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Table 4 Key themes and subthemes (triangulated with associated TDF domains) as facilitators and barriers

From: Perceived barriers and facilitators to uptake of non-traditional roles by pharmacists in Saudi Arabia and implications for COVID-19 pandemic and beyond: a qualitative study using Theoretical Domain Framework

Themes Subtheme Sample quote TDF domains Facilitator Barrier
Items predominantly identified as facilitators      
Pharmacist’s perception of their current roles   “The pharmacist must provide the patient with information about their medications, how to take them, what to do if they miss a dose, what to do if the patient has an adverse reaction, answering the patient’s questions and ensure the high-quality use of medicines and advise other healthcare professionals about safe and effective use of medications.” [Female, 20–29 years, hospital pharmacist] Social professional role and identity; Optimisms; Intentions  
Pharmacist’s perceived definition of non-traditional role in Saudi Arabia New service that has been established in pharmacy “I think the new one for me, as I told you, when I saw the anticoagulant clinic, I’ve never seen a clinic that is run by pharmacist.” [Female, 30–39 years, hospital pharmacist] Knowledge  
How the roles of pharmacists are developing   “The pharmacist role back then was only dispensing medications, but now the pharmacist is more involved with other healthcare professionals in making clinical decisions about patient's care in their scope of practice” [Female, 20–29 years, hospital pharmacist] Knowledge, Optimism, Environmental context and resources  
Attitude towards progression of pharmacist’s roles Impact of ease of access to pharmacists on the up-take of non-traditional roles “I think for the out-patient, some patients need to be highlighted and to be monitored regularly even by phone, or access to the pharmacist to have consultations whenever they need to do so. I think this is the true role of a clinical pharmacists” [Female, 30–39 years, hospital pharmacist] Skills, Belief about capabilities, Intentions  
Views on the education system to allow the uptake of non-traditional roles Course structure and focus “Yes I do believe it is fit. Saudi Arabia pharmacy graduates are trained and exposed to the current pharmacist non-traditional role. After graduating they are fully prepared to lead pharmacist non-traditional role. They are re defining the role of a pharmacist..” [Female, 20–29 years, hospital pharmacist] “Oh yes, pharmacists are taught how to do blood pressure monitoring but also again I’ve never seen this occur to be honest” [Female, 30–39 years, academic] Knowledge, Environmental context and resources
  Practical experience during degree “That’s not part of my undergraduate degree and I actually helped developing the training programmes, I actually helped pitch it to our executives, that we need to get more students involved with the Saudi FDA role, even if they don’t work with us, they graduate and they know about us. They can help to educate people.” [Male, 30–39 years, Senior pharmacist, Saudi FDA]
“As I say, the PharmD student, they can grow faster than the bachelor, than the pharmB student, because they have different, actually it’s a one year internship but it makes a difference in their life.” [Female, 30–39 years, clinical trials pharmacist]
Skills, Environmental context and resources
Institutional barriers and facilitators Universities differ in the courses they offer “Erm, yeh so the curriculum has changed differently from one university to another. But most of them, they focus on the clinical side, how to manage the drug and counsel the patient to use it in the most appropriate way. But, the curriculum changes depending on the update of pharmacy, but also depending on the city and the level of prestige of the university.” [Female, 30–39 years, military hospital pharmacist] Knowledge, skills and environmental context and resources
  Hospitals differ in recognising clinical pharmacy “So some hospitals are really developed, they know the concept of clinical pharmacy and they give you the opportunity to work as a clinical pharmacist. However, some hospitals are still stuck to the rules that some pharmacists have to dispense medicines, sometimes just to say a brief description or protocol to the patient, but it depends on the hospital” [Female, 30–39 years, hospital pharmacist] Social/professional role and identity, Social influences, Environmental context and resources
Sector specific barriers and facilitators   “Yeh, but as I said before the community pharmacy does not provide all of the service. Its not all of the service active like in the hospital.” [Female, 30–39 years, hospital pharmacist] “Because the hospital gives you the opportunity to have direct contact with the patient, to update information in databases, to provide a lot of courses during the month and the year.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources
Wider support to uptake non-traditional roles Employer “Absolutely. We have a tremendous amount of opportunities all year long. From national and international conferences being held in the kingdom to internal staff development programs in hospitals for pharmacy staff. For example, at my hospital we have weekly lectures and updates on pharmacotherapy guidelines.” [Female, 20–29 years, hospital pharmacist] Environmental context and resources  
  Governmental policies “So any university, some research related in the hospital, also in research centres which is separate and is supported directly by the government” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Behavioral regulations  
Impact of new technology on the uptake of non-traditional roles Patient records are now computerised and easily accessible “Now with the technology, its very easy to access, the data can be accessed online or through an archive. I think the technology has really helped the clinical pharmacy to develop their roles.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources  
Pharmacist’s willingness to develop their own roles Some pharmacists stick to traditional roles “I think that there are a lot of sources that pharmacist can look at again it depends on the pharmacist himself or herself err I think there are a lot of sources from the hospital and outside the hospital. Some pharmacist I think, they are very satisfied with traditional concept of pharmacy, dispensing and that’s it and there are a lot of pharmacists that need to develop, and I think the courses are accessible for them.” [Female, 30–39 years, hospital pharmacist] Intentions  
  Some pharmacists take the opportunities to develop “Yes but I would say, when I graduated from university, I got 40% experience from the university and 60% from the practice itself. So university only gives you the key, so what speciality you want. But the rest you have to decide yourself, you are responsible for this, how to improve yourself.” [Male, 30–39 years, senior hospital pharmacist] Intentions  
Awareness/knowledge of pharmacist’s non-traditional roles Patients awareness of the non-traditional roles “To be honest, I think the patient thinks that pharmacist are only supposed to give them the medication. And tell them how to use it and that’s it. I don’t think they are really educated about the role of pharmacist.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Social influences  
  Hospital institutions recognition of non-traditional roles “hospitals like King Faisal and King Abdulaziz in Jeddah, these are very well developed. They know and acknowledge and know how to apply these concepts of clinical pharmacists.” [Female, 30–39 years, hospital pharmacist] “I think some of the healthcare providers need to be aware of the changes in the pharmacist roles over the years and they should support us. We must make patients' aware of the new pharmacist roles.” [Female, 20–29 years, hospital pharmacist] Environmental context and resources; Social influences
Items predominantly identified as barriers
Perceptions on the roles of pharmacists in Saudi Arabia Patients perceptions on the roles of pharmacists “most of the pharmacist role is behind the scenes, so reporting adverse drug pharmacovigilance, or there is erm, drug shortage, or this is erm, any clinical trial, the patient usually they are not involved so that can’t see the role of pharmacist in these kinds of scenarios. So that’s why. The only contact point between the patient and the pharmacist when they dispense their medication only.” [Female, 30–39 years, clinical trials pharmacist] Environmental context and resources; Social influences  
  Lack of support from other healthcare professionals “However, I’ve seen this, when the pharmacist is just dispensing the drug and are calling for a check-up about something with the physician, this is where the clashes happen” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Social influences  
Pharmacist-patient relationship (trust) Patients do not trust pharmacists as much as doctors “so if pharmacists come to a patient to take a blood test or blood glucose level for example, a patient would hesitate. So maybe they can claim that pharmacists have no expertise in this one, so like a fear of the unusual.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Social influences  
  Patients who have more contact with pharmacists trust them “However, some patients who are in chronic disease and require chronic medication and chronic follow up. They acknowledge the role of pharmacists. For example, as I told you, this anticoagulant clinic, when the patient comes, you can really see the trust the patient has for the pharmacist.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Social influences  
Lack of communication between healthcare professionals and pharmacists in community settings   “I think it would be very rare that a pharmacist will just call the GP and ask about it. Its very rare. The role of a pharmacists is just to dispense. If there is a very serious interaction though, that needs to be highlighted, the pharmacy will say it. But other than that, it is very rare that the pharmacist will contact the GP for any enquiries.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources  
Lack of resources Staff shortage “there is a shortage of pharmacists and staff. They always complain of this one. So if they are going to do this and apply it in the right way, I think they need to find enough pharmacists for this. To decrease the load for pharmacists, this is the most reasonable solution” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Social influences  
  Lack of access to patient records “If we suggest any changes to the plan, and the patient tells the GP later, that would make a conflict. Because I don’t know their history. In this case I would just send them back to their GP. I wouldn’t recommend anything id just send them back.” [Female, 30–39 years, hospital pharmacist with previous experience in community pharmacy] Environmental context and resources; Social influences  
  Lack of consultation rooms “No, no, I think this is really important, this would be really helpful, really helpful, like even the patient that can feel more secure when they discuss the drug or how to take the medication or to follow-up with the pharmacist. I think the… I saw this here which is really nice, but no unfortunately. This is one of the things that I really wish to have it in the future.” [Female, 30–39 years, academic] Environmental context and resources; Social influences  
Healthcare system related factors Patients are not registered at community pharmacies “No no, in community we don’t do that. Because you know patients, they don’t commit with one GP. They tend to go to several hospitals with different GP’s. So the doctor is always changing.” [Female, 30–39 years, hospital pharmacist] Environmental context and resources; Social influences  
  Patients do not obtain their medication from community pharmacies “But not all of drug, mainly the cosmetic because all of the drugs, they can get in from the hospital. The medical drugs in Saudi Arabia are free from A-Z. The patient no need to take medications from outside but some cosmetic products they need to take from outside so this is the need of community pharmacists, to tell them how to use.” [Female, 30–39 years, military hospital pharmacist] Environmental context and resources; social influences