Critical Thoughts on the Pharmacists’ Care Process

By: Carla Dillon, BScPharm, PharmD

Time for Change?

With the introduction of pharmaceutical care in the 1990s, the profession began shifting from a product-focused to a patient-focused approach. The Pharmacists’ Patient Care Process (PPCP) framework has been widely used in North America to train patient-centered care.¹ However, our profession is undergoing another significant shift from largely making recommendations to physicians to making and enacting decisions as pharmacists gain more prescribing authority. The PPCP focuses on foundational knowledge and clinical action, but not the clinical reasoning underpinning clinical decision-making. Do we need a new framework to prepare students for the expanding role of the profession?

Another significant shift since the 1990s is the recognition of the social determinants of health on health outcomes. In Aotearoa New Zealand, the indigenous Māori population has poorer health outcomes and a shorter life expectancy than the non-Māori population.¹  The current Aotearoa pharmacists’ competency includes applying perspectives on the health and wellness of the indigenous Māori population. Does a truly patient-centered framework need modification to be culturally safe, particularly for indigenous populations?

A Sea of Frameworks

Others have already proposed a focus on pharmacist decision-making. Zaggar et al. proposed the Foundational Thinking Application Framework. Looking across the pond, Rutter and Harrison proposed the Clinical Reasoning Cycle. Looking down under, Wright et al. proposed a framework of information gathering, clinical reasoning, clinical judgment, and decision-making (IRJD).

At our institution, we used the PPCP, IRJD, and Hui Process (a Māori consultation framework) in various parts of our program. Student feedback and assessment suggested confusion between the models. In striving to make our graduates person-focused, culturally safe, and good clinical decision-makers, are we losing them in an alphabet soup of frameworks? 

An N of 1 Change

Our team proposed the University of Otago Pharmacists’ Care Process, utilizing the PPCP, IRJD, and Hui Process as our foundational frameworks (Figure 1).

Figure 1: University of Otago’s Pharmacist’s Care Process

The cognitive processes of reasoning, judgment, and decision-making are distinct steps in this framework.  The pharmacist applies deductive and/or inductive reasoning to compare the information they gathered with their knowledge of conditions to formulate a working diagnosis (e.g., acute cough due to a common cold) or their knowledge of medications to identify a medication therapy problem (e.g., a dabigatran dose that is too high). Reasoning processes are similarly applied to management options. Determining the best option involves making a judgment, weighing the options, and prioritizing them by incorporating the patient’s perspective, the best available evidence, and ethical principles (i.e., beneficence, non-maleficence, justice, and autonomy). A decision is made, and the pharmacist takes responsibility for it by creating a safety net (e.g., discussing symptoms indicating the patient needs further medical assessment for their cough).

The Hui process utilizes Māori principles of greeting and engagement (mihi), establishing a connection (whakawhānaungatanga, which extends beyond building rapport), attending to the purpose of the encounter (kaupapa), and concluding an encounter (poroporoaki) that clinicians can follow when consulting with Māori patients and whānau (family and close friends).⁵ This indigenous process is relevant to the Aotearoa New Zealand population. The Hui process is well aligned with the Calgary-Cambridge model—a Western framework for clinical interviews that emphasizes building rapport, gathering patient information, engaging in shared decision-making, and planning follow-up. In other countries, integrating the Calgary-Cambridge consultation model with the PPCP and IRJD may be more applicable. Even more meaningfully, consider partnering with local Indigenous communities to ensure culturally grounded care.

The Joint Commission of Pharmacy Practitioners is in the final stages of revising its PPCP. New to the proposed PPCP are the concepts of equity and social determinants of health, which are welcome additions. But will this be enough?

Does contemporary practice need a larger leap forward to incorporate clinical decision-making and indigenization? Share your experiences and opinions to help us continue the conversation.

References: 

1. New Zealand Government, Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2024. 4th ed. Wellington, NZ: New Zealand Government; 2024. Accessed July 14, 2025. https://www.health.govt.nz/publications/tatau-kahukura-maori-health-chart-book-2024
2. JCPP: The Pharmacists’ Patient Care Process. Joint Commission of Pharmacy Practitioners; 2014 May 29. Available at: https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf  Accessed February 26, 2025
3. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J. 2011;124(1347):72-78. 

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Pulses is a scholarly blog supported by a team of pharmacy education scholars.