- Email: [email protected]
Exploring employer perceptions of pharmacy technician certification in the community pharmacy setting
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Contents lists available at ScienceDirect
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Exploring employer perceptions of pharmacy technician certification in the community pharmacy setting Chelsea P. Renfro, James S. Wheeler, Sharon L.K. McDonough, Junling Wang, Kenneth C. Hohmeier∗ Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Community pharmacy Pharmacy technician certification Workforce Pharmacy technicians
Background: With the evolving roles of pharmacy technicians in the United States, the profession has attempted to define a national standard. Community pharmacy employers to-date have preferred on-the-job training to formal, accredited training programs or credentialing, however, limited evidence exists on the perceived needs of pharmacy technicians in the United States compared to those of community pharmacy employers. Objectives: The aims of this study were to explore: 1) community pharmacy employer perceptions of associated benefits and perceived value of pharmacy technician certification and 2) needs of employers related to pharmacy technician attitudes and knowledge, skills and abilities (KSAs). Methods: Using a semi-structured interview guide, researchers interviewed 7 community pharmacy employers within top management teams in a variety of community pharmacy settings. The data were analyzed for themes using the human capital vs. signal theory. Results: Employers and managers generally saw both attitude and KSAs as vital to success. However, given a choice between experience and attitude, attitude was preferred. There was general agreement that certified technicians offered more value to their organization, however gaps in certified technician KSAs were noted (i.e., lack of day-to-day practical skills, vaccination screening, motivating patients to change behaviors, patient communication and workflow management). Conclusions: New emerging directions for certification now exist due to the rapidly shifting pharmacy landscape, which is revolves around new and expanded clinical patient care services. This shifting landscape has exposed gaps, reinforced strengths, and uncovered potential new opportunities and needs related to technician certification.
Introduction Well trained and qualified pharmacy technicians are crucial to scalable and sustainable pharmacist-delivered patient care and efficient pharmacy operations. Historically, the driving force behind their job duties was to free up pharmacist time by performing the technical duties related to the medication distribution process (e.g., selling prescriptions, prescription data entry, prescription filling).1 Globally, pharmacy technician roles have evolved in scope and complexity, including both clinical and non-clinical support duties.2–5 Importantly, these new roles have had a positive impact on both patient care and the profession itself, including increased clinical care activities provided by pharmacists and lower technician turnover intentions.2,3,6,7 Emerging roles for the pharmacy technician are similarly based on technical task delegation which does not involve professional judgement. Such roles
∗
include technician product verification (i.e., “tech-check-tech” or “checking technician”)5,7–9 quality measure improvement,10 and vaccine administration.11 With evolving roles of increasing complexity, the United States has attempted to define a national standard for pharmacy technicians.1 However, today there is still a wide variation in technician training and credentialing requirements from state to state. Entry-level practice requirement statistics for pharmacy technicians across the United States indicate that 55% (28 of 51 states/districts) require no education/ training or certification; 10% (5 of 51 states/districts) require certification only, 14% (7 of 51 states/districts) require education/training and certification, and 14% (7 of 51 states/districts) require either education/training or certification.12 Consequently, calls for training and credentialing standards have grown recently.1,12 The call for national uniform standards of pharmacy technician
Corresponding author. University of Tennessee Health Science Center College of Pharmacy, 301 Perimeter Park Dr, Nashville, TN, 37211, USA. E-mail address: [email protected] (K.C. Hohmeier).
https://doi.org/10.1016/j.sapharm.2019.12.003 Received 10 May 2019; Received in revised form 28 November 2019; Accepted 2 December 2019 1551-7411/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Chelsea P. Renfro, et al., Research in Social and Administrative Pharmacy, https://doi.org/10.1016/j.sapharm.2019.12.003
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training and education has largely come from professional associations.13 However, certified community pharmacy technicians to-date have valued on-the-job training to formal, accredited training programs or credentialing.14 This dichotomy between the perceived skills and knowledge required of pharmacy technicians by the profession compared to those of community pharmacy employers has yet to be explored in the published literature.
Table 1 Interview guide. Domain 1: Knowledge, Skills, and Ability (Technician Level) 1. Which pharmacy technician knowledge, skills, and abilities would you consider most important to your organization? [PROBE] Which of these are learned? [PROBE] Which of these are innate? 2. Thinking about the knowledge, skills and abilities you just mentioned, which do you believe should be included in a pharmacy technician training program? 3. Describe your process for recruiting technicians with these qualifications. [PROBE] What difficulties, if any, have you came across? Domain 2: Aptitude (Technician Level) 4. What entering characteristics predict success in a pharmacy technician? [PROBE] What types of prerequisite abilities do you look favorably upon when hiring a technician? Domain 3: Attitude (Technician Level) 5. Tell me about a time you were working with a technician, and the technician had a general “good attitude” towards work. [PROBE] What went well? [PROBE] What could have been improved, if anything? 6. How does pharmacy technician training affect attitude? 7. How does a good attitude benefit the pharmacy? [PROBE] How can one ensure technicians have good attitudes? Domain 4: Desirability and Trade-offs Between Traits (Technician Level) 8. Based on what we have just discussed, what knowledge, skills and abilities are most desirable in a pharmacy technician? [PROBE] Which of these items are most essential? [PROBE] Which traits do you prefer over others? 9. Are knowledge, skills and abilities more important than attitude? 10. Which knowledge, skills and abilities you either unwilling or unable to “pay more for”? [PROBE] Which are you willing to “pay for”? Domain 5: Certification Value (Certificate Level) 11. Describe how the pharmacy technician certification has had an impact on your organization. 12. How valuable is certification in your opinion? Domain 6: Certification Shortfalls/Downsides (Certificate Level) 13. What problems or downsides, if any, do you see in technician certification? 14. Are there any knowledge, skills or ability gaps you are aware of in certified technicians? Domain 7: Implementation (Certificate Level) 15. Have you had any difficulties implementing policies requiring certification? [PROBE] What issues, if any, would you foresee when implementing such policies? 16. Describe the current incentives process, if any, at your organization for encouraging certification. [PROBE] How do you retain quality technicians at your pharmacy? [PROBE] What strategies, if any, do you use to help them to perform optimally? 17. How do you keep talent in your technician workforce? Domain 8: Future (Profession Level) 18. How would you describe the future role of the pharmacist at your organization? 19. What is the future role of the pharmacy technician at your organization?
• •
Objective
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The aims of this study were to explore: 1) community pharmacy employer perceptions of associated benefits and perceived value of pharmacy technician certification and 2) needs of employers related to pharmacy technician attitudes and knowledge, skills and abilities (KSAs).
• • •
Methods Recruitment and participants
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To obtain diverse employer perspectives regarding pharmacy technician certification, employers who represent different community pharmacy settings were recruited. Participants were stratified based on the type of community pharmacy setting (e.g., traditional chain, mass merchandiser, supermarket chain, and independent pharmacy) and role on top management team (e.g., leadership, management, or ownership). Participants within top management teams were selected as these individuals represent a unique perspective on trade-offs, competing priorities, future directions and requirements necessary for success within the business and operations of community pharmacy practice. This perspective is distinct from the needs of front-line stakeholders (e.g., staff pharmacists), whose perspectives would likely be based on experiences with direct patient care rather than on the business operations of the pharmacy. Participants were recruited using a purposeful sampling approach. A recruitment email was sent to request an interview about their perceptions regarding pharmacy technician skills, abilities, training and credentialing. Five participants declined participation due to a lack of time. Recruitment was stopped after 7 pharmacies since theme saturation (i.e., occurrence of the same themes with no new information being collected) was reached.15 The Institutional Review Board at the researchers’ university approved this study.
• • •
• • •
Data collection Three members of the research team trained in qualitative methods conducted 7 in-depth, semi-structured interviews from November 2017–January 2018. Interviews lasted approximately 45 min and were conducted via phone to ensure that participants could take part in the study regardless of location. Interviews were chosen to best understand individual employer perspectives about pharmacy technician KSAs and attitudes as compared to other methods that focus on collective perspectives or obtaining a consensus, such as focus groups.16 A semi-structured interview guide was developed (Table 1) based on the human capital vs. signal theory.17,18 The interview guide included questions categorized within 8 domains: 1) technician knowledge, skills and ability, 2) technician aptitude, 3) technician attitude, 4) technician desirability and trade-offs between traits, 5) certification value, 6) certification shortfalls/downsides, 7) certification implementation, and 8) future of the pharmacy profession. Prior to conducting the interview, participants provided informed consent over the phone.
depth understanding of the information gathered and its context.21 Rapid analysis has been used in previous evaluation studies of health care organizations and delivery models22 as well as standalone qualitative studies.23–27 Rapid analysis allows for data to be analyzed in a short timeframe. This is compared to the rigorous, traditional coding process where an initial set of codes are inductively developed during the first phase of coding and then emerging themes are captured during the second phase.28 Researchers identified neutral domains in advance to structure and focus the interviews. Each neutral domain corresponded to a set of interview questions (Table 1). Transcripts were coded independently by two team members and coding was discussed until a consensus was achieved. Codes were then transferred into a matrix to allow for all participant comments to be viewed by neutral domain.29 This allowed for the synthesis of important findings and identification of major themes.
Data analysis Results Each interview was digitally recorded and transcribed verbatim. Rapid analysis19,20 was used. This approach is used to provide an in
A total of 7 pharmacists participated in this study. Among the 2
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Trade-offs between KSAs and attitude
Table 2 Participant characteristics. Type of Pharmacy
Participant Role
Number of Participants
Traditional chain Traditional chain Supermarket chain Mass merchandiser Independent Independent
Executive leadership Mid-level corporate Corporate Executive Leadership Owner Manager
2 1 1 1 1 1
Employers and managers generally saw both attitude and KSAs as vital to success. However, given a choice between experience and attitude, attitude was preferred as KSAs can be taught after hire. Of all potential KSAs, the following were identified as the most valuable: application of knowledge, communication skills, and adaptability.
Perceptions of certification in current pharmacy landscape participants interviewed, 2 served as either a manager or owner of an independent pharmacy. Five are part of top management teams for either a traditional, supermarket, or mass merchandiser chain (Table 2).
Employers were generally supportive of certification as its overall value was noted. Overall value of certification was most often identified by participants as giving a sense of accomplishment and pride to certified technicians. Regulatory statutes surrounding certification were also mentioned as a major driver for employers in the community pharmacy setting to advocate for or require certification for technicians. Expanded technician roles or duties, or the ability for a higher pharmacist-to-technician supervision ratio because of technician certification were specifically mentioned as drivers for employer advocated technician credentialing. Several concerns were noted which included the recognition that the business case for certification to top management teams is lacking, difficulty incentivizing certification due to current pay levels, and few opportunities for advancement or expanded responsibilities at their pharmacy. Participants stated they experienced difficulty in incentivizing technicians to pursue certification, as the marginal pay increase and expanded duties alone are not enough to meet technician expectations when compared to the time and cost of certification. It was also noted that employers would oftentimes provide training
KSAs and attitudes valued by employers When participants were asked to identify KSAs and attitudes valued by employers as learned, innate or both, participants listed the ability to influence patient behavior (e.g., adherence, vaccinations), accuracy in filling prescriptions, mathematical calculations, pharmacology (e.g., top 200, brand/generic), computer skills, medical terminology, and third-party adjudication as learned (Table 3). Participants noted that motivation/drive, work ethic, adaptability, and organization were innate skills. Customer service skills, ability to be caring and friendly with patients, communication, interpersonal skills, and team work were listed by participants as both learned and innate.
Table 3 Interview domains and illustrative quotations. Neutral Domains
Illustrative quotation
Knowledge, Skills, and Ability (Technician Level)
More than ever now our pharmacy technicians are in a position of influence. Influencing patients to adopt different services that keep them regular and routine on their medications. But also, influencing them in a way they really understand the importance of medication adherence. If we do all that and we do it well than obviously we keep them healthy, we keep them out of the hospital, we keep them from having recurring issues with their particular disease state. So I think those are probably the two things that I would probably say would be the most important. Because there's a lot going on it can feel chaotic and stressful at times. When you think about the characteristics of someone who isn't bothered by that, someone who can actually thrive and not be overwhelmed by that kind of pace. And still be able to think about their role and take every customer one by one. If I'm motivated as an employee to build relationships within our pharmacy, I'm going to be friendly and build rapport. I think those are the things that lead to everything else. Someone who's thirsting for information, willing to learn, and just has a great overall attitude because, to me, you can go miles with that person. And that person will probably do well in pharmacy and then who knows what else they can do in their career. That is your prime person and even maybe even better than with a worse attitude with some prior experience in pharmacy, cause that is sometimes you might struggle more with that person, even though they had a prior experience. Certification surely proves some level of that knowledge base, which then supports all the other traits. It's easier to be efficient and accurate when you have that base, and it's easier to train for clinical service engagement and that type of thing. It's really hard to say that certification in and of itself causes a person to be able to perform their job better. You'd like to think it does, but I'm not certain in all cases, that it does. But what I do think is that it does give them a sense of accomplishment and pride. Until the state boards of pharmacy allow for technicians to do more than they are doing today, it's just an added cost without a payout. In many ways we have to get the pay right but on the other hand we need to be making sure that we're creating a culture within the pharmacy where, you know we're providing the right sort of development and leadership capabilities for the pharmacist that's running the pharmacy, so that they're thinking about their role in terms of how I run a really good store. I think there's some states are looking at things that might provide an avenue to have a little bit of a higher-level technician that would require additional training or certification, but then would provide that aspirational piece where you can get to that point and earn more pay associated with that. That might give it a little bit more of a career, I don't know, look and feel. Then that could help with retention. I think that's definitely the struggle here. The technician would confirm medication lists and confirm health history, and then the pharmacist would use that gathered information to have adherence discussions, conversations about health conditions, cooperatively establish goals and solutions to help address drug-related problems. The technician would potentially do vaccine administration, for instance, but the pharmacist would be the one who would evaluate the appropriateness of vaccination, screen for additional vaccines, counsel on the vaccines, that kind of thing. But the administration is a task that could be completed by a technician. They [technicians] would definitely continue to do data entry supported as much as possible by electronic prescribing and system improvements. They would verify that what's on the prescription matches what was entered into the system. They would fill the prescription. The pharmacist would assess the clinical appropriateness of the medication for the patient, and perform a DUR. In order to get the pharmacist to be in a more clinical role, the technician's going to have to pick up more of the responsibility for the dispensing function.
Aptitude (Technician Level)
Attitude (Technician Level)
Desirability and Trade-offs Between Traits (Technician Level) Certification Value (Certificate Level) Certification Shortfalls/Downsides (Certificate Level) Implementation (Certificate Level)
Future (Profession Level)
3
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lowest level of legally or regulatory permissible responsibilities. In 2017, the Pharmacy Technician Stakeholder Consensus Conference conveyed several recommendations including requiring national certification prior to practice entry and minimalizing state-to-state variability in technician regulations.30 Employers also indicated that credentialing was associated with socalled “brain drain,” or pharmacy technician turnover from their pharmacy to another pharmacy setting upon gaining credentialing, training, and/or experience. This concept has been previously reported by cross-sectional surveys of pharmacy technicians which indicate poor job satisfaction and high turnover intentions.31,32 Reasons for why turnover intentions are high generally relate to lack of advancement opportunity, poor salary, and desire for a “change.”31 Participants also commented that because of limits of additional technician responsibilities, there is a lack of career growth potential within their organizations, creating a “ceiling” effect for the highest skilled and qualified technicians. This too is reflected by technician perceptions previously reported in the published literature, and illustrates an area in which there is much work still to be done to expand permissible technician duties.31,32 Overall key informant perceptions of certification in relation to employability and pharmacy technician quality were positive. However, views on the value of credentialing and certification by top management teams within these pharmacy organizations were less positive. These views are in line with employer perceptions across other industries. They demonstrate the general principle that members of the profession associated with a specific credential value such credentials higher than their employers.33 These obstacles to realizing a national standard for technician training and credentialing are not insurmountable as evidenced in the literature. In many states, state boards of pharmacy permit expanded duties or larger pharmacist-to-technician ratios of supervision-based, specified technician qualifications (e.g. certification).34–36 This creates readily perceivable value for employers. Moreover, as technicians engage in future roles with a higher level of technical difficulty, these roles will likely make pharmacy technicians’ work more rewarding and challenging – theoretically reducing turnover intentions.31 For instance, emerging evidence demonstrates that this is the case for technicians engaged in tech-check-tech, a responsibility requiring a high degree of drug knowledge and attention to detail previously reserved as a duty only for registered pharmacists.6 Employer perceived value may indeed be increased through the training and credentialing for new pharmacy technician knowledge, skills, and abilities. As this study found, some of these future areas include behavior motivation, screening for vaccines and facilitating pharmacist recommendations, and tech-check-tech.113 Incorporating these future areas into education and credentialing programs may further improve value of credential and allow for career latter within community pharmacy which could reduce turnover and further improve the value-proposition for employers.
experiences and sometimes even pay for certification for technicians or provide an increase in pay upon certification. However newly certificated technicians would leave soon after achieving certification for higher-paying positions with added responsibilities and room for advancement. Perceptions of certification needs for the future Although there was general agreement that certified technicians offered more value to their organization than non-certified technicians, participants reported gaps in certified technician KSAs, including a lack of day-to-day practical skills (e.g., navigating workflow, patient interactions, motivating patient behavior), screening patients for vaccines based on guidelines, motivating patients to improve adherence and otherwise influencing patient behaviors, drug diversion prevention, patient communication and workflow and time management. Participants identified expanded duties for technicians in the future of pharmacy practice as technician product verification (a.k.a. tech-checktech), working with patients to improve adherence, vaccination delivery, and overseeing the dispensing process. Discussion This was the first study to date to explore pharmacy employer perceptions of attitudes, knowledge, skills, and abilities needed of pharmacy technicians. The results of this study provide the pharmacy profession, as well as pharmacy technician training and credentialing stakeholders, with important insights useful in guiding future directions for technician training, credentialing, and scope of roles and responsibilities. Importantly, results here underline employers’ pragmatic approach to viewing technician characteristics as a combination of attitude and aptitude, as well as their unique needs among other pharmacy settings related to engaging with patients. A study of high performing teams uncovered 6 common characteristics: team member competencies, processes/techniques, interpersonal skills/communication, a shared value system, shared vision/direction, and supporting organizational values including openness.17 Given these common characteristics, employers are presumably in a position to understand the value of a well-trained pharmacy technician as it is vital to the success of their business. Yet, as compared with health-system employers, community pharmacy employers have been slower to mandate training or credentialing requirements for pharmacy technicians. Results from this study present a two-fold explanation for this phenomenon. First, the high degree of patient interaction within outpatient pharmacy settings requires that a successful pharmacy technician concurrently possess characteristics which would allow them to communicate with patients and motivate behavior change such as would be required to provide patient/customer service, vaccine-related conversations, adherence-related conversations, and relationship building. This, in addition to technical task completion, makes for a requirement unique to outpatient settings like the community pharmacy. Moreover, these items are not traditionally an area of focus for technician training and credentialing. Second, even with training or credentialing standards which would assure this level of competency, outpatient community pharmacy employers articulate a difficulty in retaining such highly trained talent. A key insight from this study was that these employers described a situation by which credentialed technicians do not generally have legal or regulatory permitted expansions in duties, which subsequently reduces the value that these technicians bring to these organizations and their ability to increase wage scales. In some cases, even though some expansions in duties are available in some states, the multi-state nature of the national chain pharmacy would require separate training, policies, and procedures for each state for which the chain operated – making it logistically simpler to adopt a policy of only allowing the
Limitations This study had several limitations. The interviews were conducted with only employers in the community pharmacy setting and do not capture other pharmacy settings (i.e., inpatient). This setting was purposefully chosen because the community pharmacy setting typically has the least uptake of certification. It was important to capture perceptions of employers in this settings as the lack of uptake likely means there is something missing or means to improve upon. More chain pharmacy employers were interviewed than independent pharmacy employers. Therefore, the findings from this study may not be representative of independent pharmacies. Future studies are warranted to gather perceptions from other pharmacy settings such as outpatient pharmacies associated with a hospital or clinic. 4
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Conclusion 10.
Initial findings suggest that technician certification may offer benefits to technicians and employers. These findings should be further explored in future research studies. Furthermore, new emerging directions for certification now exist due to the rapidly shifting pharmacy landscape, which revolves around new and expanded clinical patient care services. This shifting landscape has exposed gaps, reinforced strengths, and uncovered potential new opportunities and needs related to technician certification.
11. 12. 13.
14.
Funding sources
15.
The Pharmacy Technician Certification Board (PTCB) funded this research through a grant. The funder played no role in analysis, interpretation, writing on the results, or decision to submit for publication. The funder was given the opportunity to review semi-structured interview questions and provide input. Final selection of interview questions was made at the sole discretion of the authors.
16. 17. 18. 19.
CRediT Author Statement
20.
Chelsea Phillips Renfro: Methodology, Formal Analysis, Investigation, Writing – Original Draft; James Wheeler: Conceptualization and Writing – Review & Editing; Sharon McDonough: Methodology and Investigation; Junling Wang: Writing – Review & Editing; Kenneth Hohmeier: Conceptualization, Methodology, Formal Analysis, Investigation, Writing – Original Draft, Project Administration, Funding Acquisition
21.
22.
23.
Appendix A. Supplementary data
24.
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.sapharm.2019.12.003.
25.
References
26.
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Contents lists available at ScienceDirect
Research in Social and Administrative Pharmacy journal homepage: www.elsevier.com/locate/rsap
Exploring employer perceptions of pharmacy technician certification in the community pharmacy setting Chelsea P. Renfro, James S. Wheeler, Sharon L.K. McDonough, Junling Wang, Kenneth C. Hohmeier∗ Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Community pharmacy Pharmacy technician certification Workforce Pharmacy technicians
Background: With the evolving roles of pharmacy technicians in the United States, the profession has attempted to define a national standard. Community pharmacy employers to-date have preferred on-the-job training to formal, accredited training programs or credentialing, however, limited evidence exists on the perceived needs of pharmacy technicians in the United States compared to those of community pharmacy employers. Objectives: The aims of this study were to explore: 1) community pharmacy employer perceptions of associated benefits and perceived value of pharmacy technician certification and 2) needs of employers related to pharmacy technician attitudes and knowledge, skills and abilities (KSAs). Methods: Using a semi-structured interview guide, researchers interviewed 7 community pharmacy employers within top management teams in a variety of community pharmacy settings. The data were analyzed for themes using the human capital vs. signal theory. Results: Employers and managers generally saw both attitude and KSAs as vital to success. However, given a choice between experience and attitude, attitude was preferred. There was general agreement that certified technicians offered more value to their organization, however gaps in certified technician KSAs were noted (i.e., lack of day-to-day practical skills, vaccination screening, motivating patients to change behaviors, patient communication and workflow management). Conclusions: New emerging directions for certification now exist due to the rapidly shifting pharmacy landscape, which is revolves around new and expanded clinical patient care services. This shifting landscape has exposed gaps, reinforced strengths, and uncovered potential new opportunities and needs related to technician certification.
Introduction Well trained and qualified pharmacy technicians are crucial to scalable and sustainable pharmacist-delivered patient care and efficient pharmacy operations. Historically, the driving force behind their job duties was to free up pharmacist time by performing the technical duties related to the medication distribution process (e.g., selling prescriptions, prescription data entry, prescription filling).1 Globally, pharmacy technician roles have evolved in scope and complexity, including both clinical and non-clinical support duties.2–5 Importantly, these new roles have had a positive impact on both patient care and the profession itself, including increased clinical care activities provided by pharmacists and lower technician turnover intentions.2,3,6,7 Emerging roles for the pharmacy technician are similarly based on technical task delegation which does not involve professional judgement. Such roles
∗
include technician product verification (i.e., “tech-check-tech” or “checking technician”)5,7–9 quality measure improvement,10 and vaccine administration.11 With evolving roles of increasing complexity, the United States has attempted to define a national standard for pharmacy technicians.1 However, today there is still a wide variation in technician training and credentialing requirements from state to state. Entry-level practice requirement statistics for pharmacy technicians across the United States indicate that 55% (28 of 51 states/districts) require no education/ training or certification; 10% (5 of 51 states/districts) require certification only, 14% (7 of 51 states/districts) require education/training and certification, and 14% (7 of 51 states/districts) require either education/training or certification.12 Consequently, calls for training and credentialing standards have grown recently.1,12 The call for national uniform standards of pharmacy technician
Corresponding author. University of Tennessee Health Science Center College of Pharmacy, 301 Perimeter Park Dr, Nashville, TN, 37211, USA. E-mail address: [email protected] (K.C. Hohmeier).
https://doi.org/10.1016/j.sapharm.2019.12.003 Received 10 May 2019; Received in revised form 28 November 2019; Accepted 2 December 2019 1551-7411/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Chelsea P. Renfro, et al., Research in Social and Administrative Pharmacy, https://doi.org/10.1016/j.sapharm.2019.12.003
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training and education has largely come from professional associations.13 However, certified community pharmacy technicians to-date have valued on-the-job training to formal, accredited training programs or credentialing.14 This dichotomy between the perceived skills and knowledge required of pharmacy technicians by the profession compared to those of community pharmacy employers has yet to be explored in the published literature.
Table 1 Interview guide. Domain 1: Knowledge, Skills, and Ability (Technician Level) 1. Which pharmacy technician knowledge, skills, and abilities would you consider most important to your organization? [PROBE] Which of these are learned? [PROBE] Which of these are innate? 2. Thinking about the knowledge, skills and abilities you just mentioned, which do you believe should be included in a pharmacy technician training program? 3. Describe your process for recruiting technicians with these qualifications. [PROBE] What difficulties, if any, have you came across? Domain 2: Aptitude (Technician Level) 4. What entering characteristics predict success in a pharmacy technician? [PROBE] What types of prerequisite abilities do you look favorably upon when hiring a technician? Domain 3: Attitude (Technician Level) 5. Tell me about a time you were working with a technician, and the technician had a general “good attitude” towards work. [PROBE] What went well? [PROBE] What could have been improved, if anything? 6. How does pharmacy technician training affect attitude? 7. How does a good attitude benefit the pharmacy? [PROBE] How can one ensure technicians have good attitudes? Domain 4: Desirability and Trade-offs Between Traits (Technician Level) 8. Based on what we have just discussed, what knowledge, skills and abilities are most desirable in a pharmacy technician? [PROBE] Which of these items are most essential? [PROBE] Which traits do you prefer over others? 9. Are knowledge, skills and abilities more important than attitude? 10. Which knowledge, skills and abilities you either unwilling or unable to “pay more for”? [PROBE] Which are you willing to “pay for”? Domain 5: Certification Value (Certificate Level) 11. Describe how the pharmacy technician certification has had an impact on your organization. 12. How valuable is certification in your opinion? Domain 6: Certification Shortfalls/Downsides (Certificate Level) 13. What problems or downsides, if any, do you see in technician certification? 14. Are there any knowledge, skills or ability gaps you are aware of in certified technicians? Domain 7: Implementation (Certificate Level) 15. Have you had any difficulties implementing policies requiring certification? [PROBE] What issues, if any, would you foresee when implementing such policies? 16. Describe the current incentives process, if any, at your organization for encouraging certification. [PROBE] How do you retain quality technicians at your pharmacy? [PROBE] What strategies, if any, do you use to help them to perform optimally? 17. How do you keep talent in your technician workforce? Domain 8: Future (Profession Level) 18. How would you describe the future role of the pharmacist at your organization? 19. What is the future role of the pharmacy technician at your organization?
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Objective
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The aims of this study were to explore: 1) community pharmacy employer perceptions of associated benefits and perceived value of pharmacy technician certification and 2) needs of employers related to pharmacy technician attitudes and knowledge, skills and abilities (KSAs).
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Methods Recruitment and participants
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To obtain diverse employer perspectives regarding pharmacy technician certification, employers who represent different community pharmacy settings were recruited. Participants were stratified based on the type of community pharmacy setting (e.g., traditional chain, mass merchandiser, supermarket chain, and independent pharmacy) and role on top management team (e.g., leadership, management, or ownership). Participants within top management teams were selected as these individuals represent a unique perspective on trade-offs, competing priorities, future directions and requirements necessary for success within the business and operations of community pharmacy practice. This perspective is distinct from the needs of front-line stakeholders (e.g., staff pharmacists), whose perspectives would likely be based on experiences with direct patient care rather than on the business operations of the pharmacy. Participants were recruited using a purposeful sampling approach. A recruitment email was sent to request an interview about their perceptions regarding pharmacy technician skills, abilities, training and credentialing. Five participants declined participation due to a lack of time. Recruitment was stopped after 7 pharmacies since theme saturation (i.e., occurrence of the same themes with no new information being collected) was reached.15 The Institutional Review Board at the researchers’ university approved this study.
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Data collection Three members of the research team trained in qualitative methods conducted 7 in-depth, semi-structured interviews from November 2017–January 2018. Interviews lasted approximately 45 min and were conducted via phone to ensure that participants could take part in the study regardless of location. Interviews were chosen to best understand individual employer perspectives about pharmacy technician KSAs and attitudes as compared to other methods that focus on collective perspectives or obtaining a consensus, such as focus groups.16 A semi-structured interview guide was developed (Table 1) based on the human capital vs. signal theory.17,18 The interview guide included questions categorized within 8 domains: 1) technician knowledge, skills and ability, 2) technician aptitude, 3) technician attitude, 4) technician desirability and trade-offs between traits, 5) certification value, 6) certification shortfalls/downsides, 7) certification implementation, and 8) future of the pharmacy profession. Prior to conducting the interview, participants provided informed consent over the phone.
depth understanding of the information gathered and its context.21 Rapid analysis has been used in previous evaluation studies of health care organizations and delivery models22 as well as standalone qualitative studies.23–27 Rapid analysis allows for data to be analyzed in a short timeframe. This is compared to the rigorous, traditional coding process where an initial set of codes are inductively developed during the first phase of coding and then emerging themes are captured during the second phase.28 Researchers identified neutral domains in advance to structure and focus the interviews. Each neutral domain corresponded to a set of interview questions (Table 1). Transcripts were coded independently by two team members and coding was discussed until a consensus was achieved. Codes were then transferred into a matrix to allow for all participant comments to be viewed by neutral domain.29 This allowed for the synthesis of important findings and identification of major themes.
Data analysis Results Each interview was digitally recorded and transcribed verbatim. Rapid analysis19,20 was used. This approach is used to provide an in
A total of 7 pharmacists participated in this study. Among the 2
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Trade-offs between KSAs and attitude
Table 2 Participant characteristics. Type of Pharmacy
Participant Role
Number of Participants
Traditional chain Traditional chain Supermarket chain Mass merchandiser Independent Independent
Executive leadership Mid-level corporate Corporate Executive Leadership Owner Manager
2 1 1 1 1 1
Employers and managers generally saw both attitude and KSAs as vital to success. However, given a choice between experience and attitude, attitude was preferred as KSAs can be taught after hire. Of all potential KSAs, the following were identified as the most valuable: application of knowledge, communication skills, and adaptability.
Perceptions of certification in current pharmacy landscape participants interviewed, 2 served as either a manager or owner of an independent pharmacy. Five are part of top management teams for either a traditional, supermarket, or mass merchandiser chain (Table 2).
Employers were generally supportive of certification as its overall value was noted. Overall value of certification was most often identified by participants as giving a sense of accomplishment and pride to certified technicians. Regulatory statutes surrounding certification were also mentioned as a major driver for employers in the community pharmacy setting to advocate for or require certification for technicians. Expanded technician roles or duties, or the ability for a higher pharmacist-to-technician supervision ratio because of technician certification were specifically mentioned as drivers for employer advocated technician credentialing. Several concerns were noted which included the recognition that the business case for certification to top management teams is lacking, difficulty incentivizing certification due to current pay levels, and few opportunities for advancement or expanded responsibilities at their pharmacy. Participants stated they experienced difficulty in incentivizing technicians to pursue certification, as the marginal pay increase and expanded duties alone are not enough to meet technician expectations when compared to the time and cost of certification. It was also noted that employers would oftentimes provide training
KSAs and attitudes valued by employers When participants were asked to identify KSAs and attitudes valued by employers as learned, innate or both, participants listed the ability to influence patient behavior (e.g., adherence, vaccinations), accuracy in filling prescriptions, mathematical calculations, pharmacology (e.g., top 200, brand/generic), computer skills, medical terminology, and third-party adjudication as learned (Table 3). Participants noted that motivation/drive, work ethic, adaptability, and organization were innate skills. Customer service skills, ability to be caring and friendly with patients, communication, interpersonal skills, and team work were listed by participants as both learned and innate.
Table 3 Interview domains and illustrative quotations. Neutral Domains
Illustrative quotation
Knowledge, Skills, and Ability (Technician Level)
More than ever now our pharmacy technicians are in a position of influence. Influencing patients to adopt different services that keep them regular and routine on their medications. But also, influencing them in a way they really understand the importance of medication adherence. If we do all that and we do it well than obviously we keep them healthy, we keep them out of the hospital, we keep them from having recurring issues with their particular disease state. So I think those are probably the two things that I would probably say would be the most important. Because there's a lot going on it can feel chaotic and stressful at times. When you think about the characteristics of someone who isn't bothered by that, someone who can actually thrive and not be overwhelmed by that kind of pace. And still be able to think about their role and take every customer one by one. If I'm motivated as an employee to build relationships within our pharmacy, I'm going to be friendly and build rapport. I think those are the things that lead to everything else. Someone who's thirsting for information, willing to learn, and just has a great overall attitude because, to me, you can go miles with that person. And that person will probably do well in pharmacy and then who knows what else they can do in their career. That is your prime person and even maybe even better than with a worse attitude with some prior experience in pharmacy, cause that is sometimes you might struggle more with that person, even though they had a prior experience. Certification surely proves some level of that knowledge base, which then supports all the other traits. It's easier to be efficient and accurate when you have that base, and it's easier to train for clinical service engagement and that type of thing. It's really hard to say that certification in and of itself causes a person to be able to perform their job better. You'd like to think it does, but I'm not certain in all cases, that it does. But what I do think is that it does give them a sense of accomplishment and pride. Until the state boards of pharmacy allow for technicians to do more than they are doing today, it's just an added cost without a payout. In many ways we have to get the pay right but on the other hand we need to be making sure that we're creating a culture within the pharmacy where, you know we're providing the right sort of development and leadership capabilities for the pharmacist that's running the pharmacy, so that they're thinking about their role in terms of how I run a really good store. I think there's some states are looking at things that might provide an avenue to have a little bit of a higher-level technician that would require additional training or certification, but then would provide that aspirational piece where you can get to that point and earn more pay associated with that. That might give it a little bit more of a career, I don't know, look and feel. Then that could help with retention. I think that's definitely the struggle here. The technician would confirm medication lists and confirm health history, and then the pharmacist would use that gathered information to have adherence discussions, conversations about health conditions, cooperatively establish goals and solutions to help address drug-related problems. The technician would potentially do vaccine administration, for instance, but the pharmacist would be the one who would evaluate the appropriateness of vaccination, screen for additional vaccines, counsel on the vaccines, that kind of thing. But the administration is a task that could be completed by a technician. They [technicians] would definitely continue to do data entry supported as much as possible by electronic prescribing and system improvements. They would verify that what's on the prescription matches what was entered into the system. They would fill the prescription. The pharmacist would assess the clinical appropriateness of the medication for the patient, and perform a DUR. In order to get the pharmacist to be in a more clinical role, the technician's going to have to pick up more of the responsibility for the dispensing function.
Aptitude (Technician Level)
Attitude (Technician Level)
Desirability and Trade-offs Between Traits (Technician Level) Certification Value (Certificate Level) Certification Shortfalls/Downsides (Certificate Level) Implementation (Certificate Level)
Future (Profession Level)
3
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lowest level of legally or regulatory permissible responsibilities. In 2017, the Pharmacy Technician Stakeholder Consensus Conference conveyed several recommendations including requiring national certification prior to practice entry and minimalizing state-to-state variability in technician regulations.30 Employers also indicated that credentialing was associated with socalled “brain drain,” or pharmacy technician turnover from their pharmacy to another pharmacy setting upon gaining credentialing, training, and/or experience. This concept has been previously reported by cross-sectional surveys of pharmacy technicians which indicate poor job satisfaction and high turnover intentions.31,32 Reasons for why turnover intentions are high generally relate to lack of advancement opportunity, poor salary, and desire for a “change.”31 Participants also commented that because of limits of additional technician responsibilities, there is a lack of career growth potential within their organizations, creating a “ceiling” effect for the highest skilled and qualified technicians. This too is reflected by technician perceptions previously reported in the published literature, and illustrates an area in which there is much work still to be done to expand permissible technician duties.31,32 Overall key informant perceptions of certification in relation to employability and pharmacy technician quality were positive. However, views on the value of credentialing and certification by top management teams within these pharmacy organizations were less positive. These views are in line with employer perceptions across other industries. They demonstrate the general principle that members of the profession associated with a specific credential value such credentials higher than their employers.33 These obstacles to realizing a national standard for technician training and credentialing are not insurmountable as evidenced in the literature. In many states, state boards of pharmacy permit expanded duties or larger pharmacist-to-technician ratios of supervision-based, specified technician qualifications (e.g. certification).34–36 This creates readily perceivable value for employers. Moreover, as technicians engage in future roles with a higher level of technical difficulty, these roles will likely make pharmacy technicians’ work more rewarding and challenging – theoretically reducing turnover intentions.31 For instance, emerging evidence demonstrates that this is the case for technicians engaged in tech-check-tech, a responsibility requiring a high degree of drug knowledge and attention to detail previously reserved as a duty only for registered pharmacists.6 Employer perceived value may indeed be increased through the training and credentialing for new pharmacy technician knowledge, skills, and abilities. As this study found, some of these future areas include behavior motivation, screening for vaccines and facilitating pharmacist recommendations, and tech-check-tech.113 Incorporating these future areas into education and credentialing programs may further improve value of credential and allow for career latter within community pharmacy which could reduce turnover and further improve the value-proposition for employers.
experiences and sometimes even pay for certification for technicians or provide an increase in pay upon certification. However newly certificated technicians would leave soon after achieving certification for higher-paying positions with added responsibilities and room for advancement. Perceptions of certification needs for the future Although there was general agreement that certified technicians offered more value to their organization than non-certified technicians, participants reported gaps in certified technician KSAs, including a lack of day-to-day practical skills (e.g., navigating workflow, patient interactions, motivating patient behavior), screening patients for vaccines based on guidelines, motivating patients to improve adherence and otherwise influencing patient behaviors, drug diversion prevention, patient communication and workflow and time management. Participants identified expanded duties for technicians in the future of pharmacy practice as technician product verification (a.k.a. tech-checktech), working with patients to improve adherence, vaccination delivery, and overseeing the dispensing process. Discussion This was the first study to date to explore pharmacy employer perceptions of attitudes, knowledge, skills, and abilities needed of pharmacy technicians. The results of this study provide the pharmacy profession, as well as pharmacy technician training and credentialing stakeholders, with important insights useful in guiding future directions for technician training, credentialing, and scope of roles and responsibilities. Importantly, results here underline employers’ pragmatic approach to viewing technician characteristics as a combination of attitude and aptitude, as well as their unique needs among other pharmacy settings related to engaging with patients. A study of high performing teams uncovered 6 common characteristics: team member competencies, processes/techniques, interpersonal skills/communication, a shared value system, shared vision/direction, and supporting organizational values including openness.17 Given these common characteristics, employers are presumably in a position to understand the value of a well-trained pharmacy technician as it is vital to the success of their business. Yet, as compared with health-system employers, community pharmacy employers have been slower to mandate training or credentialing requirements for pharmacy technicians. Results from this study present a two-fold explanation for this phenomenon. First, the high degree of patient interaction within outpatient pharmacy settings requires that a successful pharmacy technician concurrently possess characteristics which would allow them to communicate with patients and motivate behavior change such as would be required to provide patient/customer service, vaccine-related conversations, adherence-related conversations, and relationship building. This, in addition to technical task completion, makes for a requirement unique to outpatient settings like the community pharmacy. Moreover, these items are not traditionally an area of focus for technician training and credentialing. Second, even with training or credentialing standards which would assure this level of competency, outpatient community pharmacy employers articulate a difficulty in retaining such highly trained talent. A key insight from this study was that these employers described a situation by which credentialed technicians do not generally have legal or regulatory permitted expansions in duties, which subsequently reduces the value that these technicians bring to these organizations and their ability to increase wage scales. In some cases, even though some expansions in duties are available in some states, the multi-state nature of the national chain pharmacy would require separate training, policies, and procedures for each state for which the chain operated – making it logistically simpler to adopt a policy of only allowing the
Limitations This study had several limitations. The interviews were conducted with only employers in the community pharmacy setting and do not capture other pharmacy settings (i.e., inpatient). This setting was purposefully chosen because the community pharmacy setting typically has the least uptake of certification. It was important to capture perceptions of employers in this settings as the lack of uptake likely means there is something missing or means to improve upon. More chain pharmacy employers were interviewed than independent pharmacy employers. Therefore, the findings from this study may not be representative of independent pharmacies. Future studies are warranted to gather perceptions from other pharmacy settings such as outpatient pharmacies associated with a hospital or clinic. 4
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Conclusion 10.
Initial findings suggest that technician certification may offer benefits to technicians and employers. These findings should be further explored in future research studies. Furthermore, new emerging directions for certification now exist due to the rapidly shifting pharmacy landscape, which revolves around new and expanded clinical patient care services. This shifting landscape has exposed gaps, reinforced strengths, and uncovered potential new opportunities and needs related to technician certification.
11. 12. 13.
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Funding sources
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The Pharmacy Technician Certification Board (PTCB) funded this research through a grant. The funder played no role in analysis, interpretation, writing on the results, or decision to submit for publication. The funder was given the opportunity to review semi-structured interview questions and provide input. Final selection of interview questions was made at the sole discretion of the authors.
16. 17. 18. 19.
CRediT Author Statement
20.
Chelsea Phillips Renfro: Methodology, Formal Analysis, Investigation, Writing – Original Draft; James Wheeler: Conceptualization and Writing – Review & Editing; Sharon McDonough: Methodology and Investigation; Junling Wang: Writing – Review & Editing; Kenneth Hohmeier: Conceptualization, Methodology, Formal Analysis, Investigation, Writing – Original Draft, Project Administration, Funding Acquisition
21.
22.
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Appendix A. Supplementary data
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Supplementary data to this article can be found online at https:// doi.org/10.1016/j.sapharm.2019.12.003.
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References
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