Strengths and limitations of this study

The roles of community pharmacists during the closure stage of COVID-19 were explored in an in-depth manner using qualitative case study research methods.

Data may predominantly reflect certain regions of the province of Newfoundland and Labrador, Canada and may not be transferrable to other jurisdictions.

The perceived burden of COVID-19 at the time of the interview may have influenced the reflections provided by the community pharmacists.

Introduction

The global outbreak of COVID-19 led to unprecedented closures of community health centres as well as non-essential services (eg, restaurants, hair salons, gyms) to reduce the transmission of the novel coronavirus and pressure on the healthcare system.1–3 Unlike acute care centres, which have well-established pandemic preparedness plans, primary healthcare (PHC) providers (eg, family physicians, nurse practitioners, pharmacists) faced tremendous uncertainty about how to sustain the delivery of PHC services in the early days of the COVID-19 pandemic. Historically, pandemic preparedness plans have concentrated on acute care and creating surge capacity in hospitals, tailored for geographically specific or time-limited events.4 5 However, these plans fail to account for the need to support and maintain PHC services, which became particularly evident given the essential role of PHC services in ensuring continuity of care. Continuity of care has been defined as the relationship between a provider and patient that exists beyond a specific episode of illness, involving coordination and communication to facilitate patient care.6 It is rooted in providing high-quality care over time for individual patients by one or more healthcare professionals.6

PHC in the province of Newfoundland and Labrador (NL) is delivered by a multidisciplinary group of providers working in various settings, including primary care clinics, community health clinics, public health clinics and community pharmacies.7 Primary care clinics in the province include those that are funded by the Provincial Health Authority (PHA) (ie, the publicly funded health service provider in the province of NL) and privately run practices by family physicians and nurse practitioners (NP).7 Clinics run by the PHA are typically colocated with other PHC services, including public health (ie, health initiatives focused on the health of the entire population) and community health (ie, health initiatives focused on the health needs and concerns of particular communities or groups)8; these clinics are primarily physician-led except for some rural and remote areas of the province, which are predominately staffed by registered nurses (RNs) with support from visiting locum physicians.7 Whereas, privately owned primary care physician (PCP) clinics operate independently and are funded under a fee-for-service model via claim submission through the provincial medical care plan.7 On the other hand, community pharmacies and NP clinics operate entirely as private businesses,7 with few services funded by the government. The majority of residents of NL have access to primary care services; however, the number of those without access to a PCP is growing.9 Residents who do not have access to a PCP or NP often rely on emergency departments that operate low-acuity Fast Track Clinics,10 the provincial health line (ie, 811) or community pharmacies for non-urgent care (eg, prescription refills, chronic disease management, management of cold or influenza symptoms).

In NL, community pharmacies provide a range of pharmacist-delivered PHC services, including pharmaceutical care and medication dispensing, immunisation, acute management of common ailments, drug information, and screening and monitoring for chronic disease.11 In regions lacking access to emergency medical facilities or where PCP or NP waiting times are significant, patients frequently seek non-urgent healthcare services from local community pharmacies. This is particularly common in rural areas of the province that are not regularly staffed with a PCP.11 As such, community pharmacists play a pivotal role in sustaining continuity of care, frequently serving as the primary or sole healthcare provider in some areas of the province.11

At the beginning of the COVID-19 pandemic, there was a scarcity of published studies examining the roles of community pharmacists in pandemic response efforts. Like other primary care providers, pharmacists lacked guidance on their roles and responsibilities during a global pandemic. There were no provincial guidance documents or pandemic preparedness plans available to community pharmacists. The only document available in the early days of COVID-19 was a guideline published by the International Pharmaceutical Federation (FIP) titled, ‘COVID-19: Guidelines for pharmacists and the pharmacy workforce’ which provided guidance on measures to reduce infection, patient isolation and referral, diagnostic testing and immediate roles pharmacists could play to support public and patient safety during COVID-19.12 At the time, there was limited understanding of the extent to which the FIP guidelines could be implemented in NL. Therefore, it should come as no surprise that in the absence of clear guidance and pandemic preparedness plans, specifically tailored to the role of community pharmacists in sustaining continuity of care and supporting the PHC system during a pandemic, community pharmacists were left to figure out how to adapt their roles to help support their patients during the pandemic. This knowledge gap was important to address and served as the motive behind our study, which aimed to describe pharmacists’ roles during the COVID-19 pandemic in NL and to identify the supports and barriers that facilitate or hinder pharmacists’ performance in these roles.

In this paper, we explored the experiences of community pharmacists during the closure stage of the COVID-19 pandemic in the Canadian province of NL. More specifically, we aimed to (i) describe the roles of community pharmacists in delivering PHC services and (ii) describe the facilitators and barriers to enacting these roles. This study is part of a larger programme of research that aims to understand the proposed, actual and potential roles of primary care providers (PCPs, NPs, RNs and pharmacists) in NL and to integrate findings into a pandemic preparedness plan for PHC delivery in the province.

MethodsStudy design

Situated within the paradigm of pragmatism13 and drawing on the case study methodology described by Yin14 and Merriam,15 we used a single embedded case study design that included a document analysis, semistructured interviews and reflexivity. The document analysis facilitated the development of a chronology document (see online supplemental appendix A). The chronology document described key milestones during the COVID-19 pandemic, regulatory changes to pharmacy practice during the same time period and proposed roles for pharmacists during each pandemic stage, as described in government, health system and pharmacy professional bodies documents. Semistructured interviews provided an in-depth understanding of the experiences of community pharmacists during the COVID-19 pandemic, including any new roles they undertook during the closure stage of the COVID-19 pandemic and barriers and facilitators to these roles. Researcher reflexivity was used to enhance the study’s rigour and enable a comprehensive exploration of the case. By embracing reflexivity, we acknowledged and documented the researchers’ subjectivity, providing understanding into its impact on study decisions (see researchers and positionality in online supplemental appendix B).

Study period

This paper is specifically focused on the period of the COVID-19 pandemic from 18 March to 15 May 2020, which we have defined as the ‘Closure Stage’ in accordance with the COVID-19 chronology proposed by Mathews and colleagues.16 The closure stage is defined as the time period when many public services, including some healthcare services, were closed to the public. During this time, the provincial Chief Medical Officer of Health (CMOH) deemed all retail services that provide food and medicines essential services. As such, community pharmacies, due to their pivotal role in providing access to essential health products (eg, medicines, devices), remained operational and were open to the public with appropriate social distancing measures in place. However, PCP and NP clinics were advised to cease non-urgent or emergent services and operate using virtual modes of care.

Sampling and recruitment

Pharmacists were eligible to take part in this study if they were licensed to practice pharmacy in NL and worked in a community pharmacy setting during the COVID-19 pandemic. A variety of purposive sampling techniques, including maximum variation sampling and snowball sampling, were used. Maximum variation sampling was used to capture a variety of perspectives and ensure diversity17 across a broad range of characteristics, including age, gender, years of practice, location of practice and type of pharmacy. Given the small number of community pharmacists practising in NL (ie, approximately 600),18 snowball sampling helped to facilitate the identification of participants with some of these specific characteristics. Multiple strategies were used to recruit participants, such as social media (ie, private Facebook groups), email and telephone; interested pharmacists were asked to reach out to researchers via email. Following each interview, participants were asked to suggest other community pharmacists who could provide valuable perspectives. Recruitment continued until community pharmacists’ perspectives were well represented and data saturation14 was achieved. Data saturation was determined when no new themes, categories or insights emerged from the data.14 Participants were offered a $75 Amazon gift card as an honorarium for their participation in a research interview.

Patient and public involvement

Patients and/or the public were not involved in the design or conduct of this research.

Data collection

Semistructured interviews with community pharmacists occurred between February and August 2022. Designated team members (SF, TAL and JRD) completed interviews virtually in pairs on Zoom (ie, virtual conference or call-in). Prior to the interview, participants were provided with a copy of the chronology document (see online supplemental appendix A) to help with the recall of major events during the COVID-19 pandemic. As per the interview guide (online supplemental appendix C), interviewers asked participants for some key demographic information and provided participants with a brief description of the pandemic stage. Participants were then asked to describe their roles, and the facilitators and barriers that may have impacted their ability to enact these roles during each stage.

The interviews lasted 60 to 120 min (averaging 86 min) and were audiorecorded and then transcribed verbatim using NVivo V.12 by the first author (SF). All transcripts were reviewed for accuracy and in accordance with Jeffersonian transcribing conventions.19 After each interview, the interviewers engaged in reflective writing and later reconvened to debrief and discuss the interview and their reflections. Additionally, the first author (SF) maintained a reflexive journal throughout the study. Using these reflections, researchers were able to adapt the interview guide, avoid leading questions and improve rapport with participants.

Data analysis

For data analysis, we used the applied thematic analysis approach described by Guest and colleagues.20 Recurring ideas and codes were identified by SF, TAL and JRD inductively and independently. The research team collectively verified the coding through debriefing meetings and discussion. Data grouped under the same code were organised into categories, which were subsequently reviewed and condensed into potential themes.20 21 Themes were then developed collaboratively and finalised by the research team.20

Results

We conducted interviews with 12 participants, including five men and seven women. Our participants had been practising for an average of 15.6 years, with four pharmacists practising in rural communities. Other demographic characteristics are outlined in table 1.

Table 1

Participant demographic characteristics (n=12)

Four themes were developed: (1) pharmacists’ leadership in continuity of care, (2) pharmacists as medication stewards, (3) pharmacists as a source of COVID-19 health information and (4) the impact of COVID-19 on pharmacists’ mental health and well-being. The first three themes described the key roles played by community pharmacists during the closure stage (eg, March to May 2020). The fourth theme highlighted the significant impact of working in the PHC setting during the early days of the COVID-19 pandemic on pharmacists’ mental health and well-being. Barriers and facilitators were discussed in relation to each theme. Illustrative quotes are provided in-text and have been edited for clarity. Table 2 provides a summary of themes, roles, barriers and facilitators.

Table 2

Pharmacists’ roles during the closure stage of the COVID-19 pandemic and associated barriers and facilitators

Pharmacists’ leadership in continuity of care

The pandemic influenced access to healthcare services, which our participants described as having an important impact on the sheer number of patients who sought healthcare services more routinely from pharmacists. As such, pharmacists played a key leadership role in continuity of care. Participants described having to adapt their roles and priorities to meet the needs of their patients and a strained healthcare system. They supported and fostered continuity of care through two key elements: (i) access and coordination, and (ii) collaboration with patients and other healthcare providers. The necessary transition in pharmacy services was accompanied by unique barriers and facilitators, described below.

Access and coordination

During the closure stage, PCPs and NPs were advised by the CMOH to restrict in-person clinic visits to urgent or emergent cases and to offer virtual care where possible. As these healthcare providers shifted their practice to virtual care during the closure stage, our pharmacists described experiencing an increase in demand for pharmacist care, as a notable portion of the population turned to them for healthcare services. Likewise, individuals who lacked a PCP or NP, who had previously relied on the Fast Track Clinic within provincial emergency departments for chronic disease management, increasingly relied on community pharmacists to address their healthcare needs.

Participants in our study reported an increased demand for pharmacist-delivered chronic disease management (eg, assessment, monitoring), prescription renewals, and prescribing and care for common ailments. As noted by one pharmacist: “I did the most prescribing I've ever done in my life, extending prescriptions and all that.” – P6. In addition, due to the inaccessibility of PHA-run clinics, which are most commonly located in community hospitals, and low-acuity emergency room services for many people, our participants had felt a greater need to coordinate care for their patients: “So, the hospital wouldn't take any patients, they wouldn't see any patients. And if the patient needed refills, it got sent to me to figure out.” – P1. Participants also described numerous changes to their provision of care for patients requiring opioid agonist maintenance therapy (OAMT), where they engaged in providing prescription delivery and at-home witnessed dosing of OAMT for patients unable to visit the pharmacy in person.

Common barriers emerged from the pharmacists’ stories. For example, barriers included lack of financial compensation for the extra roles played during COVID-19, the delay in care caused by regulatory paperwork and lack of adequate staff. For example, there was a lag between the implementation of new pharmacist-delivered services for patients isolating due to COVID-19, such as delivery and witnessed dosing of OAMT, and government funding/reimbursement for these services:

But you know, at the beginning stages, there was no talk about reimbursement for all these extra services that were going to be required because of [self-isolation for patients experiencing symptoms of COVID-19]. – P3

Other barriers included the increase in paperwork. For example, participants described the many steps involved in the approval process for OAMT delivery and witnessed dosing—a new government-funded service introduced during the closure stage of the pandemic. The pharmacy service fee and approval process for patients to access the service did not account for the time-sensitive nature of OAMT or the urgency of approval when a patient receiving OAMT was suspected to have COVID-19. As a result, some pharmacists described providing the service without reimbursement:

(The service fee) is $50 […]but you used to have to get approval (from public health) … So, I delivered a lot of OAMT (Opioid Agonist Maintenance Treatment) and never was paid for it because I just didn't have time to call public health and wait for (approval). (OAMT) is time-sensitive stuff. – P2

Additional barriers included lack of access to personal protective equipment (PPE) and lack of adequate staff. Pharmacists felt there was no proactive consideration of pharmacists’ patient care roles during the closure phase, which often excluded pharmacists from important resources, such as PPE and resulted in some pharmacists making their own forms of PPE (eg, masks). As one participant noted, “We weren't included in [PPE rollout,] and we really had to fight to have access to PPE […]. The government had a store of it, but they wouldn't release it to us even to purchase.” – P2

Despite the reported barriers, facilitators were also described by some participants. These included physician support and cooperation, their scope of practice, access to delivery services and reimbursement for delivery and witness dosing of OAMT. Company-specific policies designed to prevent the spread of COVID-19, such as the stratification of pharmacy personnel into designated teams, were also reported as supportive measures. This facilitated the safe operation of community pharmacies and allowed pharmacists to remain accessible to their patients and communities during the pandemic:

I think, (it) was a company-wide decision, at least in the province, that stores were going to kind of split their staff up into two teams. The overall goal was to prevent total closure of places in case team members did contract COVID. So that was a fairly big shift, because we wound up then kind of working days on days off in sort of like a half-half of the team sort of a situation. – P4

Collaboration

Pharmacists also discussed their crucial role in collaborating with other healthcare providers to help maintain continuity of care. During the closure stage of COVID-19, the majority of family physicians’ offices were closed with few virtual care options, creating challenges for patients to access their family doctor for prescription renewals and clinical assessments. To fill the gap in communication between patients and physicians, pharmacists facilitated connecting patients with their PCP when necessary. Some physicians provided pharmacists with their personal phone numbers. When needed, pharmacists would allow patients to use their offices and connect with the physician to facilitate virtual assessments and verbal prescriptions while maintaining the privacy of the physician’s personal contact information.

Barriers to communicating and collaborating with other providers to achieve continuity of care were described. Information on which providers worked remotely from home during the closure stage was not readily available. Pharmacists described feeling left in the dark and without necessary contact information for their primary care colleagues. Essentially, they had to wait for the other provider to reach out to them with alternate contact information. Some participants felt that the professional associations (ie, the pharmacy association and the medical association) should have taken a greater leadership role in coordinating resources to aid in delivering primary care. As one participant noted, “It would have been great if the (medical association) had compiled a list of alternate contact information for (physician) prescribers (who were) managing patients from home.”– P3

In terms of supports, when contact information was available for a PCP or NP, the pharmacist was then able to facilitate care between the patient and the physician or NP. Pharmacists viewed having this information as a key facilitator to collaboration and continuity of care. For example, one pharmacist discussed connecting with the other providers at the medical clinic next door to the pharmacy who were regularly working from home during the closure stage, “I would take a picture of his arm or whatever was happening […]and text it to their family doctor.”– P5. The use of technology in this case helped to facilitate communication and collaboration between the pharmacist, the patient and other healthcare providers.

Pharmacists as medication stewards

At the risk of depleting the drug supply and its potential negative impact on public health, the pharmacist’s traditional role as a medication steward re-emerged as a necessity. The roles of pharmacists as medication stewards were discussed extensively during the interviews, which included limiting the sales of over-the-counter medication and devices, following the 30-day medication supply limit and ensuring a consistent supply of medications to long-term care homes.

The public fear of pandemic-associated supply chain restrictions led to the hoarding of over-the-counter (OTC) medications and devices, and requests for larger quantities of prescription medications in many areas of the province. To combat this problem and prevent drug shortages, pharmacies were directed by their regulatory board—the Newfoundland and Labrador Pharmacy Board—to limit medication dispensing to a 30-day supply. One participant described the situation as follows, “The shelves became bare in every pharmacy…all analgesics and cough and cold products and things like that, they all got (bought) out across the country.” – P5. As such, pharmacists played a key role in protecting the drug supply, including limiting the sale of OTC medications and devices. Pharmacists working in pharmacies that serviced long-term care homes also described being especially diligent about their medication stewardship role; they took steps to ensure that their affiliated long-term care homes (ie, residential facilities that provide long-term care services that are associated with a specific pharmacy) had an adequate and consistent supply of medication. However, this came at a cost, as participants described time, medication shortages, access to PPE and access to the facility as notable barriers to maintaining medication supply at long-term care homes.

Instead of just bringing the drugs through the front door of the long-term care home. (Access was via) a back door, which is not designed for receiving inventory due to it being the furthest place from the residents. Not a lot of long-term care homes are designed for pandemics. – P11

Having to limit the dispensing of medications to a 30-day supply created many challenges. It increased the workload associated with dispensing and increased fees/costs for patients. Furthermore, there was considerable miscommunication about the necessity of the 30-day supply, with the provincial Minister of Health proclaiming that it was not absolutely necessary or supported by the government. This created a media frenzy, and as a result, pharmacists described feeling villainised in their role as medication stewards: “We were definitely the villains as pharmacists for [30-day supply] at that time.” – P6

Pharmacists as a source of COVID-19 health information

Early in the pandemic, there was limited information on COVID-19 available to the public. Our participants described a general lack of patient-friendly resources regarding COVID-19, which led patients to seek information from pharmacists on many topics, such as COVID-19 symptoms, symptom management and other related clinical questions: “At that point there was no treatment options or recommended recommendations on what to give. So (we suggested medications) if there was something that we could give them over-the-counter to treat symptoms.” – P7

Barriers included the lack of evidence-based information, the sheer volume of information about COVID-19 from public health authorities and conflicting public health information. Our study participants reported feeling an increased responsibility to stay informed about various aspects of COVID-19, which came with its own challenges. One pharmacist described the sheer exhaustion that came as a result: “I remember it was just like so stressful every day trying to go in and figure everything (out) […]. Everything was changing, like every other hour.” – P6

Pharmacists working in independent pharmacies seemed to experience greater challenges acquiring up-to-date information on COVID-19 recommendations and policies. These pharmacists did not have access to the different levels of support that come with working within a larger organisation, like a pharmacy chain: “I'm an independent pharmacy, so I don't have anybody relaying information down to me. […] So just day by day, (I had) to figure it out and then communicate (it) to everybody.” – P6. Facilitators supporting their informational roles included support from other pharmacists and healthcare workers, as well as their company/pharmacy chain.

The impact of COVID-19 on community pharmacists’ mental health and well-being

The COVID-19 pandemic impacted all aspects of pharmacists’ lives, including their mental health and well-being. Pharmacists in our study expressed that they felt feelings of fear, guilt and isolation. As one participant stated, “A simple word to describe it was, you know, working hell […] You know, so you're half afraid to go to work then half afraid to come home to your family at times.” – P1. Many spoke about the fear of catching COVID-19 and spreading it to their family, friends and patients, which often led them to isolate themselves from their partners, children, parents, friends and pets. This was illustrated by the following quote:

You know, I couldn't even go near any of them, couldn't see my dog (inaudible), couldn't go to a store. I couldn't go to visit anyone. I couldn't, you know, they talk about your steady 20 and you're tight 10 in that kind of thing. I didn't even (have) that. I had myself. That’s all I had. Just because of that fear of contracting and having to shut down. – P1

The topic of the limited availability of mental health support and childcare support was also frequently discussed. One pharmacist mentioned that they often felt like an essential mental health support for the community but there was limited support available to them as a pharmacist, which led to feelings of burnout. The participant stated, “I felt like I was a support for everyone else, which was an additional level of burnout for me.” – P2. Another pharmacist expressed concern about the lack of available and affordable childcare services:

My husband goes to work, and I go to work, and we've relied on family members essentially for almost 2 years. Increasing the daycare availability to working parents at an affordable rate to $15 or $10 a day is a great idea. But there is no point if there is a 2 to 3 year wait list. – P8

Pharmacists working in independently owned pharmacies felt the added stress of completing management duties simultaneously with their patient care tasks. They did not have access to the additional supports that are often available through larger corporations. As a result, they described struggling to keep up and balance all their responsibilities. Whereas, within chain pharmacies, head offices were often able to acquire PPE and cleaning supplies and offered suggestions on best practices to minimise the spread of COVID-19 between staff members (ie, rotating shift work to minimise interactions).

A grassroots initiative that emerged during the COVID-19 pandemic—developed by pharmacists in NL—that seemed to support pharmacists’ well-being and professional responsibilities was a social media community group. The majority of participants described how the private NL Pharmacists Facebook page created a support network among practising pharmacists. The information sharing and collaboration that occurred through this network strengthened participants’ sense of community and belonging and helped to build resilience: “That Facebook group was very helpful as well, seeing that a lot of people were going through the same stuff and feeling the same feelings and that type of thing.” – P2

Discussion

This paper described the roles community pharmacists played in the delivery of PHC during the closure stage of the COVID-19 pandemic and explored the barriers and facilitators to these roles. Our findings draw attention to community pharmacists’ critical role in maintaining continuity of care, protecting the drug supply and disseminating COVID-19 health information during the closure stage. Community pharmacists engaged in coordinating care, prescribing for common ailments, delivering medications and supplies, providing information on COVID-19 symptoms and their management, renewing chronic medications and limiting the sale of OTC and prescription medications and devices. Many barriers and facilitators influenced the roles of many participants in our study; serving as the most accessible healthcare provider during the closure stage significantly impacted their mental health and well-being.

Our study highlighted how the pandemic necessitated that community pharmacists’ practice to full scope (eg, prescribing, monitoring drug therapy, managing chronic diseases), whether or not they were prepared or not. Pharmacists practised to their full scope and took on new roles to ensure continuity of care for their patients and communities. Similar results were reported in a cross-sectional survey of Canadian pharmacist roles during the pandemic, which identified that 70.4% of pharmacists were renewing and extending prescriptions, 67.4% of pharmacists were educating the public on reducing the spread of the COVID-19 infection, 19.9% were independent prescribing and 23.7% were collaborating with other healthcare providers on COVID-19 infection treatments.22

Roles associated with the theme of ‘pharmacist leadership in continuity of care’ during the closure stage of COVID-19 were prominent findings in our study. Reports and publications from other regions in Canada and beyond supported this finding. For example, Lee and colleagues found that pharmacists from 10 Canadian provinces and one territory demonstrated leadership by adapting their practices to meet the needs of society (eg, provided emergency supply refills, established remote pharmacy services and provided patients with psychological first aid).23 Other forms of pharmacist leadership in PHC have also been described in the literature. In Alberta, Watson and colleagues described how pharmacists demonstrated leadership through visible and invisible roles, regardless of whether they were in a management position.24 Pharmacists recognised the importance of establishing a precedent for their staff, colleagues, patients and community by enforcing and practising public health measures and policies.23 Community pharmacists also demonstrated leadership within the pharmacy by focusing on the team dynamic by outlining their responsibilities to protect and take into consideration the mental health and well-being of their pharmacy staff and colleagues.23 This contrasted our findings, which highlighted the barriers in accessing supports to improve the well-being and mental health of community pharmacists in NL.

Amidst the challenges during the COVID-19 pandemic, community pharmacists’ role as medication stewards was brought to the forefront with the need to protect the drug supply and minimise potential drug shortages. Specifically, pharmacists were required to dispense medication in 30-day increments rather than a 90-day supply often provided for chronic medications.24 Other studies have also shown that pharmacists played a key role in protecting the drug supply.25 26 For example, pharmacists in different countries used pre-existing mobile applications to help guide patients on where to purchase their medications or arrange a medication delivery.25 Additionally, pharmacists provided patients with a therapeutic substitution to reduce the strain on the supply chain.26

The participants in our study also served as a source of COVID-19 health information. They provided patients with information on COVID-19 prevention, symptoms, symptom management and how COVID-19 may impact an individual’s other health conditions. Similar experiences were reported globally. For example, in Egypt, pharmacists contributed to patient education regarding infection control, disease management, hygiene practices, counteracting falsified claims and serving as a point of reference in their community.27 A study in France reported that pharmacists provided education on hygiene practices and social distancing to mitigate the spread of COVID-19.28 In Jordan, pharmacists provided patient education regarding COVID-19 symptom management, practices related to decreasing the spread of COVID-19 and medication counselling.29 In contrast to the experiences reported by participants in our study, particularly those employed in independent pharmacies, who highlighted the limited accessibility of reliable sources of COVID-19 information, Hoti and colleagues30 described numerous helpful sources of COVID-19-related information available for community pharmacists during the closure stage practising in Kosovo. These included pharmacy professional bodies, the internet, television, social media and scientific articles, which acted as facilitators in supporting pharmacists in their COVID-19 health information role.30

New PHC roles (eg, educating patients on symptoms associated with COVID-19, providing advice on supportive measures to reduce COVID-19 symptoms) that emerged as a result of COVID-19 caused an increase in pharmacist workload, especially in light of patients having limited access to other healthcare providers. In our study, participants described having spent considerable amounts of time facilitating patient care with other providers. The same observation was made by Isenor and colleagues31 in Nova Scotia, who found that the workload of community pharmacists increased during the COVID-19 pandemic due to the accessibility of pharmacies and the closure of many other healthcare centres, which prompted pharmacists to adapt their roles to meet the needs of their patients.31 However, pharmacists were not compensated for time spent coordinating care with other healthcare providers. For example, consulting with physicians to facilitate assessments and diagnoses for patients is not routinely part of their daily roles.

Gaps in access to mental health and childcare services can considerably strain pharmacists’ well-being and impede their ability to carry out their roles effectively. Commentary published by the Canadian Pharmacists Association described an increase in pharmacists’ levels of stress, burden and frustration during the early days of the pandemic, which impacted their mental health.32 In our study, participants gave examples of instances where they experienced high levels of stress and isolation in their role as a provider of primary care. Yet, there was also evidence of resilience and determination. This coexistence of symptoms of burnout and resilience among pharmacy professionals is not unique to our study, as other researchers have reported similar findings.33 34

Strength and limitations

To enhance the rigour, reliability and credibility of this study through triangulation, our results drew on evidence gathered through policy analysis, chronology and qualitative interviews.35 Additionally, the participants represented a broad range of perspectives with respect to gender, years of experience and geographical location. The research team included individuals who practice as pharmacists and have had experience in qualitative methods, which contributed their knowledge in the development of the protocol and interpretation of the results. In addition, the incorporation of reflexivity (reflective journal and post-interview reflections) enhanced the study’s rigour by allowing researchers to acknowledge their assumptions and preconceptions that influenced the study’s design, data collection, analysis and interpretation (ie, adapted the interview guide, avoided leading questions and improved rapport with participants).35 In terms of limitations, interviews took place 2 years after the beginning of the pandemic between February and August of 2022, which could have affected the perceived burden of the COVID-19 pandemic in the early stages of the pandemic and may have influenced participants’ ability to recall and recount past experiences accurately. This study took place in the province of NL and may not represent pharmacists’ experiences in other Canadian provinces or beyond.

Conclusion

The delivery of PHC services plays an important role in pandemic response. We identified key roles enacted by community pharmacists during the COVID-19 pandemic and identified facilitators and barriers that should be taken into account in future pandemic preparedness plans. These plans should acknowledge and support the roles of pharmacists in the continuity of care and medication stewardship and include appropriate compensation for any new roles that emerge as a result of the need for pharmacists to preserve the delivery of PHC. Appropriate levels of remuneration would allow for adequate staffing to match the increased demand and patient care responsibilities. Future pandemic preparedness plans should include the creation of an evidence-based information hub or online portal for healthcare professionals to use in educating their patients. Such a portal must be easy to navigate and provide real-time health information updates. Recognising the impact associated with being the most accessible front-line PHC provider during the closure stage of COVID-19, future pandemic preparedness plans should also prioritise the well-being of pharmacists by facilitating access to mental health and childcare services.

Data availability statement

No data are available. We did not obtain approval to share data related to this work from our Health Research Ethics Board.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by Newfoundland & Labrador Health Research Ethics Board Reference No. 2020.251. Participants gave informed consent to participate in the study before taking part.