et al. 3

surveys, a group of volunteers at the oncology clinic Patient responses to the questions evaluating their
helped to assess the clarity of the questions and the face level of satisfaction were measured using a 7-point
validity of the tools. Likert scale ranging from very dissatisfied to very sat-
Eligible patients receiving treatment at the oncology isfied. One-sample t-tests were used to determine
clinic were offered the opportunity to participate in the whether average ratings differed significantly from the
study. Upon meeting the patient, the pharmacist neutral point in the scale.
described the study and ensured that the patient under- Analysis of the data collected through patient inter-
stood that participation was completely voluntary and views was completed by two researchers who worked
refusal would not have any effect on the care received independently to identify themes in the interviews. This
through the clinic. The pharmacist left the patient with was followed by extensive discussion to identify global
a detailed consent form, the initial survey and a manila themes that organized, united and summarized the
envelope and allowed the patient time to complete the lower-order themes. Further discussion by the entire
survey independently. The patient was instructed to research team led to the development of a model that
place the survey in the envelope whether they decided highlighted the inter-relationships between the global
to participate or not to ensure that the pharmacist themes through the lens of clinical pharmacy services.
involved was blind to the patient’s decision. As a final step, the original transcripts were reviewed
The initial survey was open for eight weeks in total once more by the main author to confirm the validity of
to recruit as many eligible individuals as possible. The the themes and to identify quotations used for data
second survey was also offered for eight weeks to col- presentation.
lect follow-up data after the patient had received care.
The final component of this study involved patient Results
telephone interviews. On the initial consent form, the
patient had the opportunity to consent to participation Patient demographics
in a short one-on-one telephone interview during the
A total of 44 participants completed the initial consent
follow-up phase to gather qualitative data regarding
form and survey. Of these, 35 subsequently completed
the study objectives. The patient was asked to provide the follow up survey. Nine patients were lost to follow
a telephone number for the interview on the consent up due to various reasons including six who did not
form, thus negating the need to access the patient’s receive treatment in the six to eight week time frame,
personal information from the clinic chart. one individual who passed away and two patients who
The same set of guiding questions were used for all declined consent to complete the follow up survey.
interviews. Patients were asked (a) their perception of Of the 35 participants included in the study, 30 con-
the role of hospital pharmacists before their treatment sented to the telephone interview during the follow-up
began and (b) how this perception changed during their phase. Eleven interview participants were randomly
treatment, (c) to describe times when the pharmacist chosen from these eligible candidates.
was particularly helpful, (d) to describe times when The average patient age was 61 years old and
they wished the pharmacist had provided more serv- approximately 54% were female. The most commonly
ices, and (e) to describe what they would tell a new reported diagnosis was breast cancer (29%) followed
patient about the role of the pharmacist in oncology closely by gastrointestinal cancer (26%). The vast
care. Patients were also able to add further comments majority of patients did not recall past experience
about pharmacy services if they wished. with a hospital pharmacist but did report having a reg-
ular community pharmacy and/or pharmacist. Patient
Statistical analysis demographics are further outlined in Table 1.
Descriptive statistics were used to summarize demo-
graphic information of study participants. For all Importance of clinical pharmacy services
items using an analog scale, patients were instructed The results of the initial survey indicated that the per-
to mark an X on a 10 cm line anchored by “not at all ceived importance of each of the services evaluated was
important” and “very important”. The response was significantly higher than the midpoint on the visual
coded as the distance between the “not at all analog scale at both Time 1 and Time 2 (p< .01), as
important” anchor to the middle of the X to the nearest shown in Figure 1. At Time 1, the highest ranked ser-
millimeter. Change in ratings between the first and vice was the importance of the pharmacist to review all
second survey were evaluated using a series of repeated current medications to make sure they were safe with
measures t-tests. A critical alpha of p ¼ 0.01 was used the cancer medications (M ¼ 9.19; SD 0.83). The lowest
to correct for the large number of tests. ranked service was the importance of the pharmacist in
4 Journal of Oncology Pharmacy Practice 0(0)

Table 1. Baseline characteristics.

Age (years; mean (SD)) 61.34 (10.91)

Gender (%) Female 54.3%

Male 45.7%
Education (%) Post-secondary 57.1%
High school 40%
Junior high school 2.9%
Cancer diagnosis (%) Breast 28.6%
Gastrointestinal 25.7%
Hematological 17.1%
Lung 17.1%
Genitourinary 2.9%
Other 8.6%
Route of treatment (%) IV 80%
PO 2.8%
IV and PO 8.6%
No response 8.6%
Past experience with hospital pharmacist (%) Yes 22.9%
No 74.3%
No response 2.9%
Past experience with this ambulatory oncology clinic (%) Yes 22.9%
No 71.4%
No response 5.7%
Regular community pharmacist/pharmacy (%) Yes 77.1%
No 17.1%
No response 5.7%

p < 0.01 p < 0.01

10
9
8
Importance (Mean)

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3
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Pre-treatment Post-treatment

Figure 1. Importance of clinical pharmacy services before and after treatment.

providing education regarding the cancer diagnosis treatment. The highest ranked service at Time 2 was
(M ¼ 7.93; SD 2.37). the importance of the pharmacist to review the
At Time 2, 82.9% of patients recalled speaking to a patient’s cancer medications for appropriateness
pharmacist in the oncology clinic since they began (M ¼ 9.17; SD 0.62). The lowest ranked service was
Munro et al. 5

the importance of the pharmacist in providing educa- that and helped me to understand what was going on and
tion regarding the cancer diagnosis (M ¼ 7.56; SD things”.
2.50).
The rated importance of only two pharmacy services Accessibility. Patients appreciated being able to commu-
changed significantly from the first to the second nicate with the pharmacist when needed, and particu-
survey: (a) the importance of meeting the pharmacist larly noted the use of multiple means of
in the oncology clinic significantly increased from the communication such as telephone calls and email
initial survey to the second survey [t(33) ¼ 2.74, responses. (“[He] was actually there for us and he’ll
p ¼ 0.01], and (b) the importance of the pharmacist actually communicate quite quickly with me if I have
aiding in the adjustment of anti-nausea medications any questions. He’s there even for emails. That was
decreased from the first to second survey [t(28) ¼ one thing [. . .] we mentioned over and over that we
3.04, p ¼ 0.005]. Further comparisons between average were really pleased that he was there for us.)”
ratings from the first and second survey are highlighted
Support. The accessibility of the pharmacist allowed the
in Figure 1.
patient to feel supported by the pharmacist, which
helped them feel comforted and reassured during
Patient satisfaction their treatment. “[He was] very informative, very
The second survey evaluated patient’s satisfaction level friendly, very professional. And acted like he always
for each of the clinical pharmacy services assessed. An has an open door”).
additional question inquired about the patient’s satis-
faction with the oncology pharmacist’s ability to Utilization of pharmacy services during cancer treatment.
answer questions. Overall, patients were very satisfied Patients discussed the importance of the pharmacist’s
with the services with means ranging from 5.97 to 6.70, role in medication and dose adjustments to manage
out of a possible 7, with all ratings found to be signif- side effects and sequelae from cancer treatment. (“and
icantly above the neutral point of the scale. The service I did end up getting shingles during [. . .] my second
with the highest mean of satisfaction was the education [treatment and he] answered all the questions and was
able to put me on the right track and change
received regarding cancer medications and the service
medications”)
with the lowest mean of satisfaction was the education
Figure 3 is a visual representation of these five
received regarding the cancer diagnosis. Average rat-
themes and the relationship that exists between them.
ings of the patient satisfaction scores are outlined in
Support is at the core and is intricately linked to all the
Figure 2.
other themes identified. Patients feel supported as a
result of the initiative shown by the pharmacist in pro-
Qualitative analysis viding a contact from the first clinic visit, and contin-
The interview data were analyzed by two research team ued education and easy access throughout the process.
members to determine common themes in the This support leads to patients not only having access to
responses. The following five themes were identified continued services throughout their oncology treat-
through this process. ments, but also results in patients’ willingness to be
educated about their medications, and to seek pharma-
Initiative. Patients consistently stressed the importance cy care when needed.
of meeting the pharmacist in the oncology clinic, and
highly valued the initiative of the pharmacist to meet Discussion
them face-to-face before their treatment began, as well Overall, patients about to receive anti-cancer therapy in
as the pharmacist’s physical presence in the clinic the ambulatory oncology clinic expected all pharmacy
during subsequent treatments. (“At our first visit he services listed on the survey to be important in their
just came and sat down with us”). care, and six to eight weeks later they continued to rate
both importance and satisfaction with these services
Education. This theme was discussed in terms of medi- very highly.
cation counselling but patients also highlighted the It has been shown that a positive relationship
importance of the pharmacist’s role in reviewing the between patients and their oncology pharmacist leads
overall process in the clinic allowing them to prepare to reduced symptoms of distress and increased overall
psychologically for the treatment and to form realistic satisfaction.14–16 The results of the qualitative analysis
expectations. (“I found that she [. . .] had a lot of infor- presented here propose mechanisms for how increased
mation and you know, told me things I didn’t know and patient satisfaction may be linked to positive
6 Journal of Oncology Pharmacy Practice 0(0)

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Satisfaction (mean)

Figure 2. Patient satisfaction with clinical pharmacy services.

Initiative
(First contact by Pharmacist)

• 1:1 interaction
• Time spent with patient
• Physical presence

Education Accessibility

• Medication information • Open communication

• Process overview • Open door
• Expectations Support • Multiple mediums
• Availability between treatments

• Reassurance
• Comfort/Ease

Utilization of
Pharmacy services
• Medication changes/adjustments
• Responses to inquires
• Quick and consistent responses

Figure 3. Visual representation of the five common themes identified and the inter-relationships that exist between them.

relationships with oncology pharmacists: the sense of To the authors’ knowledge, the present study is
being supported by the pharmacist may not only unique in that it aimed to evaluate the patient’s level
enhance emotional well-being but also improve the of satisfaction with the clinical pharmacy services pro-
quality of care received if patients communicate with vided in addition to investigating patients’ change in
pharmacists regarding emerging issues and are more perception of the pharmacist’s role before receiving
adherent to recommended pharmaceutical treatments. care to after receiving care. This information allowed
Munro et al. 7

for a deeper understanding on the true importance of attitudes. It would also be interesting to evaluate sim-
specific services. ilar outcomes from the caregiver perspective as many
We expected that the ratings of the importance of of these oncology patients have an invested support
clinical pharmacy services would increase significantly system involved in their care.
over time. We also expected this change to be partic-
ularly large for services such as supportive care
management for nausea and/or vomiting, as well as
Conclusion
on-going monitoring since the general public may not Overall, patients in the ambulatory oncology clinic per-
expect these to be part of a pharmacist’s scope. ceived all of the clinical pharmacy services evaluated as
Interestingly, a different pattern of results was found. important to their care and they were highly satisfied
Ratings of the importance of the different services with the services provided. The importance of the phar-
remained consistently high. However, the perceived macist’s role in side effect management was less impor-
importance of the pharmacist’s role in the management tant than initially expected by patients, but the
of nausea and vomiting decreased significantly from importance of meeting the pharmacist in the clinic
pre-treatment to the 6th week of treatment. It is possi- was significantly more important.
ble that this finding is due to public perceptions that The relationship initiated by the pharmacist allowed
these symptoms will be the most debilitating during patients to receive medical information and provided
chemotherapy. Improved tolerability of modern them with an accessible and reliable contact at the
cancer medications combined with a focus on preven- clinic. This relationship also provided them with reas-
tative measures may have alleviated patient distress surance and support to help them through their treat-
such that patients experienced much less distress than ment and was an important component of their care.
they expected.
Patient ratings of the importance of meeting with Acknowledgements
the pharmacist in the clinic significantly increased on
The authors thank Sarah St. Pierre for her aid in data entry
the second survey. This result duplicates findings from
and interview transcriptions.
previous literature on the topic.11 This sentiment was
also reiterated during the patient interviews as
Declaration of Conflicting Interests
described above.
Repeatedly, the service that was ranked as least The author(s) declared no potential conflicts of interest with
important was the education provided by pharmacists respect to the research, authorship, and/or publication of this
about the cancer diagnosis. This could indicate that article.
there is a limit to the type of information patients
expect the pharmacist to discuss and that they expect Funding
other health care professionals, such as their oncologist The author(s) received no financial support for the research,
or nurse, to focus on this type of information. authorship, and/or publication of this article.
The strengths of this study include the mixed meth-
ods design that incorporates both quantitative and ORCID iD
qualitative data. This combined with the use of two
Glenn Myers https://orcid.org/0000-0002-5239-4350
times of measurement allowed for a more comprehen-
sive understanding of the patients’ changing
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