Background

Pharmacy staff across all practice settings are reliant on information technology (IT).1^–4 Pharmacists, graduate (pre-registration) pharmacists, pharmacy technicians, dispensing assistants and medicine counter assistants use widely available office, retail and management information systems alongside dedicated pharmacy management and electronic health (ehealth) applications in a range of community, hospital and other pharmacy settings. The abilities of pharmacy staff to use these applications at home and at work, also known as digital literacy or digital competence or e-skills, depend on personal experience and related education and training.5^–8 The British Computer Society defines digital literacy as, ‘being able to make use of technologies to participate in and contribute to modern social, cultural, political and economic life’.9 A similar definition of digital literacy is adopted in the US, ‘the ability to use information and communication technologies to find, evaluate, create, and communicate information; it requires both technical and cognitive skills’.10 Both definitions are grounded in historical and conceptual definitions of digital literacies.11

IT facilitates the provision of core pharmacy services in the UK in collaboration with other healthcare professionals with similar examples worldwide.12^–15 In the US, digital literacy also forms the basis for pharmacy led health literacy as a tool for improving public health and patient outcomes.16

Collaborative working in health has been viewed as both beneficial to patients and a more efficient use of health professionals’ skills since long before the advent of ehealth.17^–19 Health strategists worldwide promote the adoption of IT and ehealth to support patient care through collaborative working, which is tracked globally by World Health Organization.1^–3,12,13,20^–22 Both the adoption of ehealth and standards of digital literacy at home and in the workplace are key themes of interest at the international level.23^–25

United Nations Educational Scientific and Cultural Organisation identifies digital literacy as both a ‘life skill’ and ‘gate skill’ because ‘it targets all areas of contemporary existence’.26 The European Commission Information Society promotes and tracks citizens’ and member states’ digital engagement.27,28 Similarly, the European Parliament promotes digital literacy for lifelong learning along with a recommendation for ‘better identification of occupational needs’.29

In the US, a government initiative to create a ‘digital nation’ recognised the role of digital literacy in promoting inclusion.23 A government commissioned report into digital literacy in Australia concluded that ‘both citizen and worker will need to be digitally literate for the digital economy to work effectively’ while a report from New Zealand argues ‘that technology can change the nature of work faster than people can change their skills’.24,25

In the UK, a range of strategic principles, national competency frameworks for training, core skills and digital literacies for the general public, and recently more specific targets for the health sector, have been developed by the government, advisory and professional bodies.30^–36

Pharmacy students in the UK undertake the General Pharmaceutical Council accredited and regulated Master of Pharmacy course.5 This undergraduate university course is followed by a pre-registration year, based in practice culminating in an end of year written examination. Training for pharmacy technicians, dispensing assistants and medicines counter assistants is similarly accredited and regulated but undertaken as a combination of practical experience, college and open learning.6 Specific mention of the digital literacies required to facilitate pharmacy staff’s collaborative healthcare role is not evident in the UK curricula for initial training or their continuing professional development (CPD).37,38 The Accreditation Council for Pharmacy Education (ACPE) in America added health informatics to its standards for pharmacist training in 2007. The focus was initially on basic computer skills and then on ability to find appropriate relevant evidence base for practice.39 Pharmacy program accreditation in Canada, Australia and New Zealand make explicit mention of the need to prepare students to make best ‘use of information technology in pharmacy and more widely in health care’.40,41 While digital literacy may be covered to an extent in some initial training programmes, there is limited evidence that it features in CPD for existing members of pharmacy staff.

In summary, despite the increasing adoption of IT and ehealth to support the role of pharmacy staff, there is a paucity of research exploring their perceptions and digital literacy knowledge and related training. This review identifies evidence of perceived levels of digital literacy amongst pharmacy staff and their related training experiences and future needs.

Objective

To explore the digital literacy knowledge and needs of pharmacy staff.

Review question

This review asks, ‘What are the digital literacy knowledge and needs of pharmacy staff?’ to summarise existing evidence of pharmacy staff perceptions and measures of:

1. levels of digital literacy knowledge;

2. inclusion of digital literacy in pharmacy training;

3. specific digital literacy training experiences;

4. digital literacy training needs.

Assessment of methodological quality

To reduce risk of bias, papers selected for critical appraisal were assessed independently by two reviewers for methodological quality before inclusion using a standardised critical appraisal tool adapted to suit all study types.49

Data extraction

Data were extracted using a bespoke data extraction tool (Table 3). The data extraction was performed independently by two reviewers before cross-checking to minimise errors and reduce risk of bias.

Data synthesis

Findings were narratively explored through Kirkpatrick’s 4 level model for evaluating training programmes by focusing on evidence of reaction, learning, behaviour and results.

Study selection

Systematic application of the search strategy returned 86 published papers, which after independent screening of titles, abstracts and full papers was reduced to 5 (Figure 1 and Table 1).

There were no studies featuring pharmacy staff other than pharmacists and no unpublished studies identified.

Quality assessment

Each study was independently reviewed for quality by two of the research team. Details of the clarity of the research question, appropriateness of the design, description of context, population, sampling, data collection and analysis along with results, limitations and conclusions are provided in Table 2. It also details reasons for the exclusion of one study on quality grounds, while four were taken forward for data extraction.

Study characteristics

The data extraction table (Table 3) provides summarised study characteristics and contextual information. In brief, one of the studies was a survey conducted to establish baseline computer skills of hospital pharmacists in Canada prior to an educational intervention.50 Another surveyed allied health professionals (AHPs), including pharmacists, in Australia about their use of electronic evidence resources.53 A further Australian study, based on community pharmacists, combined pre-intervention focus groups with a post-educational intervention evaluative survey.51 The final study used mixed methods to review informatics content, including computer and digital literacy skills, in pharmacy education by mapping syllabi returned by schools of pharmacy against the US ACPE Standards.52

Pharmacy staff digital literacy level

Balen and Jewesson50 concluded there was not yet ‘a standard definition of computer literacy and valid dimensions of computer competency for pharmacy practice’. Based on a literature review, Bearman et al51 found ‘there was little or no information regarding community pharmacists’ skills and knowledge levels or how they currently employ internet technologies’. Through focus groups, they identified a ‘wide variety of technical knowledge and skills.’ Where access was available, participants most commonly used the internet at work for email and to search pharmacy-related topics, such as medicines or patient information, with a small proportion contributing to a pharmacy message forum. They were ‘less familiar with local health-specific portals or websites.’ Lack of familiarity or expertise and difficulty finding relevant information online were noted issues.

Balen and Jewesson50 found pharmacists were likely to have both home and work access to computers. Work use included information management, internet searching and email, drug distribution systems, patient care systems but minimal use of spreadsheets, statistical or presentation software. They concluded hospital pharmacists were ‘computer literate’ and ‘not anxious’ about using IT.

Fox et al52 identified ‘confusion within the academy/profession between pharmacy informatics and drug information practice’ and low compliance with ACPE Standards 2007 on pharmacy informatics competencies. Three progressive levels of pharmacy informatics competency were detailed under headings of terminology, systematic approaches, benefits and constraints. Fox et al52 concluded that pharmacists ‘must utilize information technology and automation’ implying but not specifying levels of digital literacy.

In a convenience sample survey of AHP, Gosling and Westbrook53 found pharmacists were the highest users of an online evidence system. Two of 25 closed questions in the survey related to database searching and computer skills. Across all AHPs, nearly three quarters reported their computer skills as good, very good or excellent with pharmacists rated most able to find online information.

Digital literacy in pharmacy training

The study by Fox et al52 focused on searching pharmacy syllabi for elements of informatics training. They cite Flynn55 in asserting ‘few pharmacy programs provide formal pharmacy informatics’. However, they elaborated the role of the Institute of Medicine (IOM) who recognise ‘utilizing the tools and techniques of informatics’ as a core competency for all clinical healthcare professionals. This is further evidenced by the initiatives around educational provision by the American Medical Informatics Association (AMIA) and International Medical Informatics Association (IMIA) whose recommendations were adopted by the American Society of Health-Systems Pharmacists (ASHP).

Balen and Jewesson50 noted that ‘informatics is not a formal component of the core undergraduate or graduate programs’ at their local university and ‘remains an uncommon component of most pharmacy and medical school curricula’ in North America. Findings from Bearman et al’s51 literature review showed that ‘many [community pharmacists] have not been educated in internet use for professional practice’. Although Gosling and Westbrook53 found a ‘marked difference between professions use’ of an online evidence system, there is no clear way to relate this back to pharmacy or other allied health professional training.

Digital literacy training experiences

Balen and Jewesson50 found that 79% of pharmacists (n =106) who responded to their survey ‘had received no formal computer training’. Following their educational intervention, Bearman et al51 received positive feedback from participants about improved searching skills and more effective searching while ‘almost half of the 93 respondents reported a change in practice’. While declaring informatics a new discipline for pharmacy, Fox et al52 emphasised the intricate link between IT and pharmacy informatics explaining ‘IT tools provide the infrastructure for information management to support pharmacy informatics’. In findings across all AHPs, Gosling and Westbrook53 identified social, organisational and professional support, along with general computer skills training, as important facilitators influencing the use of technologies in pharmacy practice.

Digital literacy training needs

Each of the included studies indicated participants want or need more digital literacy related training. Balen and Jewesson50 found that 77% (n =106) in need of ‘general computer skills upgrading’ ranking medical database and Internet search as priority areas. Access to Internet related education was viewed as a priority for community pharmacists by Bearman et al,51 while Gosling and Westbrook53 found ‘general training aimed at improving computer skills more important… than specific system-based training’. Finally, Fox et al52 recommended a set of foundational core competencies, ‘based on themes extracted from course syllabi and from personal experience’, and encouraged pharmacy educators to ‘look to informatics in other disciplines, such as medicine and nursing, for guidance’.

Applying the analytical framework

In terms of Kirkpatrick’s 4 level model, the pre-training survey of computer skills conducted by Kirkpatrick and Kirkpatrick45 and Balen and Jewesson50 evidenced baseline evaluation recognised as a preliminary activity for level 2 (learning). Similarly, Gosling and Westbrook53 conducted a survey which included measures of baseline skills (level 2: learning). Although good computer skills were shown to be associated with the use of technology by pharmacists (level 3: behaviour), it is not clear from the findings presented whether pharmacists were included in the AHPs who received training. Bearman et al51 reported pharmacists ‘were highly positive about the learning experience’ (level 1: reaction), in particular the ‘flexible delivery of the course,’ while online resource identification attracted most comments. Findings also reported ‘specific changes in practice’ (level 3: behaviour) around ‘use of new websites, more effective searching, a change to regular use of specific resources.’ The emphasis in the article by Fox et al52 was on syllabus content: which informatics skills (level 2: learning) are taught in pharmacy education. Their conclusions and recommendations aspired to levels 3 (behaviour) and 4 (results) in urging pharmacy programs ‘to prepare future pharmacists to approach their professional practice as drug safety experts and medication knowledge workers who must utilize information technology and automation in order to create a safer, more effective medication-use system’.

Strengths and weaknesses

It is a strength of this review that it demonstrates the lack of research conducted around digital literacy of pharmacy staff, but it is also its main weakness. With so few studies on which to base the review, findings must be treated with caution. Although not a weakness of this review, the survey-or evaluation-based studies used self-reporting, which is recognised for its inherent bias. The use of standardised tools in this review applied independently by more than one reviewer reduced the risk of bias for both inclusion and reporting.