Study design

This study used semi-structured focus group interviews to better understand the barriers and facilitators of promoting task shifting/sharing among hospital pharmacists. Using the focus group interviews, interactions among group members can reveal multiple aspects of the problem under evaluation. Furthermore, information regarding the individual perspectives of each member within the group is often obtained simultaneously. This report follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline (S1 File) [18].

Sampling and recruitment

We used the theoretical sampling technique, until theoretical saturation was reached and an explanation was generated for the process or phenomenon under investigation [19,20]. We were keen to capture specialized insights regarding pharmacist duties related to chemotherapy. The eligibility criteria for this study were pharmacists with at least three years of clinical experience who worked at hospitals at the forefront of task shifting/sharing and were involved in chemotherapy-related duties [21]. Initially, we used purposive sampling to recruit participants who met the eligibility criteria. As data collection and analysis proceeded concurrently, tentative categories emerged, suggesting that conditions within both the pharmacy department and the wider hospital influenced the implementation of task shifting/sharing. To clarify the underdeveloped dimensions of some concepts, theoretical sampling was employed. In addition to meeting the initial eligibility criteria, additional participants recruited at this stage were pharmacists working at hospitals that had recently and successfully implemented task shifting/sharing. This targeted sampling allowed a deeper exploration of the process of implementing task shifting/sharing from physicians to pharmacists in cancer chemotherapy. We contacted the participants by email. Although participation was voluntary, not a single person declined. No one else was present besides the participants and researchers.

Data collection

Two semi-structured focus group interviews were conducted at each site in university and general hospitals between February 1, 2023, and May 31, 2024, following the interview guide (S2 File); one for pharmacists in management positions and one for those in nonmanagement positions. Participants were informed of the study’s purpose and provided written informed consent. Each group was interviewed only once; there were no repeat interviews. KI conducted the interviews under the supervision of AY and HO. The interviews were recorded in the workplace and transcribed verbatim. Saturation was assessed via sample size adequacy, specificity, theoretical background, dialogue quality, and analysis strategy [20]. We evaluated the interview content at the end of the study to ensure that no new information emerged.

Data analysis

The interview data were analyzed using a modified grounded theory approach [22]. Transcripts were uploaded onto the qualitative data analysis software NVivo 12.0 (QSR International Pty Ltd.) [23]. Data analysis was conducted by KI and AY under the supervision of HO. KI conducted line-by-line coding of the interview transcripts, reading each transcript multiple times and generating initial codes and analytic memos grounded in the data. Using the constant comparative method, KI and AY continuously compared each code and data segment with the rest of the dataset to refine concepts and develop analytical categories [24,25]. Interpretive differences were discussed among KI, AY, and HO through regular meetings, during which emerging categories, relationships, and clinical implications were critically reviewed. This iterative analytic process proceeded concurrently with data collection and theoretical sampling, consistent with grounded theory methodology. In the final analysis phase, we used ongoing memos and constant comparison to examine how different categories were related to each other. Specifically, we focused on how each factor influenced the implementation of task shifting/sharing—either as a barrier or a facilitator. By analyzing these dynamic relationships among the categories, we combined these connections to build our final process model. After 10 interviews, theoretical saturation was reached because no new conceptual categories or properties emerged. However, to ensure the comprehensiveness of the data, two additional interviews were conducted. We did not return the transcripts to participants for comment; therefore, no one provided feedback on the findings.

Researcher’s characteristics and reflexivity

To ensure transparency and rigor, we clearly stated the research team’s position and any potential conflicts of interest. The primary interviewer was a pharmacist with a PhD in epidemiological research and less than two years of clinical experience and received training in qualitative methodology from an experienced qualitative researcher. To ensure analytical depth and contextual accuracy, the research team included two senior researchers as supervisors: a pharmaceutical researcher with extensive clinical experience and an expert in qualitative research. The senior researchers actively participated in the research design, ongoing analytic discussions, and data interpretation, offering diverse and complementary perspectives that strengthened the overall rigor of the study. We recognized that our shared professional backgrounds as pharmacists might lead us to hold positive assumptions about expanding the pharmacist’s role. To enhance reflexivity, we kept field notes after each interview and held regular discussions among the research team to reflect on how our perspectives and interactions might influence data collection and interpretation. Pilot interviews were conducted at a facility separate from the study sites under conditions that simulated the main study, primarily to train the interviewer. Furthermore, through these pilot interviews, the team validated the interview guide (S2 File), identified potential biases, and refined the interview questions. In addition, none of the researchers had any prior personal or professional relationships with the participants or participating institutions, ensuring that the interviews were conducted from an independent standpoint. Regarding the expansion of pharmacist-led oncology services and task shifting/sharing, our team had no organizational, financial, or professional stake in promoting this specific model. Reflexivity was maintained throughout the study to ensure transparency and credibility.

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. The study protocol was approved by the Kyoto University Hospital Ethics Committee (R3737-1). Each participant was informed of the study’s purpose and provided informed written consent.

Barriers

The first category was barriers to the process of promoting task shifting/sharing. Participants identified a range of barriers.

Cultural change

Three key factors were identified from the interview survey to overcome the barriers to initiating task shifting/sharing. The first was health care professionals’ perceptions. From the interviews, it was indicated that a positive attitude of health care professionals and government officials toward pharmacists’ involvement in cancer chemotherapy is an enabler of task shifting/sharing.

Workflow redesign

The second key factor for overcoming the barriers was securing physical resources, specifically ensuring sufficient pharmacy department capacity and the availability of necessary equipment.

Improving professional knowledge and clinical skills

The final key factor was the pharmacists’ skills. The interview findings suggested that enhancing knowledge and experience related to cancer chemotherapy, along with interprofessional communication skills, contributes to promoting task shifting/sharing.

Success of interprofessional collaborative practices

Finally, after overcoming barriers through these three key factors, participants who had already initiated task shifting/sharing shared their opinions on its benefits and what is needed to further promote it.

Key findings

This interview highlighted the process of implementing task shifting/sharing in oncology— specifically, its barriers to introduction and strategies for overcoming them, its effectiveness, and future expectations. Our findings suggest that task shifting/sharing was initiated through collaboration with physicians and other health care professionals, facilitated by medical fee revisions and official administrative notifications. Initially, several barriers emerged: differing attitudes toward task shifting/sharing, increased workloads for pharmacists, and challenges in ensuring staff competence. Overcoming these barriers required multifaceted strategies structured around three keywords: “Workflow redesign,” “Improving professional knowledge and clinical skills,” and “Cultural change.” To secure operational capacity, streamlining internal workflows through standardized protocols was essential. This standardization ensured consistent practice aligned with guidelines, facilitated the skill development of pharmacists in outpatient cancer chemotherapy, and enabled cross-departmental task sharing to mitigate individual workloads. Concurrently, external triggers, including medical fee revisions, prompted hospital executives to change their mindset, which accelerated staff recruitment and automated system integration. This executive transformation fostered an institution-wide cultural shift, reshaping physicians’ perceptions of the pharmacists’ roles and creating an environment more conducive to task shifting/sharing. Addressing these interconnected elements collectively allows task shifting/sharing to progress. Finally, evaluating implementation outcomes and disseminating their efficacy through academic presentations and publications can influence future medical fee revisions, generating a virtuous cycle of task shifting/sharing. Fig 1 illustrates the conceptual model of the process for promoting task shifting/sharing based on selective coding.

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Fig 1. Framework for promoting task shifting/sharing from physicians to pharmacists in cancer chemotherapy in Japan.

https://doi.org/10.1371/journal.pone.0358247.g001

Interpretation

The introduction of task shifting/sharing faced certain barriers. Three keywords, “Workflow redesign,” “Improving professional knowledge and clinical skills,” and “Cultural change” may help overcome these barriers.

Efficiency and standardization of operations are essential for systematizing workflows and securing dedicated time for pharmacists. Such improvements lead to better patient outcomes [26], shorter working hours [27], fewer medication errors [28], and cost reductions [29]. Recently, protocol-based pharmacotherapy management (PBPM) has been increasingly implemented in some hospitals. In Japan, the Health, Labor and Welfare Ministry issued a notification in April 2010 to encourage pharmacist involvement in the appropriate management of pharmacotherapy [11]. The notification recommends that changes in medication type, dosage, route of administration, duration of therapy, as well as laboratory test orders, be carried out in collaboration with physicians and other health care professionals based on protocols that have been developed and agreed upon in advance by pharmacists, physicians, and related staff. In this context, the introduction of PBPM in oncology has also expanded across hospitals, with growing evidence of its effectiveness [13–16]. Developing PBPMs tailored to each facility and the needs of other health care professionals contributes to the standardization and efficiency of pharmacy practice. Furthermore, by sharing PBPM not only within the hospital but also with nearby pharmacies, we can standardize operations between hospitals and pharmacies, which in turn fosters collaboration between pharmacies and contributes to community-wide coordination. Some participants noted that reducing pharmacists’ workload requires task shifting/sharing to non‑pharmacist personnel, such as pharmacy technicians. Studies in other countries have found that transferring such duties improved operational efficiency [30,31]. Similarly, one report indicated that duty transfer is progressing and could become more efficient in Japan [32]. However, Japan lacks a qualification system for non-pharmacists. Improving hospital infrastructure is also a facilitator of task shifting/sharing. Dispensing machines improve medical safety [33], but their implementation requires significant resources. Thus, hospital management approval or support from the government could further promote this.

To ensure patient safety, pharmacists performing medical procedures for physicians must maintain high professional skills. Promoting specialized cancer chemotherapy qualifications can demonstrate and improve pharmacists’ expertise. However, this raises the workload for some pharmacists, making duty standardization essential. Standardization serves as an educational tool and leads to the continual updating of clinical skills. This approach helps ensure the quality of care and improves patient safety, regardless of pharmacists’ experience. Clinical pathways are one method of standardizing treatment policies. Their introduction promotes multidisciplinary collaboration in cancer treatment [34]. These pathways also served as educational tools, improving patient outcomes, promoting interprofessional collaboration [35], and building trust among professionals. In addition, PBPM contributes to the standardization of pharmacists’ practice and can therefore serve as an educational tool. Establishing clinical procedures for pharmacy operations is important for duty stabilization and promoting task shifting/sharing. However, the lack of established operational rules remains a barrier.

Positive attitudes toward multidisciplinary collaboration in cancer chemotherapy are also facilitators of task shifting/sharing. In facilities where task shifting/sharing has been implemented, the cooperation of hospital directors and physicians can be an important starting point. If the hospital management approves task shifting/sharing, it will become easier for physicians and other professionals to cooperate, and other health care professionals’ perceptions of pharmacists may also become more positive. However, to faster more positive awareness of pharmacists’ roles among other medical professionals and governmental officials, it is necessary to raise awareness of the role of pharmacists among physicians and other health care professionals. To achieve this, it is important to disseminate evidence of the effectiveness of pharmacists’ contributions.

Further intervention

The interviews highlighted barriers to task shifting/sharing. Previous studies have highlighted similar barriers including staff shortages, excessive workload, and anxiety about knowledge and skills [36–39]. From the perspective of implementation science, these findings can be comprehensively structured across individual, interprofessional, organizational, and policy levels.

At the individual level, our findings highlight that limited specialized knowledge and the pressure of increased responsibility are primary psychological barriers for staff pharmacists. Implementing a clinical pathway or PBPM addresses these individual clinical concerns by providing a structured, evidence-based protocol that guides clinical decision-making, thereby ensuring patient safety and facilitating oncology-specific skill development. Once individual competency is supported, PBPM acts as a powerful catalyst at the interprofessional level. As pharmacists demonstrate their expertise through PBPM, their clinical contributions gain wider recognition, establishing and reinforcing trusting relationships with physicians and nurses. These individual and collaborative advancements are directly sustained by the organizational level. To embed task shifting/sharing into routine hospital workflows, pharmacy managers must take proactive steps to streamline workflows and reduce the burden on staff pharmacists. This includes, for example, delegating some duties to non-pharmacist personnel and optimizing pharmaceutical operational systems.

A mindset transformation among hospital executives is vital to secure the resources necessary for long-term implementation. However, individual pharmacists or hospitals cannot overcome these barriers alone [40]. Administrative support is important [41]. At the policy level, the WHO emphasizes that governments, professional councils, and associations should work together to develop appropriate task-sharing models and interprofessional collaboration, and ensure that all cadres with a clinical role, beyond dentists, midwives, nurses, pharmacists, and physicians, also benefit systematically from accreditation and regulation processes. Specifically, support is needed to establish educational systems targeting beginners and those seeking to obtain qualifications and create environments where professionals can collaborate [42]. In Japan, while the introduction of new reimbursement incentives for clinical pharmacist activities in cancer chemotherapy has promoted task shifting/sharing, individual hospital efforts alone are not enough. Broader promotion requires vital support from government and professional organizations, including the creation of pharmacist training systems, development of guidelines and standard operating procedures, increased staffing, and facilitating access to new equipment

Further research

As highlighted in this study, task shifting/sharing from physicians to pharmacists could improve patient outcomes and medical safety. Reporting efforts could gain administrative support and promote adoption. While studies show the effectiveness of this approach [13–16], results are difficult to generalize due to varying evaluation metrics. To promote the initiative, standardized clinical indicators across facilities are needed.

Strengths and Limitations

This study has several strengths. Pharmacists with diverse professional backgrounds and varying years of experience were recruited, enabling the identification of challenges and key factors related to task shifting/sharing from multiple perspectives. In addition, separating discussion groups into managerial and frontline pharmacists helped minimize potential response bias associated with differences in professional roles. Importantly, the results demonstrate that although differences in clinical experience existed between managers and frontline pharmacists, their impressions and concerns regarding the promotion of task shifting/ sharing were similar.

This study has several limitations. The participating facilities were limited to large hospitals; therefore, challenges and potential solutions specific to small- and medium-sized hospitals may not have been captured. A prior study demonstrated that these hospitals perform fewer aseptic preparations and drug concentration monitoring tasks than large hospitals [43]. This suggests that smaller hospitals still face broader pharmacy practice barriers. In large hospitals with established ward duties, the keywords identified in this study promoted the initiative. By contrast, small and medium-sized hospitals continue to face fundamental barriers, making it difficult to promote these initiatives based on our findings. Specific support is essential to advance these initiatives in smaller hospitals. This study did not include an objective outcome evaluation to measure the quantitative efficacy of task shifting/sharing. Although some participants were pioneering researchers who had evaluated the usefulness of this practice and published their findings in peer-reviewed journals [13–16], their participation did not provide objective evidence of its effectiveness. Further quantitative research is needed to evaluate effectiveness. Another limitation is that, while this study reflects the perspectives of hospital pharmacists, it does not include those of physicians, nurses, community pharmacists or patients. Although focusing on hospital pharmacists allowed for more context-specific insights, the findings may reflect pharmacists’ professional aspirations or role-advocacy bias. Integrating the perspectives of other health care professionals and patients would provide a more comprehensive understanding of this service and should be explored in future research.