Perspectives on pharmacist prescribing in an outpatient dialysis center: Qualitative interviews with patients and clinicians

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Choi, Madeline Theodorlis, Angelina Abbaticchio, Marisa Battistella This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8109125/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Jan, 2026 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted 11 You are reading this latest preprint version Abstract Introduction: Pharmacist prescribing is expanding across care settings, supported by their expertise in pharmacology, therapeutics, disease management, and medication optimization. In settings where pharmacists can prescribe, patients and providers report positive outcomes. However, limited research has examined pharmacist prescribing in dialysis centers. Aim This study explores patient and clinician perspectives on pharmacist prescribing in the outpatient hemodialysis unit at Toronto General Hospital, University Health Network (TGH-UHN) in Toronto, Canada. Method Semi-structured, one-on-one qualitative interviews were conducted with English-speaking adults on hemodialysis, and clinicians, including nephrologists, pharmacists, dietitians, and nurse practitioners in the outpatient hemodialysis unit at TGH-UHN. Participants were recruited through convenience sampling until data saturation was reached. Interviews were audio-recorded, transcribed, and analyzed thematically using an inductive approach. Results Eleven patients and 11 clinicians (six nephrologists, two pharmacists, two dietitians, one nurse practitioner) were interviewed in June and July 2025. Participants noted communication gaps and delays as challenges of the current prescribing process, and accessibility of prescribers and interdisciplinary collaboration as strengths. Pharmacists were recognized as valuable care team members given their expertise in medication management and rapport with patients. Potential benefits of pharmacist prescribing included enhanced medication optimization, improved workflow efficiency, timely care, and pharmaco-economic savings. Barriers included limited prescribing knowledge among some pharmacists. Implementation considerations included a collaborative approach, maintaining physician oversight, limiting prescribing to specific clinical areas, phased rollout, patient and clinician buy-in, adequate resources, and clearly defined roles and communication. Conclusion While patients and clinicians were generally supportive of pharmacist prescribing in the hemodialysis unit, they identified several considerations for implementation. Interviews in additional hemodialysis care settings could offer further insight to guide implementation strategies. Pharmacists pharmacist prescribing hemodialysis qualitative interviews INTRODUCTION In 2023, nearly 30,000 Canadians were receiving chronic dialysis [ 1 ], with more than 75% receiving hemodialysis (HD) in hospital-based settings. Patients receiving HD typically undergo four-hour treatments three times per week and take an average of 12 ( ± 5) medications daily [ 2 – 4 ]. These medications often require specific timing around dialysis sessions and are frequently adjusted based on blood work results. Furthermore, patients undergoing HD often interact with multiple healthcare services and providers regarding their medication management. For example, a nephrologist may adjust medications for electrolyte balance, a family physician may prescribe antibiotics for an infection, and a pharmacist may provide patients with relevant medication counseling. Pharmacists serve as integral members of multidisciplinary HD care teams, providing evidence-based recommendations on medication selection, dosing, and therapeutic monitoring, often in collaboration with physicians and other prescribers and in accordance with regulatory standards [ 5 – 7 ]. Pharmacists play a key role in managing medication non-adherence, prescription renewals, and duplicate or missing medications [ 5 , 8 , 9 ], all of which contribute to safer medication use by reducing inappropriate prescribing and optimizing therapy [ 10 – 19 ]. Pharmacist-led interventions, such as deprescribing, can significantly reduce pill burden and improve adherence without compromising patient safety [ 13 , 20 ]. In addition, pharmacists support patient-centered care through counseling and motivational interviewing, which reduce medication-related problems, improve satisfaction and adherence, and enhance overall patient outcomes [ 21 – 23 ]. While prescribing is typically performed by physicians and nurse practitioners [ 7 ], pharmacists are becoming increasingly recognized within the medical community as qualified to prescribe given their expertise in pharmacology, therapeutics, disease management, pharmacokinetics, drug interactions, and adverse effects [ 24 – 26 ]. In Alberta, Canada, both community and hospital pharmacists can independently adapt, renew, and initiate prescriptions, with additional prescribing authorization available [ 27 , 28 ]. In some other Canadian provinces, such as Ontario, community pharmacists have the authority to prescribe for minor ailments such as uncomplicated urinary tract infections, gastroesophageal reflux disease, and conjunctivitis [ 29 ]. Evidence suggests that pharmacist prescribing is both safe and effective [ 30 ], and in settings where pharmacists have prescribing rights, patients and healthcare providers report positive outcomes [ 31 , 32 ]. For instance, sharing prescribing responsibilities with pharmacists reduces physicians’ workload, allowing them more time to manage other complex health issues [ 30 ]. Furthermore, pharmacists’ role in prescribing may reduce healthcare costs by optimizing drug therapy and preventing hospital readmissions [ 33 , 34 ]. Despite growing evidence that pharmacists possess the knowledge and skillset to prescribe safely, several challenges remain to support this practice in HD centers [ 30 , 35 ]. These include concerns related to liability, inter-provider communication, and inadequate infrastructure, such as time, staffing, training resources, and technology [ 8 , 31 , 36 , 37 ]. Addressing these barriers requires coordinated efforts, including policy changes and organizational supports [ 30 ]. Given the complexities of medication management for patients receiving HD, multidisciplinary teams with clear communication pathways are essential to ensure safe and effective pharmacist prescribing [ 30 , 35 , 38 ]. Ongoing education and training for pharmacists and other healthcare providers are also critical to the successful integration of pharmacists into prescribing models in HD settings [ 8 , 31 , 36 , 37 ]. To date, no study has explored patient and clinician views regarding pharmacist prescribing in outpatient HD centers [ 39 – 41 ], and research is needed to identify barriers and facilitators for its successful implementation. AIM This study examines patient and clinician perspectives on pharmacist prescribing in an outpatient HD unit in Toronto, Canada, and aims to generate evidence to support expansion of pharmacists’ prescribing privileges. METHOD Study design This study involved one-on-one, semi-structured interviews and adopted a qualitative descriptive design, which aims to provide rich, detailed data that remains a true reflection of participants’ perspectives [ 42 ]. Findings are reported in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 43 ]. Setting This single-centre study was conducted in the outpatient HD unit at Toronto General Hospital, University Health Network (TGH-UHN), in Toronto, Ontario, Canada. The research team consisted of the Principal Investigator (MB, female), who is a pharmacy clinician scientist; two research coordinators in the Pharmacy Department (MT, AA), both female with a Master of Public Health; and a pharmacy research student (AC, female). At TGH-UHN, the current prescribing practice for patients on HD typically involves nephrologists and nurse practitioners in the HD unit, and family physicians in the community. Sampling and recruitment Participants were recruited between June and July 2025. Eligible patients were 18 years or older and receiving HD in the outpatient HD unit at TGH-UHN. Patients were excluded if they did not speak English or had cognitive impairment. The study team approached eligible patients in person during their dialysis session and provided a brief verbal overview of the study. Eligible clinicians included nephrologists, pharmacists, nurse practitioners, and dietitians working in the same unit. Clinicians meeting eligibility criteria were contacted via email by the study team and provided with a description of the study and instructions to contact the team if interested in participating. Participants were recruited until data saturation was reached. All participants provided written informed consent. Interview guide development The semi-structured interview guides (Online Resource 1 and 2) were developed by the study coordinators (MT, AA), the pharmacy research student (AC), and the Principal Investigator (MB). The guides included open-ended questions to explore 1) the strengths and challenges of the current prescribing process for patients on HD; 2) the perceived role of pharmacists in the HD unit; and 3) perspectives on pharmacist prescribing in the HD unit. Probing questions were used to capture a comprehensive understanding of participant views. The guides were pilot tested with one social worker from the outpatient HD unit and one patient partner receiving HD at TGH-UHN, then revised based on their feedback to improve clarity. Data collection Interviews were conducted by AC between June and July 2025. Patient interviews took place in person, at the bedside during dialysis sessions. Clinician interviews were conducted either in person or via Microsoft Teams, scheduled at the clinician’s convenience. There was no prior relationship between AC and study participants. All interviews were audio-recorded using Microsoft Teams and transcribed verbatim in Microsoft Word. To ensure transcription accuracy and data integrity, the study team reviewed and verified each transcript against the original recordings, after which all audio files were deleted. Identifying information was redacted and transcripts were de-identified. Transcripts were not returned to participants for comment or correction. Patient demographic data were obtained from patients’ electronic medical record (EMR) or directly from the patient when unavailable in their chart. Variables collected included age, sex, ethnicity, education, marital status, comorbidities (diabetes, hypertension, cardiovascular disease, and dyslipidemia), total number of medications, and dialysis vintage. Clinician demographic data were self-reported and included age, sex, ethnicity, clinical role, and years of clinical practice. Data analysis Patient and clinician characteristics were summarized using descriptive statistics. Categorical variables were reported as frequencies and percentages, and continuous variables as means with standard deviations, or medians with interquartile ranges. Interview transcripts were analyzed manually using the “comments” and “track changes” features in Microsoft Word. Data analysis followed an iterative process using a general inductive approach, whereby themes and subthemes were derived “directly” from the interview data [ 44 ]. To ensure inter-rater reliability, AC, MT, and AA independently analyzed the first three patient and clinician transcripts to develop a preliminary coding framework. This framework was then applied to all subsequent transcripts, which were independently coded by the same researchers. AC, MT, and AA held regular meetings to discuss discrepancies and refine the framework. Interviews were conducted and analyzed concurrently until thematic saturation was reached and no new themes or subthemes emerged. Participants did not provide feedback on findings. Identified themes were then mapped deductively to the Theoretical Domain Framework (TDF), a validated framework developed by psychology theorists and implementation researchers to guide the design of implementation interventions [ 45 , 46 ]. The TDF is comprised of 14 domains: knowledge ; skills ; social/professional role and identity ; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; intentions; goals; memory, attention and decision processes ; environmental context and resources ; social influences ; emotion ; and behavioural regulation [ 46 ]. Ethics approval The study received approval from the University Health Network Research Ethics Board (Study ID: 25-5303) on February 1, 2022. RESULTS Eleven patients and 11 clinicians (six nephrologists, two pharmacists, two dietitians, and one nurse practitioner) were interviewed between June and July 2025. Interviews lasted between 11 and 26 minutes. Patients had an average age of 66 years, and more than half (55%) were white (Table 1). Clinicians varied widely in their years of clinical practice, ranging from 10 to 19 years (Table 2). Table 1. Patient interview characteristics Characteristic Patients (N=11) Mean age (± SD) 66 (±14) Sex (%) Male Female 5 (45) 6 (55) Ethnicity (%) Black, African Black, Caribbean South Asian Southeast Asian White 1 (9) 1 (9) 1 (9) 2 (18) 6 (55) Highest level of education (%) Elementary school (up to grade 6) Middle school (up to grade 8) High school (up to grade 13) College/university Postgraduate 1 (9) 0 2 (18) 7 (64) 1 (9) Marital status Single Divorced Married/common law Widowed 3 (27) 1 (9) 5 (45) 2 (18) Comorbidities (%) Diabetes Hypertension Cardiovascular disease Lipid disorder 7 (64) 8 (82) 6 (55) 6 (55) Total number of medications (± SD) 11 (± 5) Median dialysis vintage, in months (IQR) 32 (10-48) Median dialysis vintage at TGH-UHN, in months (IQR) 27 (10-40) Abbreviation: SD, standard deviation; IQR, interquartile range; TGH-UHN, Toronto General Hospital – University Health Network Table 2. Clinician interview characteristics Characteristic Clinicians (N=11) Mean age (± SD)* 45 (± 12) Sex (%) Male Female 5 (45) 6 (55) Ethnicity (%) Black, African East Asian South Asian Southeast Asian White 1 (9) 1 (9) 1 (9) 4 (36) 4 (36) Clinical role (%) Dietitian Nephrologist Nurse practitioner Pharmacist 2 (18) 6 (55) 1 (9) 2 (18) Median years of clinical practice (IQR)* 12 (10-19) Abbreviation: SD, standard deviation; IQR, interquartile range *n=10; one clinician preferred not to answer Four main themes, along with several subthemes, were identified from patient and clinician interviews. Nine TDF domains, noted in italics below, were mapped to the identified themes and subthemes. A summary of themes, subthemes, and exemplary quotes mapped to the TDF are in Table 3. All patient and clinician interview data are available in Online Resource 3. Table 3. Patient and clinician interview themes, subthemes, and exemplar quotes, mapped to the Theoretical Domain Framework (TDF) Themes and subthemes Exemplar quotes TDF domain(s) Strengths and challenges of the current prescribing process for patients on hemodialysis Prescribers are accessible In the last eight years since I am a dialysis patient, I never have any issues because here, doctor, fill up the prescription... send it right away to [the community pharmacy]. Just go directly over there. And when the medication is ready they call you to pick it up... It's very convenient whenever you need it. [If] your regular doctor is not available… [other physicians] always help. (Patient 01, male, age 53) Environmental context and resources: Any circumstance of a person’s situation or environment that encourages of discourages the development of skills and abilities, independence, social competence and adaptive behaviour. Communication gaps lead to delays If one of the several medications doesn't have a refill, the pharmacist will have to get a fax from the doctor or nurse requesting additional refill… And as a patient, I find it frustrating to do that particular administrative job... I had to go to the doctor, say “the pharmacist wants to know the dose. Could you call the pharmacist and give the dose?” It's just to me, I understand the situation, but it seems a silly thing to delay my receiving the meds. (Patient 11, female, age 69) Strong interdisciplinary collaboration Our teams are very collaborative and close-knit, and we work very much together on a lot of the decision making and between rounds and then also just outside of rounds collaborating as needed. (Clinician 01, dietitian, 21 years of practice) Electronic medical record (EMR) system Prescriptions are entered via our electronic health record, EPIC, and usually electronically faxed directly to patients’ pharmacies... The electronic prescription format allows for good record keeping to verify when prescriptions have been sent. (Clinician 11, nephrologist, 9 years of practice) Sometimes [EMR] it's difficult to maneuver… You could click on the wrong thing, so there's always potential for error... it's not sometimes as intuitive as you want it. (Clinician 03, nurse practitioner, 12 years of practice) Multiple prescribers challenge communication Some covering prescribers that are sort of in and out of the unit and come in and maybe make a change but then are not back. I do find at times maybe the follow-up or communication, that's where you sometimes see the gaps, right, where something has been adjusted and maybe not fully communicated with the team or not an opportunity because they've been moved to a different area, different rotation. (Clinician 01, dietitian, 21 years of practice) Perceived role of pharmacists in the hemodialysis unit Optimize medication management and educate patients To keep an eye out on the medications that are being prescribed and to see if they're still relevant... I think they definitely contribute towards the care... asking you to bring the medications in and go over the dosage… [Explain] the purpose is of something being increased or decreased and how it's going to affect me, or if a new prescription is ordered, to find out what, if there are chances that I would have some reaction to it and how to deal with whatever the problem is. (Patient 08, female, age 81) The role of the pharmacist is to review all medications that the patients are taking at home and also that they're receiving while they're in the dialysis unit… Reviewing the appropriateness, the dosing frequency, checking for interactions, reviewing blood work and performing assessments and recommendations for any drug therapy issues that they identify… Also providing any education to the patients and then collaborating with other healthcare team members. (Clinician 10, pharmacist, 15 years of practice) Social or professional role and identity: A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting. Accessible members of the care team [Pharmacists are] always available to answer my questions… I consider them part of a team in my well-being... they've been very helpful, and they are an integral part of my treatment. (Patient 11, female, age 69) [I see the pharmacist] at least monthly… anytime I have a need [to see them], whether it's because of the monthly blood work consultation or a complaint that I have or an inquiry that I have, it gets addressed immediately. (Patient 10, male, age 69) Assist with administrative tasks of prescribing Pharmacists and pharmacy trainees also assist greatly with reviewing coverage for medications and completion of things like exceptional access forms, which are quite important to allowing for medication coverage and therefore adherence for patients. (Clinician 11, nephrologist, 9 years of practice) Perceived benefits and barriers of pharmacist prescribing Improve workflow efficiency and timely care I mean, it could help. Yeah, obviously, the more care you have, including pharmacists that can help you if it's to prescribe even minor medications to help, totally fine with that... the more care you have, the better… You have the pharmacist helping you, you're taking some of the work off the doctors, so you're helping everybody in general. (Patient 09, male, age 50) It really would free up the ability for these physicians or nurse practitioners to take care of patients in other ways and not be, if needed, and deal with other patients or more acute issues that are coming from either nursing concerns or patient concerns... There could be a model in which the workflow lends to pharmacists being the most readily available clinician that can be involved in prescribing and adjusting these types of medications... allowing pharmacists maybe in addition to already the prescribers that are available to do that does add more, it could lend to patients getting better care and more timely care. (Clinician 02, pharmacist, 12 years of practice) Beliefs about consequences: Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation. Beliefs about capabilities: Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use. Knowledge: An awareness of the existence of something. Skills: An ability or proficiency acquired through practice. Support medication adherence and safety [Pharmacists] are more concentrating on the medication aspect of things, they can spend more time reviewing the indications, the contradictions, the side effects… patients might appreciate that. Just having somebody that can spend a little bit more time going through their medications and helping them with strategies to ensure better adherence and access. (Clinician 07, nephrologist, 10 years of practice) Pharmaco-economic savings There's probably also actually definitely some cost saving perspectives both from the patients, if they're getting medications as outpatients, but also on the unit. I do think if pharmacists were prescribing, there could be more judicious use of some medications that could lead to cost savings for the units as well. (Clinician 02, pharmacist, 12 years of practice) Pharmacists have existing rapport with patients Our staff pharmacist, many of the patients have a pretty solid relationship with that pharmacist… the prescribing role of pharmacists, I actually support that because I think it allows the team to utilize their strengths and experience for the patient, for patient care going forward... it's taking advantage of a skillset that they have. (Clinician 06, nephrologist, 36 years of practice) Pharmacists’ skillset and expertise I think that [pharmacists] are very knowledgeable, but to get to use that knowledge more would be excellent... they’re professional people; they should be able to use all their capabilities. (Patient 05, female, age 78) It's 100% dependent on the pharmacist... There are some pharmacists who I would trust implicitly and there are other pharmacists I would not wish them to be involved with any prescribing... it's a knowledge base. I think some pharmacists have an incredibly high knowledge base and have incredibly solid academic thinking patterns... But there are other pharmacists where I will double check things just because I feel that there is a significant knowledge gap and a lack of familiarity with the clinical scenarios. (Clinician 08, nephrologist, prefer not to answer) Implementation considerations for pharmacist prescribing Collaborative prescribing I'd probably feel more comfortable with it as long as they're willing to cross reference with others… I just get very uncomfortable if it was just, I guess one person calling the shot... So at least everybody's on the same page... I would prefer more eyes on it than just one person. (Patient 06, female, age 37) As long as there's communication that everyone's on the same page, I have no problem with that... It has to be informed and it has to be sort of endorsed or vetted by everybody else within the clinical team... What would matter is that you have consulted with the physician or the [nurse practitioner]. (Clinician 03, nurse practitioner, 12 years of practice Reinforcement: Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus. Environmental context and resources: Any circumstance of a person’s situation or environment that encourages of discourages the development of skills and abilities, independence, social competence and adaptive behaviour. Social influences: Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours. Goals: Mental representations of outcomes or end states that an individual wants to achieve. Emphasis on physician oversight If you were to change like my heart medication for example, I would want my cardiologist to agree to that. And confirm with the pharmacist, not that I don't trust the pharmacist, but I'd want confirmation for my comfort to know that my cardiologist would agree to that. (Patient 09, male, age 50) I think the medical practitioner should still be the primary prescriber, but giving pharmacists the ability to prescribe if needed versus, you know, I guess deferring that entire prescribing practice to the pharmacist. (Clinician 10, pharmacist, 15 years of practice) Support for prescribing in specific clinical areas If the pharmacist could prescribe, I’m not sure about new tablets but certainly ones that the doctors have approved to be refilled, they can be refilled. (Patient 05, female, age 78) Medications that could be deprescribed or dose dependent could be used, like warfarin for example, those kinds of things that you can kind of titrate, titratable medications… Calcium [phosphate] binders… Antihypertensives would be another option to focus on… Medications that can be relatively easily protocolized like EPO medications, iron, those would be a good start. (Clinician 07, nephrologist, 10 years of practice) Phased approach to implementation I think it should be a phased approach. So maybe start with one thing, so we start with anticoagulation, then see how it works and just build it into the system. Or if they're going to start with, let's say, adjusting doses for antihypertensives, maybe just see how that works. Or if they’re treating minor ailments, maybe start with one thing, rather than many things at the same time... introduce it gradually. (Clinician 05, nephrologist, 20 years of practice) Patient and clinician buy-in We would have to ensure that patients would be comfortable in receiving direct prescription from the pharmacist involved in their care. (Clinician 11, nephrologist, 9 years of practice) You have to have physician buy in... I don't know if they're willing to, how comfortable they are. I can't speak for them because I'm not a physician. But some might say, yeah, it will make my job easier. But then that's taking away a bit of their role and billing. (Clinician 03, nurse practitioner, 12 years of practice) Resources to support increased responsibility of pharmacists If pharmacists are taking on another role of prescribing, they should have more allocated resources, so additional pharmacist [full-time equivalent] and presence on the unit… ensuring that there is enough money and resources to support pharmacists playing a bigger role on the dialysis unit. (Clinician 02, pharmacist, 12 years of practice) Clearly defined responsibilities and communication among the HD care team We'd have to ensure there was a clear understanding from our nursing staff as to what medications our pharmacy team may be able to assist with in prescribing versus medications that would not be… It may be helpful that there be a particular notification strategy for the pharmacists to advise the nephrologists or fellows regarding a prescription addition or change. (Clinician 11, nephrologist, 9 years of practice) Inform patients of changes (e.g., verbal, written, digital communication) I think e-mail, at least for me, and perhaps text messages... also in print. Patients can be handed a flyer or something, newsletter or something notifying the new policy… That the pharmacist is now capable of doing prescribing and perhaps the circumstances under which the pharmacist is able to do so. (Patient 02, male, age 74) It's important to have different methods that they're being conveyed this information through just to make sure that every single one of them is fully aware of what's going on. So, the portal could be one, the patient newsletter could be one, word of mouth by the unit staff, unit clerk, nurses, pharmacists, and nephrologists during rounds. So just reiterating the change often. (Clinician 04, dietitian, 3 years of practice) Theme 1: Strengths and challenges of the current prescribing process for patients on hemodialysis Patients and clinicians identified several environmental context- and resource- related strengths and challenges in current prescribing practices for patients on HD. Strengths included accessibility of prescribers and interdisciplinary collaboration, while challenges centered on communication gaps among multiple prescribers, resulting in delays in care. The EMR system was viewed as both a strength and challenge. Many patients reported that prescribers in the HD unit are readily accessible, and that requesting prescriptions is generally straightforward. Both patients and clinicians highlighted the convenience of electronic faxing, which allows prescriptions to be sent directly to community pharmacies. However, some patients described delays in receiving medications when pharmacies needed to contact prescribers for clarification. While several clinicians emphasized that interdisciplinary collaboration among the HD care team is a strength, the involvement of multiple or rotating prescribers in the HD unit, such as fellows, can lead to miscommunication, lack of follow-up, and delays in care. Many clinicians reported that the hospital’s EMR system supports prescribing through its convenience and record-keeping functions, though some mentioned limitations, such as difficulty navigating the system or inaccuracies in medication lists. Theme 2: Perceived role of pharmacists in the hemodialysis unit Participants described pharmacists as integral members of the HD care team, valued for their social or professional roles and identities within the unit. Subthemes included expertise in optimizing medication management, patient education, accessibility as members of the care team, and support with prescribing-related administrative tasks. Many clinicians, including a nurse practitioner and several nephrologists, characterized pharmacists as medication experts, providing examples of HD pharmacists optimizing therapeutic regimens and resolving clinical issues, such as identifying missing medications and adjusting doses to prevent complications. Several patients emphasized pharmacists’ approachability and availability, noting that they were accessible through structured counseling or upon request to address medication-related concerns. Some clinicians, particularly nephrologists, further highlighted pharmacists’ involvement in administrative activities, including liaising with community pharmacies and assisting with drug access and coverage programs. Theme 3: Perceived benefits and barriers of pharmacist prescribing Patients and clinicians identified potential benefits and one perceived barrier of pharmacist prescribing (beliefs about consequences, beliefs about capabilities, knowledge, and skills ). Benefits include leveraging pharmacists’ clinical expertise and established rapport with patients, enhanced medication adherence and safety, improved workflow efficiency, and pharmaco-economic savings. A barrier is that some pharmacists may lack sufficient knowledge to prescribe. Most participants expressed confidence in pharmacists’ prescribing capabilities, citing their knowledge and expertise. Patients described pharmacists in the HD unit as “accessible, friendly, knowledgeable, caring, and articulate,” noting “the trust and the qualification already demonstrated.” Many clinicians, including one nephrologist, believed that granting pharmacists prescribing authority would be “taking advantage of a skillset that they have,” and noted that pharmacists’ existing relationships with patients and knowledge of patients’ medical histories could support continuity of care. However, one nephrologist noted variability in pharmacists’ knowledge and capabilities, stating “there are some pharmacists who I would trust implicitly and there are other pharmacists I would not wish them to be involved with any prescribing... it's a knowledge base”. Clinicians also reported that pharmacist prescribing could improve patient safety by optimizing medication regimens, and several nephrologists highlighted pharmacists’ expertise in adherence strategies, including blister packing, patient-centered formulations, and patient education. Both patients and clinicians suggested that pharmacist prescribing could reduce physicians’ workload, allowing them to prioritize other areas of care. Notably, several nephrologists and both dietitians emphasized the value of pharmacist prescribing in addressing minor or primary care-related concerns, particularly for patients without a family physician who request prescriptions during in-centre dialysis sessions. Many clinicians noted that pharmacist prescribing authority could streamline workflows, as pharmacists are already involved in prescribing decisions, and formal authority could “cut out the middleman”, reducing delays caused by requiring another prescriber to finalize orders. Finally, one nephrologist and one pharmacist mentioned that pharmacists’ knowledge of medication cost and coverage, combined with their role in medication optimization, may contribute to pharmaco-economic savings. Theme 4: Implementation considerations for pharmacist prescribing Interview participants identified several key considerations for implementing pharmacist prescribing in the HD unit, including collaborative prescribing, maintaining physician oversight, targeting specific clinical areas, adopting a phased approach, securing patient and clinician buy-in, ensuring adequate resources to support pharmacists’ expanded responsibilities, establishing clear roles and communication within the HD care team, and informing patients of changes. A few patients and clinicians preferred a team-based approach to prescribing to ensure “more eyes on it than just one person” and to maintain consistent communication across the HD care team. Many patients, along with a nephrologist and a pharmacist, emphasized the need for continued physician oversight (reinforcement) . Clinicians suggested initiating prescribing in certain domains, such as prescription refills, minor ailments (e.g., gastroesophageal reflux disease), or specific clinical areas such as anticoagulation, antihypertensive es, or calcium-phosphate homeostasis ( reinforcement ). Many clinicians, particularly nephrologists, recommended a phased approach with gradual expansion of prescribing responsibilities, accompanied by frequent review and adjustment of scope (reinforcement). Clinicians further emphasized the importance of patient and clinician buy-in (reinforcement) . Participants highlighted consideration of environmental context and resources , social influences, and goals . Clinicians noted a need for adequate pharmacy staffing and remuneration for expanded clinical duties. Most participants, especially clinicians, expressed the importance for a well-defined scope of practice, clear guidelines, and strong communication processes among the HD care team, to support implementation of pharmacist prescribing. Lastly, all participants recommended informing patients of changes verbally at the bedside, or through written or digital communication (e.g., newsletters, patient portals), with some suggesting reiterating the change during monthly rounds. DISCUSSION This study explored patient and clinician perspectives on pharmacist prescribing in the outpatient HD unit at Toronto General Hospital, University Health Network in Toronto, Canada. Qualitative interview findings indicate openness to pharmacist prescribing in HD settings, with successful implementation dependent on several factors, including adequate training, additional resources, interdisciplinary collaboration, and gradual implementation. The use of TDF in our analysis helped to identify specific barriers, facilitators, and implementation considerations for pharmacist prescribing. Pharmacists were perceived as well-positioned to prescribe, given their expertise in medication management and established rapport with patients ( social or professional role and identity ) . Patients and clinicians highlighted potential benefits of pharmacist prescribing, including enhanced medication optimization and safety, improved workflow efficiency, timely care, and pharmaco-economic savings (beliefs about consequences) . One clinician noted that some pharmacists may lack the expertise to prescribe ( beliefs about capabilities, knowledge, and skills ). However, there was strong support for pharmacist prescribing within a collaborative model under physician oversight ( reinforcement) . Some clinicians recommended restricting pharmacist prescribing to areas such as prescription renewals, antihypertensives, and anticoagulants, and many suggested a phased approach to implementation (reinforcement) . Participants noted that expanding pharmacists’ roles would require patient and clinician buy-in (reinforcement) and additional resources, such as funding and personnel (environmental context and resources) . A clearly defined scope of practice and strong communication within the HD care team and with patients were further emphasized as important for successful implementation (goals, social influences). These findings contribute to the existing literature on pharmacist prescribing in both community and hospital-based settings [47–49]. For example, research in Alberta – the first Canadian province to authorize independent pharmacist prescribing – highlighted the importance of providing remuneration, establishing communication strategies, and addressing EMR adaptation, staffing, and workload to support pharmacists’ expanded role [47, 48, 50]. A key issue raised by participants was the need for effective collaboration and communication among prescribers. Fragmented communication between prescribers, including those outside of the HD unit, such as family physicians, was identified as a challenge in the current prescribing process, sometimes leading to delays in patient care and access to medications. Introducing pharmacist prescribing should therefore be accompanied by strategies to strengthen communication within the HD team and across the patient’s circle of care to ensure continuity of care. One approach may involve optimizing the use of EMR systems and reinforcing comprehensive documentation practices regarding patient medications. Still, communication across care teams remains a persistent challenge in healthcare, especially in HD settings where patients often have complex, multifaceted health needs. Consistent with our findings, previous studies on pharmacist prescribing have demonstrated high patient satisfaction with pharmacist counseling, improved quality of life [51–53], reductions in medication-related problems, and improved clinical outcomes, often achieved through collaboration with nephrologists or the HD care team [8, 50]. Reported benefits, including improved patient care and reduced physician workload [40, 47, 51, 52], as well as barriers such as discomfort with increased responsibility, resource pressures, and the need for robust training and accreditation identified in several studies [36, 40, 47, 49, 53–55], further align with our findings. For example, while patients and clinicians in our study viewed pharmacists as capable of prescribing and highlighted several potential benefits, their comfort was contingent on a collaborative prescribing model and ensuring physician oversight was maintained. This indicates that there may be limited support for independent pharmacist prescribing. Furthermore, one nephrologist raised concerns that some pharmacists may lack the skills to prescribe, suggesting that pharmacists may require additional education and training to undertake prescribing. Finally, while interview participants acknowledged that pharmacist prescribing could reduce physicians’ workload, some noted that expanded prescribing responsibilities would require additional resources, such as increased compensation and staffing, to ensure pharmacists’ focus remains on critical aspects of patient care. Further research is needed to assess the feasibility of implementing pharmacist prescribing across diverse HD settings. To our knowledge, this is the first study to use qualitative interviews to explore both patient and clinician perspectives on pharmacist prescribing in outpatient HD units [39–41]. Capturing the views of patients, pharmacists, physicians, and other clinicians is critical to developing policies that address the unique complexities of HD care. Convenience sampling was employed to maximize recruitment and reduce bias among over 300 patients in the outpatient HD unit at TGH-UHN. Rigorous data analysis was conducted, with interview transcripts independently analyzed by multiple research team members to ensure high inter-rater reliability. Furthermore, the analyzed themes were mapped deductively to the Theoretical Domain Framework, a widely recognized tool for identifying factors that influence policy implementation and support intervention design. Some limitations should be noted. Patients who did not speak English and those with cognitive impairment were excluded, limiting generalizability. Due to resource constraints, patients on the evening or nocturnal HD shifts were also excluded, which may have led to an overestimation of openness to pharmacist prescribing, as these patients have fewer interactions with pharmacists. Finally, this study was conducted at a single HD unit in an urban, academic hospital, and pharmacist involvement may differ across HD settings. Future research should involve diverse patient populations and geographically varied HD centers, including rural and remote areas, to capture broader perspectives. CONCLUSION These findings may inform future implementation of pharmacist prescribing in HD units. Expanding interviews across additional HD settings may identify further barriers and facilitators, offering valuable insight into safe and effective implementation. Declarations Corresponding author *Marisa Battistella, BSc Phm, Pharm D, ACPR, Department of Pharmacy, University Health Network, 200 Elizabeth St., EB 214, Toronto, ON, Canada, M5G 2C4 Competing interests The authors declare no competing interests. Ethics approval This study received approval from the University Health Network Research Ethics Board (Study ID: 25-5303). Consent to participate Informed consent was obtained from all individual participants included in the study. Funding The authors declare that no funds, grants, or other support were received. Author Contribution Conceptualization: Marisa Battistella, Madeline Theodorlis; Methodology: Marisa Battistella, Madeline Theodorlis; Formal analysis and investigation: Marisa Battistella, Angela S. Choi, Madeline Theodorlis, Angelina Abbaticchio; Writing – original draft preparation: Angela S. Choi, Madeline Theodorlis, Angelina Abbaticchio; Writing – review and editing: Marisa Battistella, Angela S. Choi, Madeline Theodorlis, Angelina Abbaticchio; Supervision: Marisa Battistella. All authors read and approved the final manuscript. Acknowledgement Thank you to Mary Paul and Amber Authier at Toronto General Hospital, University Health Network for pilot-testing the interview guides. Data Availability Full data are available from the corresponding author on reasonable request. References Canadian Institute for Health Information. Annual statistics on organ replacement in Canada, 2012 to 2021. 2023 https://www.cihi.ca/en/annual-statistics-on-organ-replacement-in-canada-2012-to-2021 . Accessed 26 March 2025. Chiu Y-W, Teitelbaum I, Misra M, de Leon EM, Adzize T, Mehrotra R. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol. 2009;4:1089–96. https://doi.org/10.2215/CJN.00290109 . Battistella M, Fleites R, Wong R, Jassal SV. 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Supplementary Files OnlineResource1.pdf OnlineResource2.pdf OnlineResource3.pdf Cite Share Download PDF Status: Published Journal Publication published 17 Jan, 2026 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted Editorial decision: Revision requested 05 Dec, 2025 Reviews received at journal 05 Dec, 2025 Reviews received at journal 30 Nov, 2025 Reviews received at journal 28 Nov, 2025 Reviewers agreed at journal 21 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviewers agreed at journal 14 Nov, 2025 Reviewers invited by journal 14 Nov, 2025 Editor assigned by journal 14 Nov, 2025 Submission checks completed at journal 14 Nov, 2025 First submitted to journal 13 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Patients receiving HD typically undergo four-hour treatments three times per week and take an average of 12 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e±\u003c/span\u003e 5) medications daily [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These medications often require specific timing around dialysis sessions and are frequently adjusted based on blood work results. Furthermore, patients undergoing HD often interact with multiple healthcare services and providers regarding their medication management. For example, a nephrologist may adjust medications for electrolyte balance, a family physician may prescribe antibiotics for an infection, and a pharmacist may provide patients with relevant medication counseling.\u003c/p\u003e\u003cp\u003ePharmacists serve as integral members of multidisciplinary HD care teams, providing evidence-based recommendations on medication selection, dosing, and therapeutic monitoring, often in collaboration with physicians and other prescribers and in accordance with regulatory standards [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Pharmacists play a key role in managing medication non-adherence, prescription renewals, and duplicate or missing medications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], all of which contribute to safer medication use by reducing inappropriate prescribing and optimizing therapy [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e–\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Pharmacist-led interventions, such as deprescribing, can significantly reduce pill burden and improve adherence without compromising patient safety [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In addition, pharmacists support patient-centered care through counseling and motivational interviewing, which reduce medication-related problems, improve satisfaction and adherence, and enhance overall patient outcomes [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile prescribing is typically performed by physicians and nurse practitioners [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], pharmacists are becoming increasingly recognized within the medical community as qualified to prescribe given their expertise in pharmacology, therapeutics, disease management, pharmacokinetics, drug interactions, and adverse effects [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e–\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In Alberta, Canada, both community and hospital pharmacists can independently adapt, renew, and initiate prescriptions, with additional prescribing authorization available [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In some other Canadian provinces, such as Ontario, community pharmacists have the authority to prescribe for minor ailments such as uncomplicated urinary tract infections, gastroesophageal reflux disease, and conjunctivitis [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Evidence suggests that pharmacist prescribing is both safe and effective [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and in settings where pharmacists have prescribing rights, patients and healthcare providers report positive outcomes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. For instance, sharing prescribing responsibilities with pharmacists reduces physicians’ workload, allowing them more time to manage other complex health issues [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Furthermore, pharmacists’ role in prescribing may reduce healthcare costs by optimizing drug therapy and preventing hospital readmissions [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite growing evidence that pharmacists possess the knowledge and skillset to prescribe safely, several challenges remain to support this practice in HD centers [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. These include concerns related to liability, inter-provider communication, and inadequate infrastructure, such as time, staffing, training resources, and technology [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Addressing these barriers requires coordinated efforts, including policy changes and organizational supports [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Given the complexities of medication management for patients receiving HD, multidisciplinary teams with clear communication pathways are essential to ensure safe and effective pharmacist prescribing [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Ongoing education and training for pharmacists and other healthcare providers are also critical to the successful integration of pharmacists into prescribing models in HD settings [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. To date, no study has explored patient and clinician views regarding pharmacist prescribing in outpatient HD centers [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e–\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and research is needed to identify barriers and facilitators for its successful implementation.\u003c/p\u003e\n\u003ch3\u003eAIM\u003c/h3\u003e\n\u003cp\u003eThis study examines patient and clinician perspectives on pharmacist prescribing in an outpatient HD unit in Toronto, Canada, and aims to generate evidence to support expansion of pharmacists’ prescribing privileges.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003c/div\u003e\u003c/div\u003e\n\n\n\n\n\n\n\n"},{"header":"METHOD","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis study involved one-on-one, semi-structured interviews and adopted a qualitative descriptive design, which aims to provide rich, detailed data that remains a true reflection of participants’ perspectives [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Findings are reported in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003ch3\u003eSetting\u003c/h3\u003e\u003cp\u003eThis single-centre study was conducted in the outpatient HD unit at Toronto General Hospital, University Health Network (TGH-UHN), in Toronto, Ontario, Canada. The research team consisted of the Principal Investigator (MB, female), who is a pharmacy clinician scientist; two research coordinators in the Pharmacy Department (MT, AA), both female with a Master of Public Health; and a pharmacy research student (AC, female). At TGH-UHN, the current prescribing practice for patients on HD typically involves nephrologists and nurse practitioners in the HD unit, and family physicians in the community.\u003c/p\u003e\u003ch3\u003eSampling and recruitment\u003c/h3\u003e\u003cp\u003eParticipants were recruited between June and July 2025. Eligible patients were 18 years or older and receiving HD in the outpatient HD unit at TGH-UHN. Patients were excluded if they did not speak English or had cognitive impairment. The study team approached eligible patients in person during their dialysis session and provided a brief verbal overview of the study. Eligible clinicians included nephrologists, pharmacists, nurse practitioners, and dietitians working in the same unit. Clinicians meeting eligibility criteria were contacted via email by the study team and provided with a description of the study and instructions to contact the team if interested in participating. Participants were recruited until data saturation was reached. All participants provided written informed consent.\u003c/p\u003e\u003ch3\u003eInterview guide development\u003c/h3\u003e\u003cp\u003eThe semi-structured interview guides (Online Resource 1 and 2) were developed by the study coordinators (MT, AA), the pharmacy research student (AC), and the Principal Investigator (MB). The guides included open-ended questions to explore 1) the strengths and challenges of the current prescribing process for patients on HD; 2) the perceived role of pharmacists in the HD unit; and 3) perspectives on pharmacist prescribing in the HD unit. Probing questions were used to capture a comprehensive understanding of participant views. The guides were pilot tested with one social worker from the outpatient HD unit and one patient partner receiving HD at TGH-UHN, then revised based on their feedback to improve clarity.\u003c/p\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eInterviews were conducted by AC between June and July 2025. Patient interviews took place in person, at the bedside during dialysis sessions. Clinician interviews were conducted either in person or via Microsoft Teams, scheduled at the clinician’s convenience. There was no prior relationship between AC and study participants. All interviews were audio-recorded using Microsoft Teams and transcribed verbatim in Microsoft Word. To ensure transcription accuracy and data integrity, the study team reviewed and verified each transcript against the original recordings, after which all audio files were deleted. Identifying information was redacted and transcripts were de-identified. Transcripts were not returned to participants for comment or correction.\u003c/p\u003e\u003cp\u003ePatient demographic data were obtained from patients’ electronic medical record (EMR) or directly from the patient when unavailable in their chart. Variables collected included age, sex, ethnicity, education, marital status, comorbidities (diabetes, hypertension, cardiovascular disease, and dyslipidemia), total number of medications, and dialysis vintage. Clinician demographic data were self-reported and included age, sex, ethnicity, clinical role, and years of clinical practice.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003ePatient and clinician characteristics were summarized using descriptive statistics. Categorical variables were reported as frequencies and percentages, and continuous variables as means with standard deviations, or medians with interquartile ranges. Interview transcripts were analyzed manually using the “comments” and “track changes” features in Microsoft Word. Data analysis followed an iterative process using a general inductive approach, whereby themes and subthemes were derived “directly” from the interview data [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo ensure inter-rater reliability, AC, MT, and AA independently analyzed the first three patient and clinician transcripts to develop a preliminary coding framework. This framework was then applied to all subsequent transcripts, which were independently coded by the same researchers. AC, MT, and AA held regular meetings to discuss discrepancies and refine the framework. Interviews were conducted and analyzed concurrently until thematic saturation was reached and no new themes or subthemes emerged. Participants did not provide feedback on findings.\u003c/p\u003e\u003cp\u003eIdentified themes were then mapped deductively to the Theoretical Domain Framework (TDF), a validated framework developed by psychology theorists and implementation researchers to guide the design of implementation interventions [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The TDF is comprised of 14 domains: \u003cem\u003eknowledge\u003c/em\u003e; \u003cem\u003eskills\u003c/em\u003e; \u003cem\u003esocial/professional role and identity\u003c/em\u003e; \u003cem\u003ebeliefs about capabilities; optimism; beliefs about consequences; reinforcement; intentions; goals; memory, attention and decision processes\u003c/em\u003e; \u003cem\u003eenvironmental context and resources\u003c/em\u003e; \u003cem\u003esocial influences\u003c/em\u003e; \u003cem\u003eemotion\u003c/em\u003e; and \u003cem\u003ebehavioural regulation\u003c/em\u003e [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003ch3\u003eEthics approval\u003c/h3\u003e\u003cp\u003e The study received approval from the University Health Network Research Ethics Board (Study ID: 25-5303) on February 1, 2022.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eEleven patients and 11 clinicians (six nephrologists, two pharmacists, two dietitians, and one nurse practitioner) were interviewed between June and July 2025. Interviews lasted between 11 and 26 minutes. Patients had an average age of 66 years, and more than half (55%) were white (Table 1). Clinicians varied widely in their years of clinical practice, ranging from 10 to 19 years (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Patient interview characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"401\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients (N=11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age (\u0026plusmn; SD)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e66 (\u0026plusmn;14)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (45)\u003c/p\u003e\n \u003cp\u003e6 (55)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBlack, African\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBlack, Caribbean\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSouth Asian\u003c/p\u003e\n \u003cp\u003eSoutheast Asian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWhite\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e6 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eElementary school (up to grade 6)\u003c/p\u003e\n \u003cp\u003eMiddle school (up to grade 8)\u003c/p\u003e\n \u003cp\u003eHigh school (up to grade 13)\u003c/p\u003e\n \u003cp\u003eCollege/university\u003c/p\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e7 (64)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003cp\u003eMarried/common law\u003c/p\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e5 (45)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003cp\u003eCardiovascular disease\u003c/p\u003e\n \u003cp\u003eLipid disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (64)\u003c/p\u003e\n \u003cp\u003e8 (82)\u003c/p\u003e\n \u003cp\u003e6 (55)\u003c/p\u003e\n \u003cp\u003e6 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number of medications (\u0026plusmn; SD)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e11 (\u0026plusmn; 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian dialysis vintage, in months (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e32 (10-48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian dialysis vintage at TGH-UHN, in months (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e27 (10-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation: SD, standard deviation; IQR, interquartile range; TGH-UHN, Toronto General Hospital \u0026ndash; University Health Network\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Clinician interview characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"401\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinicians (N=11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age (\u0026plusmn; SD)*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e45 (\u0026plusmn; 12)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (45)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (55)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBlack, African\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEast Asian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSouth Asian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSoutheast Asian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWhite\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e4 (36)\u003c/p\u003e\n \u003cp\u003e4 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical role (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDietitian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNephrologist\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNurse practitioner\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e6 (55)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian years of clinical practice (IQR)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e12 (10-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation: SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003e*n=10; one clinician preferred not to answer\u003c/p\u003e\n\u003cp\u003eFour main themes, along with several subthemes, were identified from patient and clinician interviews. Nine TDF domains, noted in italics below, were mapped to the identified themes and subthemes. A summary of themes, subthemes, and exemplary quotes mapped to the TDF are in Table 3. All patient and clinician interview data are available in Online Resource 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Patient and clinician interview themes, subthemes, and exemplar quotes, mapped to the Theoretical Domain Framework (TDF)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"945\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes and subthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 690px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExemplar quotes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTDF domain(s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 945px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrengths and challenges of the current prescribing process for patients on hemodialysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrescribers are accessible\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eIn the last eight years since I am a dialysis patient, I never have any issues because here, doctor, fill up the prescription... send it right away to [the community pharmacy]. Just go directly over there. And when the medication is ready they call you to pick it up... It\u0026apos;s very convenient whenever you need it. [If] your regular doctor is not available\u0026hellip; [other physicians] always help. (Patient 01, male, age 53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnvironmental context and resources:\u0026nbsp;\u003c/strong\u003eAny circumstance of a person\u0026rsquo;s situation or environment that encourages of discourages the development of skills and abilities, independence, social competence and adaptive behaviour.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunication gaps lead to delays\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eIf one of the several medications doesn\u0026apos;t have a refill, the pharmacist will have to get a fax from the doctor or nurse requesting additional refill\u0026hellip; And as a patient, I find it frustrating to do that particular administrative job... I had to go to the doctor, say \u0026ldquo;the pharmacist wants to know the dose. Could you call the pharmacist and give the dose?\u0026rdquo; It\u0026apos;s just to me, I understand the situation, but it seems a silly thing to delay my receiving the meds. (Patient 11, female, age 69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrong interdisciplinary collaboration\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eOur teams are very collaborative and close-knit, and we work very much together on a lot of the decision making and between rounds and then also just outside of rounds collaborating as needed. (Clinician 01, dietitian, 21 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eElectronic medical record (EMR) system\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003ePrescriptions are entered via our electronic health record, EPIC, and usually electronically faxed directly to patients\u0026rsquo; pharmacies... The electronic prescription format allows for good record keeping to verify when prescriptions have been sent. (Clinician 11, nephrologist, 9 years of practice)\u003c/p\u003e\n \u003cp\u003eSometimes [EMR] it\u0026apos;s difficult to maneuver\u0026hellip; You could click on the wrong thing, so there\u0026apos;s always potential for error... it\u0026apos;s not sometimes as intuitive as you want it. (Clinician 03, nurse practitioner, 12 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMultiple prescribers challenge communication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eSome covering prescribers that are sort of in and out of the unit and come in and maybe make a change but then are not back. I do find at times maybe the follow-up or communication, that\u0026apos;s where you sometimes see the gaps, right, where something has been adjusted and maybe not fully communicated with the team or not an opportunity because they\u0026apos;ve been moved to a different area, different rotation. (Clinician 01, dietitian, 21 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 945px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived role of pharmacists in the hemodialysis unit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOptimize medication management and educate patients\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eTo keep an eye out on the medications that are being prescribed and to see if they\u0026apos;re still relevant... I think they definitely contribute towards the care... asking you to bring the medications in and go over the dosage\u0026hellip; [Explain] the purpose is of something being increased or decreased and how it\u0026apos;s going to affect me, or if a new prescription is ordered, to find out what, if there are chances that I would have some reaction to it and how to deal with whatever the problem is. (Patient 08, female, age 81)\u003c/p\u003e\n \u003cp\u003eThe role of the pharmacist is to review all medications that the patients are taking at home and also that they\u0026apos;re receiving while they\u0026apos;re in the dialysis unit\u0026hellip; Reviewing the appropriateness, the dosing frequency, checking for interactions, reviewing blood work and performing assessments and recommendations for any drug therapy issues that they identify\u0026hellip; Also providing any education to the patients and then collaborating with other healthcare team members. (Clinician 10, pharmacist, 15 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial or professional role and identity:\u0026nbsp;\u003c/strong\u003eA coherent set of behaviours and displayed personal qualities of an individual in a social or work setting.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAccessible members of the care team\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003e[Pharmacists are] always available to answer my questions\u0026hellip; I consider them part of a team in my well-being... they\u0026apos;ve been very helpful, and they are an integral part of my treatment. (Patient 11, female, age 69)\u003c/p\u003e\n \u003cp\u003e[I see the pharmacist] at least monthly\u0026hellip; anytime I have a need [to see them], whether it\u0026apos;s because of the monthly blood work consultation or a complaint that I have or an inquiry that I have, it gets addressed immediately. (Patient 10, male, age 69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssist with administrative tasks of prescribing\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003ePharmacists and pharmacy trainees also assist greatly with reviewing coverage for medications and completion of things like exceptional access forms, which are quite important to allowing for medication coverage and therefore adherence for patients. (Clinician 11, nephrologist, 9 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 945px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived benefits and barriers of pharmacist prescribing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eImprove workflow efficiency and timely care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eI mean, it could help. Yeah, obviously, the more care you have, including pharmacists that can help you if it\u0026apos;s to prescribe even minor medications to help, totally fine with that... the more care you have, the better\u0026hellip; You have the pharmacist helping you, you\u0026apos;re taking some of the work off the doctors, so you\u0026apos;re helping everybody in general. (Patient 09, male, age 50)\u003c/p\u003e\n \u003cp\u003eIt really would free up the ability for these physicians or nurse practitioners to take care of patients in other ways and not be, if needed, and deal with other patients or more acute issues that are coming from either nursing concerns or patient concerns... There could be a model in which the workflow lends to pharmacists being the most readily available clinician that can be involved in prescribing and adjusting these types of medications... allowing pharmacists maybe in addition to already the prescribers that are available to do that does add more, it could lend to patients getting better care and more timely care. (Clinician 02, pharmacist, 12 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeliefs about consequences:\u0026nbsp;\u003c/strong\u003eAcceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBeliefs about capabilities:\u003c/strong\u003e Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge:\u0026nbsp;\u003c/strong\u003eAn awareness of the existence of something.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSkills:\u0026nbsp;\u003c/strong\u003eAn ability or proficiency acquired through practice.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSupport medication adherence and safety\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003e[Pharmacists] are more concentrating on the medication aspect of things, they can spend more time reviewing the indications, the contradictions, the side effects\u0026hellip; patients might appreciate that. Just having somebody that can spend a little bit more time going through their medications and helping them with strategies to ensure better adherence and access. (Clinician 07, nephrologist, 10 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePharmaco-economic savings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eThere\u0026apos;s probably also actually definitely some cost saving perspectives both from the patients, if they\u0026apos;re getting medications as outpatients, but also on the unit. I do think if pharmacists were prescribing, there could be more judicious use of some medications that could lead to cost savings for the units as well. (Clinician 02, pharmacist, 12 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePharmacists have existing rapport with patients\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eOur staff pharmacist, many of the patients have a pretty solid relationship with that pharmacist\u0026hellip; the prescribing role of pharmacists, I actually support that because I think it allows the team to utilize their strengths and experience for the patient, for patient care going forward... it\u0026apos;s taking advantage of a skillset that they have. (Clinician 06, nephrologist, 36 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePharmacists\u0026rsquo; skillset and expertise\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eI think that [pharmacists] are very knowledgeable, but to get to use that knowledge more would be excellent... they\u0026rsquo;re professional people; they should be able to use all their capabilities. (Patient 05, female, age 78)\u003c/p\u003e\n \u003cp\u003eIt\u0026apos;s 100% dependent on the pharmacist... There are some pharmacists who I would trust implicitly and there are other pharmacists I would not wish them to be involved with any prescribing... it\u0026apos;s a knowledge base. I think some pharmacists have an incredibly high knowledge base and have incredibly solid academic thinking patterns... But there are other pharmacists where I will double check things just because I feel that there is a significant knowledge gap and a lack of familiarity with the clinical scenarios. (Clinician 08, nephrologist, prefer not to answer)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 945px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation considerations for pharmacist prescribing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCollaborative prescribing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eI\u0026apos;d probably feel more comfortable with it as long as they\u0026apos;re willing to cross reference with others\u0026hellip; I just get very uncomfortable if it was just, I guess one person calling the shot... So at least everybody\u0026apos;s on the same page... I would prefer more eyes on it than just one person. (Patient 06, female, age 37)\u003c/p\u003e\n \u003cp\u003eAs long as there\u0026apos;s communication that everyone\u0026apos;s on the same page, I have no problem with that... It has to be informed and it has to be sort of endorsed or vetted by everybody else within the clinical team...\u0026nbsp;What would matter is that you have consulted with the physician or the [nurse practitioner]. (Clinician 03, nurse practitioner, 12 years of practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReinforcement:\u003c/strong\u003e Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEnvironmental context and resources:\u0026nbsp;\u003c/strong\u003eAny circumstance of a person\u0026rsquo;s situation or environment that encourages of discourages the development of skills and abilities, independence, social competence and adaptive behaviour.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSocial influences:\u0026nbsp;\u003c/strong\u003eThose interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGoals:\u0026nbsp;\u003c/strong\u003eMental representations of outcomes or end states that an individual wants to achieve.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmphasis on physician oversight\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eIf you were to change like my heart medication for example, I would want my cardiologist to agree to that. And confirm with the pharmacist, not that I don\u0026apos;t trust the pharmacist, but I\u0026apos;d want confirmation for my comfort to know that my cardiologist would agree to that. (Patient 09, male, age 50)\u003c/p\u003e\n \u003cp\u003eI think the medical practitioner should still be the primary prescriber, but giving pharmacists the ability to prescribe if needed versus, you know, I guess deferring that entire prescribing practice to the pharmacist. (Clinician 10, pharmacist, 15 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSupport for prescribing in specific clinical areas\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eIf the pharmacist could prescribe, I\u0026rsquo;m not sure about new tablets but certainly ones that the doctors have approved to be refilled, they can be refilled. (Patient 05, female, age 78)\u003c/p\u003e\n \u003cp\u003eMedications that could be deprescribed or dose dependent could be used, like warfarin for example, those kinds of things that you can kind of titrate, titratable medications\u0026hellip; Calcium [phosphate] binders\u0026hellip; Antihypertensives would be another option to focus on\u0026hellip; Medications that can be relatively easily protocolized like EPO medications, iron, those would be a good start. (Clinician 07, nephrologist, 10 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhased approach to implementation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eI think it should be a phased approach. So maybe start with one thing, so we start with anticoagulation, then see how it works and just build it into the system. Or if they\u0026apos;re going to start with, let\u0026apos;s say, adjusting doses for antihypertensives, maybe just see how that works. Or if they\u0026rsquo;re treating minor ailments, maybe start with one thing, rather than many things at the same time... introduce it gradually. (Clinician 05, nephrologist, 20 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient and clinician buy-in\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eWe would have to ensure that patients would be comfortable in receiving direct prescription from the pharmacist involved in their care. (Clinician 11, nephrologist, 9 years of practice)\u003c/p\u003e\n \u003cp\u003eYou have to have physician buy in... I don\u0026apos;t know if they\u0026apos;re willing to, how comfortable they are. I can\u0026apos;t speak for them because I\u0026apos;m not a physician. But some might say, yeah, it will make my job easier. But then that\u0026apos;s taking away a bit of their role and billing. (Clinician 03, nurse practitioner, 12 years of practice)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eResources to support increased responsibility of pharmacists\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eIf pharmacists are taking on another role of prescribing, they should have more allocated resources, so additional pharmacist [full-time equivalent] and presence on the unit\u0026hellip; ensuring that there is enough money and resources to support pharmacists playing a bigger role on the dialysis unit. (Clinician 02, pharmacist, 12 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eClearly defined responsibilities and communication among the HD care team\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eWe\u0026apos;d have to ensure there was a clear understanding from our nursing staff as to what medications our pharmacy team may be able to assist with in prescribing versus medications that would not be\u0026hellip; It may be helpful that there be a particular notification strategy for the pharmacists to advise the nephrologists or fellows regarding a prescription addition or change. (Clinician 11, nephrologist, 9 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eInform patients of changes (e.g., verbal, written, digital communication)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 690px;\"\u003e\n \u003cp\u003eI think e-mail, at least for me, and perhaps text messages... also in print. Patients can be handed a flyer or something, newsletter or something notifying the new policy\u0026hellip; That the pharmacist is now capable of doing prescribing and perhaps the circumstances under which the pharmacist is able to do so. (Patient 02, male, age 74)\u003c/p\u003e\n \u003cp\u003eIt\u0026apos;s important to have different methods that they\u0026apos;re being conveyed this information through just to make sure that every single one of them is fully aware of what\u0026apos;s going on. So, the portal could be one, the patient newsletter could be one, word of mouth by the unit staff, unit clerk, nurses, pharmacists, and nephrologists during rounds. So just reiterating the change often. (Clinician 04, dietitian, 3 years of practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Strengths and challenges of the current prescribing process for patients on hemodialysis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients and clinicians identified several \u003cem\u003eenvironmental context- and resource-\u003c/em\u003erelated strengths and challenges in current prescribing practices for patients on HD. Strengths included accessibility of prescribers and interdisciplinary collaboration, while challenges centered on communication gaps among multiple prescribers, resulting in delays in care. The EMR system was viewed as both a strength and challenge.\u003c/p\u003e\n\u003cp\u003eMany patients reported that prescribers in the HD unit are readily accessible, and that requesting prescriptions is generally straightforward. Both patients and clinicians highlighted the convenience of electronic faxing, which allows prescriptions to be sent directly to community pharmacies. However, some patients described delays in receiving medications when pharmacies needed to contact prescribers for clarification. While several clinicians emphasized that interdisciplinary collaboration among the HD care team is a strength, the involvement of multiple or rotating prescribers in the HD unit, such as fellows, can lead to miscommunication, lack of follow-up, and delays in care. Many clinicians reported that the hospital\u0026rsquo;s EMR system supports prescribing through its convenience and record-keeping functions, though some mentioned limitations, such as difficulty navigating the system or inaccuracies in medication lists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Perceived role of pharmacists in the hemodialysis unit\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described pharmacists as integral members of the HD care team, valued for their \u003cem\u003esocial or professional roles and identities\u003c/em\u003e within the unit. Subthemes included expertise in optimizing medication management, patient education, accessibility as members of the care team, and support with prescribing-related administrative tasks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany clinicians, including a nurse practitioner and several nephrologists, characterized pharmacists as medication experts, providing examples of HD pharmacists optimizing therapeutic regimens and resolving clinical issues, such as identifying missing medications and adjusting doses to prevent complications. Several patients emphasized pharmacists\u0026rsquo; approachability and availability, noting that they were accessible through structured counseling or upon request to address medication-related concerns. Some clinicians, particularly nephrologists, further highlighted pharmacists\u0026rsquo; involvement in administrative activities, including liaising with community pharmacies and assisting with drug access and coverage programs. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Perceived benefits and barriers of pharmacist prescribing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients and clinicians identified potential benefits and one perceived barrier of pharmacist prescribing \u003cem\u003e(beliefs about consequences, beliefs about capabilities, knowledge, and skills\u003c/em\u003e). Benefits include leveraging pharmacists\u0026rsquo; clinical expertise and established rapport with patients, enhanced medication adherence and safety, improved workflow efficiency, and pharmaco-economic savings. A barrier is that some pharmacists may lack sufficient knowledge to prescribe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost participants expressed confidence in pharmacists\u0026rsquo; prescribing capabilities, citing their knowledge and expertise. Patients described pharmacists in the HD unit as \u0026ldquo;accessible, friendly, knowledgeable, caring, and articulate,\u0026rdquo; noting \u0026ldquo;the trust and the qualification already demonstrated.\u0026rdquo; Many clinicians, including one nephrologist, believed that granting pharmacists prescribing authority would be \u0026ldquo;taking advantage of a skillset that they have,\u0026rdquo;\u003cem\u003e\u0026nbsp;\u003c/em\u003eand noted that pharmacists\u0026rsquo; existing relationships with patients and knowledge of patients\u0026rsquo; medical histories could support continuity of care. However, one nephrologist noted variability in pharmacists\u0026rsquo; knowledge and capabilities, stating \u0026ldquo;there are some pharmacists who I would trust implicitly and there are other pharmacists I would not wish them to be involved with any prescribing... it\u0026apos;s a knowledge base\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eClinicians also reported that pharmacist prescribing could improve patient safety by optimizing medication regimens, and several nephrologists highlighted pharmacists\u0026rsquo; expertise in adherence strategies, including blister packing, patient-centered formulations, and patient education.\u003c/p\u003e\n\u003cp\u003eBoth patients and clinicians suggested that pharmacist prescribing could reduce physicians\u0026rsquo; workload, allowing them to prioritize other areas of care. Notably, several nephrologists and both dietitians emphasized the value of pharmacist prescribing in addressing minor or primary care-related concerns, particularly for patients without a family physician who request prescriptions during in-centre dialysis sessions. Many clinicians noted that pharmacist prescribing authority could streamline workflows, as pharmacists are already involved in prescribing decisions, and formal authority could \u0026ldquo;cut out the middleman\u0026rdquo;,\u003cem\u003e\u0026nbsp;\u003c/em\u003ereducing delays caused by requiring another prescriber to finalize orders. Finally, one nephrologist and one pharmacist mentioned that pharmacists\u0026rsquo; knowledge of medication cost and coverage, combined with their role in medication optimization, may contribute to pharmaco-economic savings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 4: Implementation considerations for pharmacist prescribing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterview participants identified several key considerations for implementing pharmacist prescribing in the HD unit, including collaborative\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eprescribing, maintaining physician oversight, targeting specific clinical areas, adopting a phased approach, securing patient and clinician buy-in, ensuring adequate resources to support pharmacists\u0026rsquo; expanded responsibilities, establishing clear roles and communication within the HD care team, and informing patients of changes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA few patients and clinicians preferred a team-based approach to prescribing to ensure \u0026ldquo;more eyes on it than just one person\u0026rdquo; and to maintain consistent communication across the HD care team. Many patients, along with a nephrologist and a pharmacist, emphasized the need for continued physician oversight \u003cem\u003e(reinforcement)\u003c/em\u003e. Clinicians suggested initiating prescribing in certain domains, such as prescription refills, minor ailments (e.g., gastroesophageal reflux disease), or specific clinical areas such as anticoagulation, antihypertensive\u003c/p\u003e\n\u003cp\u003ees, or calcium-phosphate homeostasis (\u003cem\u003ereinforcement\u003c/em\u003e). Many clinicians, particularly nephrologists, recommended a phased approach with gradual expansion of prescribing responsibilities, accompanied by frequent review and adjustment of scope \u003cem\u003e(reinforcement).\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eClinicians further emphasized the importance of patient and clinician buy-in \u003cem\u003e(reinforcement)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eParticipants highlighted consideration of \u003cem\u003eenvironmental context and resources\u003c/em\u003e, \u003cem\u003esocial influences, and goals\u003c/em\u003e. Clinicians noted a need for adequate pharmacy staffing and remuneration for expanded clinical duties. Most participants, especially clinicians, expressed the importance for a well-defined scope of practice, clear guidelines, and strong communication processes among the HD care team, to support implementation of pharmacist prescribing. Lastly, all participants recommended informing patients of changes verbally at the bedside, or through written or digital communication (e.g., newsletters, patient portals), with some suggesting reiterating the change during monthly rounds.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explored patient and clinician perspectives on pharmacist prescribing in the outpatient HD unit at Toronto General Hospital, University Health Network in Toronto, Canada. Qualitative interview findings indicate openness to pharmacist prescribing in HD settings, with successful implementation dependent on several factors, including adequate training, additional resources, interdisciplinary collaboration, and gradual implementation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe use of TDF in our analysis helped to identify specific barriers, facilitators, and implementation considerations for pharmacist prescribing. Pharmacists were perceived as well-positioned to prescribe, given their expertise in medication management and established rapport with patients \u003cem\u003e(\u003c/em\u003e\u003cem\u003esocial or professional role and identity\u003c/em\u003e\u003cem\u003e)\u003c/em\u003e.\u0026nbsp;Patients and clinicians highlighted\u0026nbsp;potential benefits of pharmacist prescribing, including enhanced medication optimization and safety, improved workflow efficiency, timely care, and pharmaco-economic savings\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e(beliefs about consequences)\u003c/em\u003e. One clinician noted that some pharmacists may lack the expertise to prescribe\u0026nbsp;(\u003cem\u003ebeliefs about capabilities, knowledge, and skills\u003c/em\u003e). However, there was strong support for pharmacist prescribing within a collaborative model\u0026nbsp;under\u0026nbsp;physician oversight (\u003cem\u003ereinforcement)\u003c/em\u003e. Some clinicians recommended restricting pharmacist prescribing to areas such as prescription renewals, antihypertensives, and anticoagulants, and many suggested a phased approach to implementation \u003cem\u003e(reinforcement)\u003c/em\u003e. Participants noted that expanding pharmacists\u0026rsquo; roles would require patient and clinician buy-in \u003cem\u003e(reinforcement)\u003c/em\u003e and\u0026nbsp;additional resources, such as funding and personnel \u003cem\u003e(environmental context and resources)\u003c/em\u003e.\u0026nbsp;A clearly defined scope of practice\u0026nbsp;and strong\u0026nbsp;communication\u0026nbsp;within\u0026nbsp;the HD care team and with patients were further emphasized as important for successful implementation \u003cem\u003e(goals, social influences).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese findings contribute to the existing literature on pharmacist prescribing in both community and hospital-based settings [47\u0026ndash;49]. For example, research in Alberta \u0026ndash; the first Canadian province to authorize independent pharmacist prescribing \u0026ndash; highlighted the importance of providing remuneration, establishing communication strategies, and addressing EMR adaptation, staffing, and workload to support pharmacists\u0026rsquo; expanded role [47, 48, 50].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA key issue raised by participants was the need for effective collaboration and communication among prescribers. Fragmented communication between prescribers, including those outside of the HD unit, such as family physicians, was identified as a challenge in the current prescribing process, sometimes leading to delays in patient care and access to medications. Introducing pharmacist prescribing should therefore be accompanied by strategies to strengthen communication within the HD team and across the patient\u0026rsquo;s circle of care to ensure continuity of care. One approach may involve optimizing the use of EMR systems and reinforcing comprehensive documentation practices regarding patient medications. Still, communication across care teams remains a persistent challenge in healthcare, especially in HD settings where patients often have complex, multifaceted health needs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsistent with our findings, previous studies on pharmacist prescribing have demonstrated high patient satisfaction with pharmacist counseling, improved quality of life [51\u0026ndash;53], reductions in medication-related problems, and improved clinical outcomes, often achieved through collaboration with nephrologists or the HD care team [8, 50]. Reported benefits, including improved patient care and reduced physician workload [40, 47, 51, 52],\u0026nbsp;as well as barriers such as discomfort with increased responsibility, resource pressures, and the need for robust training and accreditation identified in several studies [36, 40, 47, 49, 53\u0026ndash;55], further align with our findings. For example, while patients and clinicians in our study viewed pharmacists as capable of prescribing and highlighted several potential benefits, their comfort was contingent on a collaborative prescribing model and ensuring physician oversight was maintained. This indicates that there may be limited support for independent pharmacist prescribing. Furthermore, one nephrologist raised concerns that some pharmacists may lack the skills to prescribe, suggesting that pharmacists may require additional education and training to undertake prescribing. Finally, while interview participants acknowledged that pharmacist prescribing could reduce physicians\u0026rsquo; workload, some noted that expanded prescribing responsibilities would require additional resources, such as increased compensation and staffing, to ensure pharmacists\u0026rsquo; focus remains on critical aspects of patient care. Further research is needed to assess the feasibility of implementing pharmacist prescribing across diverse HD settings.\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this is the first study to use qualitative interviews to explore both patient and clinician perspectives on pharmacist prescribing in outpatient HD units [39\u0026ndash;41]. Capturing the views of patients, pharmacists, physicians, and other clinicians is critical to developing policies that address the unique complexities of HD care. Convenience sampling was employed to maximize recruitment and reduce bias among over 300 patients in the outpatient HD unit at TGH-UHN. Rigorous data analysis was conducted, with interview transcripts independently analyzed by multiple research team members to ensure high inter-rater reliability. Furthermore, the analyzed themes were mapped deductively to the Theoretical Domain Framework, a widely recognized tool for identifying factors that influence policy implementation and support intervention design. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome limitations should be noted. Patients who did not speak English and those with cognitive impairment were excluded, limiting generalizability. Due to resource constraints, patients on the evening or nocturnal HD shifts were also excluded, which may have led to an overestimation of openness to pharmacist prescribing, as these patients have fewer interactions with pharmacists. Finally, this study was conducted at a single HD unit in an urban, academic hospital, and pharmacist involvement may differ across HD settings. Future research should involve diverse patient populations and geographically varied HD centers, including rural and remote areas, to capture broader perspectives.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThese findings may inform future implementation of pharmacist prescribing in HD units. Expanding interviews across additional HD settings may identify further barriers and facilitators, offering valuable insight into safe and effective implementation. \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCorresponding author\u003c/h2\u003e\u003cp\u003e*Marisa Battistella, BSc Phm, Pharm D, ACPR, Department of Pharmacy, University Health Network, 200 Elizabeth St., EB 214, Toronto, ON, Canada, M5G 2C4\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003e This study received approval from the University Health Network Research Ethics Board (Study ID: 25-5303).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support were received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: Marisa Battistella, Madeline Theodorlis; Methodology: Marisa Battistella, Madeline Theodorlis; Formal analysis and investigation: Marisa Battistella, Angela S. Choi, Madeline Theodorlis, Angelina Abbaticchio; Writing \u0026ndash; original draft preparation: Angela S. Choi, Madeline Theodorlis, Angelina Abbaticchio; Writing \u0026ndash; review and editing: Marisa Battistella, Angela S. Choi, Madeline Theodorlis, Angelina Abbaticchio; Supervision: Marisa Battistella. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e Thank you to Mary Paul and Amber Authier at Toronto General Hospital, University Health Network for pilot-testing the interview guides.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eFull data are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCanadian Institute for Health Information. 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Ther Adv Drug Saf. 2017;8:183\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2042098617693546\u003c/span\u003e\u003cspan address=\"10.1177/2042098617693546\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pharmacists, pharmacist prescribing, hemodialysis, qualitative interviews","lastPublishedDoi":"10.21203/rs.3.rs-8109125/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8109125/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003ePharmacist prescribing is expanding across care settings, supported by their expertise in pharmacology, therapeutics, disease management, and medication optimization. In settings where pharmacists can prescribe, patients and providers report positive outcomes. However, limited research has examined pharmacist prescribing in dialysis centers.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eThis study explores patient and clinician perspectives on pharmacist prescribing in the outpatient hemodialysis unit at Toronto General Hospital, University Health Network (TGH-UHN) in Toronto, Canada.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eSemi-structured, one-on-one qualitative interviews were conducted with English-speaking adults on hemodialysis, and clinicians, including nephrologists, pharmacists, dietitians, and nurse practitioners in the outpatient hemodialysis unit at TGH-UHN. Participants were recruited through convenience sampling until data saturation was reached. Interviews were audio-recorded, transcribed, and analyzed thematically using an inductive approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEleven patients and 11 clinicians (six nephrologists, two pharmacists, two dietitians, one nurse practitioner) were interviewed in June and July 2025. Participants noted communication gaps and delays as challenges of the current prescribing process, and accessibility of prescribers and interdisciplinary collaboration as strengths. Pharmacists were recognized as valuable care team members given their expertise in medication management and rapport with patients. Potential benefits of pharmacist prescribing included enhanced medication optimization, improved workflow efficiency, timely care, and pharmaco-economic savings. Barriers included limited prescribing knowledge among some pharmacists. Implementation considerations included a collaborative approach, maintaining physician oversight, limiting prescribing to specific clinical areas, phased rollout, patient and clinician buy-in, adequate resources, and clearly defined roles and communication.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWhile patients and clinicians were generally supportive of pharmacist prescribing in the hemodialysis unit, they identified several considerations for implementation. Interviews in additional hemodialysis care settings could offer further insight to guide implementation strategies.\u003c/p\u003e","manuscriptTitle":"Perspectives on pharmacist prescribing in an outpatient dialysis center: Qualitative interviews with patients and clinicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-25 11:07:37","doi":"10.21203/rs.3.rs-8109125/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-05T12:16:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T11:48:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-30T06:03:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-28T09:38:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232911205089256077594823238611255057677","date":"2025-11-21T11:09:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228395836775116520618042516826233757648","date":"2025-11-19T10:53:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150268949580129155665382590251003745816","date":"2025-11-14T08:36:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-14T08:22:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-14T05:05:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T05:05:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Pharmacy","date":"2025-11-13T21:52:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"34a41929-5bb3-4b39-93fb-f5c2d38a953e","owner":[],"postedDate":"November 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:50:21+00:00","versionOfRecord":{"articleIdentity":"rs-8109125","link":"https://doi.org/10.1007/s11096-025-02084-x","journal":{"identity":"international-journal-of-clinical-pharmacy","isVorOnly":false,"title":"International Journal of Clinical Pharmacy"},"publishedOn":"2026-01-17 16:30:59","publishedOnDateReadable":"January 17th, 2026"},"versionCreatedAt":"2025-11-25 11:07:37","video":"","vorDoi":"10.1007/s11096-025-02084-x","vorDoiUrl":"https://doi.org/10.1007/s11096-025-02084-x","workflowStages":[]},"version":"v1","identity":"rs-8109125","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8109125","identity":"rs-8109125","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}