- Email: [email protected]
Pharmacy technicians’ attitudes about their roles in Iowa public safety
RESEARCH
Pharmacy technicians’ attitudes about their roles in Iowa public safety Andrea L. Kjos and Michael T. Andreski
Andrea L. Kjos, PharmD, PhD, Assistant Professor of Social and Administrative Pharmacy, College of Pharmacy and Health Sciences, Drake University, Des Moines, IA
Abstract Objectives: To describe and apply a model for combining self-assessed frequency and criticality for pharmacy technicians’ roles and to evaluate similarities and differences between attitudes toward public safety in various practice settings. Design: Cross-sectional mail survey of randomly selected pharmacy technicians in one state. Setting: Iowa in fall 2012.
Michael T. Andreski, BSPharm, MBA, PhD, Assistant Professor of Social and Administrative Pharmacy, College of Pharmacy and Health Sciences, Drake University, Des Moines, IA Correspondence: Andrea L. Kjos, PharmD, PhD, College of Pharmacy and Health Sciences, Drake University, 2507 University Ave., Des Moines, IA 50311; andrea.kjos@ drake.edu Disclosures: The authors declare no relevant conflicts of interest or financial relationships.
Participants: 1,000 registered technicians. Intervention: Mail survey with option for online completion. Main outcome measures: Scored ratings related to perceptions of frequency and criticality of roles. Technicians rated role frequency on a scale from 1 (not responsible) to 6 (daily) and role criticality on a scale from 1 (no importance) to 4 (extremely important). A weighted relative importance score was ranked to show importance of the role considering frequency and criticality together. Results: The response rate was 25.81%. Ratings for frequency were correlated to ratings for criticality for 22 of 23 roles. A Mann–Whitney U test found a difference between ambulatory technicians and hospital technicians. A visual matrix of a dual-scaled analysis showed both groups’ role ratings to be positively linearly related. Hospital technicians showed wider discrimination in their ratings for some roles than for others.
Funding: Funding support for this study was provided by the Harris Research Endowment, Drake University College of Pharmacy and Health Sciences. Previous presentation: Annual Meeting, Iowa Pharmacy Association, June 14, 2013. Acknowledgments: Iowa Pharmacy Association for facilitating survey feedback and technical support; Hanna P. Raber and Alexandra M. Hendzel for data entry. Received July 9, 2014. Accepted for publication April 27, 2015. Published online in advance of print September 6, 2015.
Conclusion: Perceived role frequency and criticality can be considered together to contextualize the practice environment. The data suggest a relationship between perceived frequency of role performed and perception of a role’s criticality. The study found differences between how technicians from various practice settings perceive their roles. J Am Pharm Assoc. 2015;55:493–502 doi: 10.1331/JAPhA.2015.15010
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s pharmacy technicians’ roles evolve, it is important to understand technicians’ attitudes about their roles in patient safety. Understanding attitudes provides context for enculturation of growing expectations and may assist in professional development to ensure competence and public safety. Discussions surrounding technicians’ expanding roles have been ongoing for decades. In 1975, Jeffery hypothesized the role of the pharmacy technician in 2000, writing, “Technicians will assume, almost completely, the mechanics of prescription filling. The pharmacist’s role will be purely ‘clinical’ in this area.”1 Although technicians now have expanded roles, widespread and consistent practices remain elusive. This is attributable in part to differences in practice laws as well as organizational policy. To provide evidence to support pharmacy technician role expansion, researchers have studied the use of the technician workforce in medication therapy management and improved quality of care.2 For example, research has demonstrated that technicians have expanded their roles in medication reconciliation and in
Key Points Background: ❚❚ The pharmacy technician’s role in contemporary pharmacy practice continues to receive considerable attention. However, state practice laws and organizational policies remain inconsistent in guiding potentially evolving roles. ❚❚ Supporting professional development of technicians relies on understanding currently held perceptions and attitudes. There is a gap in the literature on how technicians perceive their current roles. ❚❚ Conducting a task analysis is one way to gather data on perceptions of the practice environment. This study used a task analysis to measure technician-assessed perceptions and attitudes about roles they perform. Findings: ❚❚ Perceived role frequency and criticality were useful in contextualizing the practice environment when conducting a task analysis. ❚❚ Roles that participating technicians perceived as critical in support of public safety in the practice environment were also the roles they self-assessed as performed most frequently. ❚❚ The specific practice setting for technicians may provide an important frame of reference for developing perceptions and attitudes about roles performed.
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assisting nurses with certain medication administration duties.3,4 Research has shown factors that predict the likelihood of technicians assuming unconventional roles are characteristics of practice settings, acceptance by pharmacists, and professional experience.5 A review of “tech-check-tech” programs reported that 12 states currently have a policy allowing for some aspect of this practice and that the published evidence on outcomes of such programs consistently support the accuracy and quality of properly implemented programs.6 It is important that the pharmacy profession supports pharmacy technicians in reaching their full potential, thereby allowing for pharmacists’ reallocation in clinical activities.6 Part of this support should be a concerted effort to fully enculturate pharmacy technicians into professional practice. This effort could include fostering professional values toward high standards of excellence in work activities, as well as an attitude of obligation toward ensuring optimal patient outcomes. As efforts to instill and enhance elements of professionalism emerge, it will be important to understand technicians’ current attitudes about and perceptions of their roles. Calls for attitude assessments when looking to expand technicians’ roles have been previously discussed.7 Such assessments could assist managers in understanding feelings and biases toward work-related functions, promote pharmacy technicians’ abilities, and help ensure a supported transition into expanded roles that are aligned with the goals of pharmacy practice. To determine attitudes of pharmacy technicians, this study examined the organizational sociology element of work8 by measuring the congruency of technicians’ perceptions of their roles. Understanding technicians’ self-assessment of the roles they perform, as well as the perceived criticality of these roles, provides context for understanding professionalism in terms of attitudes of obligation in public safety and protection. To our knowledge, no literature has been published on techniques for measuring congruency between self-assessed perceptions of frequency and criticality of roles with respect to the pharmacy workforce in general and technicians in particular.
Objectives The objectives of this study were to describe and apply a model for combining self-assessed frequency and self-assessed criticality for pharmacy technicians’ roles and to evaluate similarities and differences between attitudes toward public safety in various practice settings.
Methods As part of a longitudinal state-based technician research initiative that began in 2008, a task analysis rating assessment tool was added to a previously used technician survey in 2010 and 2012. The 2008 and subsequent surveys were derived from previous pharmacist workJournal of the American Pharmacists Association
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force studies as reported by the Pharmacy Manpower Project, Inc.9 This study’s specific survey for technicians was replicated from a survey conducted in Iowa in 2008 and 201010 and was similar to other states’ technician surveys, also based upon the Pharmacy Manpower Project.5,11–13 The entire survey tool used in 2012 is included in Appendix 1 (available under Supplemental Content on JAPhA.org). It was pretested by 20 technicians in 2010 for question clarity and comprehension of the newly added task analysis. Pretesting respondents verified their ability to understand the instructions and questions, and data collection occurred in fall 2012 using a random sample of pharmacy technicians from Iowa. The data collection process included a mixed-mode traditional mailer received by all participants with the option of online completion. The protocol followed modified elements of the Tailored Design Method, including two contacts.14 A random sample of approximately 20% of pharmacy technicians (n = 1,000), generated from a list of all Board of Pharmacy–registered Iowa technicians15 (n = 5,311), was mailed a traditional paper questionnaire. Two weeks after the initial mailing, 19 undeliverable surveys were returned; additional respondents were then randomly selected and sent a survey to replace those that could not be delivered. If these replacement surveys were returned after the 2-week period, no other replacement attempts were made. Follow-up reminders were sent 2 weeks after the initial mailing. Respondents also had the option to complete the survey online; a link was included with the mailed survey. Of the 1,019 mailed surveys, 39 were returned as undeliverable, and 980 were assumed to have reached the intended recipients. The Drake University Institutional Review Board approved this study. Student research assistants recorded and entered study data. The results presented focus specifically on responses to Question 6 of the tool (Appendix 1). The specific roles in this question were expanded into 23 roles based on the previous question’s work activity categories (e.g., “Assisting the Pharmacist in Serving Patients” and “Maintaining Medication and Inventory Control Systems”). (See survey question 5, Appendix 1.) The data herein pertain to an analytical approach summarized by the following steps: (1) conduct a dual-scaled task analysis to measure contextual effects of the practice environment, (2) rank and weight roles to quantify perception of the roles’ relative importance, and (3) develop a dualscaled analysis map matrix to visualize the data. Dual-scaled task analysis The technician workforce literature was used to create a list with 23 roles (Appendix 1).10,12,16 The 23 roles comprised 18 roles that had been included in the previously Journal of the American Pharmacists Association
conducted 2008 survey, which was based on the three major areas of assisting the pharmacist in serving patients, maintaining medication and inventory control systems, and participating in the administration and management of pharmacy practice.10 Five additional roles were added based on open-ended responses collected in 2008 and 2010. The final 23 roles were validated using a published national practice analysis of technicians in all settings17 and piloted with 20 local technicians who were contacted through the state pharmacy association and represented multiple state settings. The five added roles were (1) compound I.V. medications/fluids, (2) fill/deliver unit dose refills to hospital patients, (3) fill/deliver medication containers to nursing-home patients, (4) replenish automatic dispensing devices, and (5) supervise other techs, including scheduling. The fifth role came from open-ended feedback on previously conducted surveys, as well as responses from the pilot testers. The technicians rated the 23 roles in two ways: first, the perceived frequency of the role, performed on an ordinal scale from 1 (not responsible) to 6 (daily) (categories in Appendix 1); and second, criticality associated with how important the role was perceived to be in considering the safety and protection of the public, measured on an ordinal scale from 1 (no importance) to 4 (extremely important) (categories in Appendix 1). For the construct of criticality, “importance” was used in the survey to maintain an informal and common idiom of measurement. The structure of these dually scaled analyses was based on the example of a similar assessment for radiologic technologists.18 Ranking and weighting roles This study used a published framework to create a “multiplicative model” for combining scales.19 This provided a way to combine the measured constructs for frequency and criticality and rank the roles in order of relative importance, as well as to examine the contextual effects that may show how technicians associate frequency of roles with criticality. According to Kane et al., “The relative importance of any activity in practice will depend on the frequency of the activity and the criticality of the activity.”19 Frequency and criticality ratings were combined as a raw score, as well as with a weighted adjustment score, to control for the relative impact of each scale. The calculations used in this approach are described in Appendix 2 (available under Supplemental Content on JAPhA.org). More specifically, the weighted adjustment was calculated and transformed using an exponential model. This was done so that the relative contribution of frequency and criticality would be effectively equal. For example, this increased the weighting of activities with higher criticality ratings and decreased the weights for items with lower criticality ratings. The new calcuj apha.org
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lated relative importance score for each role could then be divided as a percentage or proportion based on the 23 roles. The weighted proportion and the adjusted weighted proportion, therefore, summed to 100 and could be ranked. Finally, because technicians’ perceptions of role frequency and criticality differed depending on practice setting, the respondents were separated by primary practice setting (community/ambulatory compared with hospital/specialty). Dual-scaled analysis mapping The data were plotted to visualize how roles related to both frequency and criticality compared with other roles. This type of plotting accords with an approach that has been used for examining contextual effects in a dual-scaled practice analysis.20 Scatterplots were created that included both the raw and adjusted weighted relative importance scores for role frequency and criticality. The data were normalized (i.e., the x and y axes, representing the difference between each role’s mean and the overall mean, were divided by the standard deviation for the overall mean of all roles). The overall mean for frequency was calculated when all role frequencies were combined and averaged, with the same done for criticality. For example, a point plotted as a zero on the x and y axes (0,0) would indicate the “average” for frequency and criticality. Thus, the figures were created to show the roles in one of four quadrants, categorized as low criticality, high frequency (quadrant 1); high criticality, high frequency (quadrant 2); low criticality, low frequency (quadrant 3); and high criticality, low frequency (quadrant 4). The raw relative importance score, as well as the adjusted relative importance, were plotted to visualize the overall impact of the adjustment on role categorization. Statistical analyses All statistical analyses were performed by the authors using IBM SPSS version 21. Spearman correlations, Mann–Whitney U tests, chi-square tests, and Fisher exact tests were performed using a critical value of alpha 0.05 to indicate statistical significance, unless otherwise noted. Correlations of the dual scale were assessed. Independent samples Mann–Whitney U tests for ordinal data were used to determine if ambulatory and hospital technicians ranked roles differently. Chi-square and Fisher exact tests were used to assess response bias.
Results Technicians provided information about work status, practice setting, position, hours worked, compensation, demographics, certification status, actual and desired roles, and ratings for frequency and criticality for specific roles. The response rate was 25.81% (253/980); respondent characteristics are included in Table 1. Of those respondents who worked primarily as a technician, 48.2% 496 JAPhA | 5 5:5 | S E P /OCT 2 0 1 5
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Table 1. Demographics for pharmacy technicians (n = 1,000) Characteristica Practice setting Independent/small (1–10 pharmacies; same ownership) Large/mass (>10 pharmacies; same ownership), mass merchandiser or supermarket Hospital Other (home infusion, mail service, etc.) Average years employed by the same employer (median; SD) Gender Female Race White/Caucasian Average age (median; SD) Education Beyond a high school diploma/GED Some college, but did not receive degree Associate’s degree Bachelor’s degree Graduate/professional degree
Response rate 89.6% (224/250) 26.4% (59/223) 42.2% (94/223) 20.1% (45/223) 11.2% (25/223) 8.1 (5.0; 8.4) 91.5% (196/214) 98.7% (208/214) 43.2% (46; 13.7) 69.0% (147/213) 36.6% (78/213) 13.1% (28/213) 14.6% (31/213) 4.7% (10/213)
a Demographic data include those respondents who indicated currently working full-time or part-time as a technician.
(108/224) were located in an urban locale, while 52.7% (516/980) of the sampling frame of invited participants was to urban-located technicians (P >0.05).21 Table 2 summarizes the findings of mean frequency and criticality ratings in all practice settings. There was a wide distribution of ratings of frequency of roles performed (mean range, 1.79–5.28). The most frequent roles performed were “receive prescription/medication orders,” “collect and communicate patient-specific information,” “process prescription and medication orders,” and “provide medication to patient or their representative.” These four roles included a mean frequency above 5.0 on the scale from 1 to 6 (Table 2). However, the responses related to criticality appeared to be skewed (mean range, 2.87–3.88 on the 1–4 scale) for all roles. A statistically significant Spearman rank-order correlation for nonparametric data was found between ratings for frequency and criticality for 22 of the 23 roles (significant at 0.01, two-tailed), with all positive correlation values ranging from 0.124 to 0.478. The only role that was not statistically significantly correlated was “maintain inventories and records, including controlled substances and investigational drugs” (Table 2). Open-ended areas in the survey instrument enabled respondents to include information about “other” roles not listed in the question. There were few responses, but those that were provided included “Medicare Part D enrollment,” “cleaning/organizing,” “giving vaccines,” “diabetes education,” and “shoe fittings.” Journal of the American Pharmacists Association
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Communicate with third-party payers. Compound I.V. medications/fluids. Fill/deliver unit dose refills to hospital patients. Fill/deliver medication containers to nursing-home patients. Identify items to be ordered. Place routine and emergency orders. Receive orders and place items into stock. Implement and monitor policies to deter theft and diversion. Maintain inventories and records, including controlled substances and investigational drugs. Replenish automatic dispensing devices. Coordinate written, electronic, and oral communication throughout the practice Update patient information. Collect productivity information. Participate in quality assurance activities. Update, maintain, and use information systems and dispensing technologies. Perform billing and/or accounting functions. Contribute to staff training and evaluation processes. Supervise other techs, including scheduling.
Role Receive prescription/medication orders. Collect and communicate patient-specific information. Assess orders for completeness, accuracy, legality and reimbursement eligibility. Process prescription and medication orders. Provide medication to patient or patient’s representative.
3.35 (171) 3.50 (204) 3.45 (192) 3.49 (207)
2.37 (224) 4.87 (223) 3.81 (223) 4.57 (225)
3.29 (189) 3.29 (187) 3.12 (182) 2.87 (166)
3.65 (223) 2.28 (222) 1.79 (224)
3.57 (197) 3.76 (200) 2.98 (178) 3.47 (191)
3.69 (198) 3.04 (168)
3.74 (221)
4.13 (224) 4.77 (223) 2.13 (218) 3.26 (225)
3.70 (224) 2.64 (221)
3.39 (191)
3.23 (159)
1.88 (223)
2.63 (224)
3.38 (198) 3.17 (158)
3.82 (203)
5.12 (222) 3.83 (223) 1.58 (221)
3.87 (200) 3.88 (205)
3.87 (211)
Mean criticalitya (C)(n) 3.83 (208)
4.41 (222) 5.08 (223)
5.28 (226)
Mean frequencya (F)(n) 5.13 (225)
0.314e 0.355e
0.298e
0.429e
0.478e 0.210e 0.356e 0.336e
0.124 0.470e
0.26e
0.342e 0.163e 0.316e 0.260e
0.300e
2.437 1.758
4.117
4.218
5.049 6.131 2.175 3.878
4.674 2.748
3.056
2.711 5.846 4.503 5.463
2.076
1.55 0.85
3.12
3.21
5.03 7.18 1.20 3.51
5.18 1.61
2.55
2.17 5.46 4.01 5.03
1.48
3.70 1.16
4.444 1.720
0.255 0.302e
8.28
6.691
7.52 8.79
9.03
W' prop. weightsa,b (100) 8.38
e
5.838 6.748
6.998
W prop. weightsa (100) 6.723
0.238e
0.242e 0.295e
0.209e
Spearman correlation (F) vs. (C) 0.260e
19 22
14
13
9 5 20 15
10 17
16
18 6 11 8
21
12 23
4
7 2
1
Ranka,b W 3
0 −1
−1
−1
0 −1 −1 2
2 −1
0
1 −1 0 −2
1
0 1
0
2 0
0
Change ranka,b (Rank W− Rank W') 0
19 23
15
14
9 6 21 13
8 18
16
17 7 11 10
20
12 22
4
5 2
1
Ranka,b W' all 3
18 21
15
16
7 6 19 13
10 20
14
17 8 12 9
23
11 22
4
5 2
1
Rankc W' amb 3
19 23
12
9
14 8 22 16
7 15
18
20 5 13 10
11
21 17
3
6 2
1
Rankd W' hosp 4
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e
Includes results of technician respondents for hospital and specialty practice settings. Weighted adjustments calculated with (a) = 3.88 as the weight-adjusted constant used to make contributions of criticality (C) and frequency (F) equal.
Correlation was statistically significant at 0.01 (two-tailed).
d
c
Includes results of technician respondents for ambulatory practice settings. Weighted adjustment conversion calculated with (a) = 4.49 as the weight-adjusted constant used to make contributions of criticality (C) and frequency (F) equal.
b
Weighted adjustment conversion calculated with (a) = 4.28, whereas (a) is the calculated weight adjustment using [Var(LnF)/Var(LnC)]1/2. This was the numerical constant used to make contributions of criticality (C) and frequency (F) equal. See Appendix 2 for equations.
a
Includes results of technician respondents in all practice settings for 2012. Frequency: from 1 (not responsible) to 6 (daily); criticality: from 1 (no importance) to 4 (extremely important).
Abbreviations used: ID, coded role description used in figures; I.V., intravenous; W prop., unadjusted proportional weight; W'prop., adjusted proportional weight; Rank W−Rank W', difference between unadjusted proportional weight and adjusted proportional weight; amb, ambulatory; hosp; hospital.
22 23
21
20
16 17 18 19
14 15
13
9 10 11 12
8
6 7
5
3 4
2
ID no. 1
Table 2. Role importance: Dual-scale results in 2012
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Ranking and weighting roles Table 2 shows the weighted proportions and adjusted weighted proportions for all roles by technicians in all settings. These proportions were ranked to show the relative importance of each role when taking into account both frequency and criticality. A change in rank description was calculated to more explicitly depict the impact of the weighted criticality adjustment on the overall relative importance of the role, compared with no weight adjustment. For example, the roles “assess orders for completeness,” “maintain inventories and records,” and “participate in quality assurance activities,” which each increased by two within the rankings, reflected the adjustment of the higher criticality score. Conversely, the role “receive orders/stock” dropped by two within the rankings (Table 2). A post hoc investigation revealed that technicians who practiced in the ambulatory or community pharmacy settings, compared with those practicing in the hospital/specialty settings, may have similar but different responsibilities as well as varying perceptions of those activities. This was reflected when the task analysis was dichotomized for technicians whose primary practice setting was community or ambulatory, compared with hospital or specialty. Although the raw weighted proportion results were not shown in the dichotomized data, Table 2 includes the weight-adjusted ranking for the roles in each type of practice setting. The ranking of the roles appeared different between ambulatory and hospital technicians’ perceptions. For example, the roles “communicate with third-party payers” and “coordinate written, electronic, and oral communication throughout the practice” were more emphasized by ambulatory practice technicians. In contrast, the roles “fill/deliver unit dose refills to hospital patients” and “information systems/dispensing technologies” were shown to have higher relative importance to hospital technicians (Table 2). Table 3 shows the statistical results for the Mann– Whitney U test distribution comparison. Frequency ratings for 12 roles and relative importance ratings for 6 roles were statistically significantly different between the two practice settings (significant at 0.05, two-tailed). Dual-scaled analysis mapping The dual-scaled analyses maps are displayed in Figures 1 and 2. The patterns of data were similar for the ambulatory and hospital technicians. Role frequency and level of criticality were linearly related in a positive direction across both groups (i.e., as technicians performed the role more often, they were more likely to perceive it as a critical role). This was consistent with the Spearman correlation reported previously. In Figures 1 and 2, the hospital group appeared to have increased discrimination between role frequency and criticality, reflected by the wider spread of data points on the scatterplot. 498 JAPhA | 5 5:5 | S E P /OCT 2 0 1 5
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More specifically, three quadrants were represented by hospital technicians, compared with two quadrants by ambulatory technicians. Figure 2 shows that certain roles (“place routine and emergency orders,” “receive orders and place items into stock,” “replenish automatic dispensing devices,” and “perform billing and/or accounting functions”) were within the quadrant of low criticality and high frequency, in contrast with ambulatory technicians. Finally, some roles of hospital technicians (“compound I.V. medications/fluids” and “identify items to be ordered”) did not follow the same linear pattern as the other roles.
Discussion Practice settings appeared to be associated with technicians’ perceptions of self-assessed frequency and criticality of roles. This finding supports that the technicians were most likely reporting on roles they were permitted to perform and that practice settings used technicians in diverse ways, such that roles performed may be directly linked to the highest patient care and administrative needs of specific practice settings. For roles more often performed, technicians perceived the criticality of performing those roles to be higher. Roles performed more often were different depending on the respondent’s practice setting. The patterns of variation among community-based technicians compared with health-system technicians have also been validated by previously reported practice analyses.17 Although we did not have an a priori hypothesis for how congruent technicians would perceive the frequency and criticality of their roles, we would have expected the dual scaling to have been less correlated or not necessarily correlated at all and the roles to populate all four quadrants of the mapping analyses as shown in Figures 1 and 2. However, the analyses showed that attitudes about roles followed a volume-driven effect—the more frequently a role was performed, the more critical it was perceived to be, which could support a hypothesis of self-justification of professional roles. Previous research supports the idea that pharmacy technicians perceive a moderate to high level of importance about most, if not all, the specific skills on which they are functionally tested for certification.22 Comparing Figures 1 and 2, we found it interesting that both groups of technicians’ roles formed a linear pattern predominately across two of the four quadrants— high criticality/high frequency and low criticality/ low frequency—thus demonstrating high congruency between the two constructs of frequency and criticality. Many technicians may have been attempting to justify the importance of their work with the self-assessed association between frequency and criticality of roles. Hospital technicians had roles that were found in three of the four quadrants, more specifically in quadrant one, representing some assessed roles with low Journal of the American Pharmacists Association
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Table 3. Differences between ambulatory and hospital technicians ID no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Role Receive prescription/medication orders. Collect and communicate patient-specific information. Assess orders for completeness, accuracy, legality, and reimbursement eligibility. Process prescription and medication orders. Provide medication to patient or patient’s representative. Communicate with third-party payers Compound I.V. medications/fluids. Fill/deliver unit dose refills to hospital patients. Fill/deliver medication containers to nursing-home patients. Identify items to be ordered. Place routine and emergency orders. Receive orders and place items into stock. Implement and monitor policies to deter theft and diversion. Maintain inventories and records, including controlled substances and investigational drugs. Replenish automatic dispensing devices. Coordinate written, electronic and oral communication throughout the practice Update patient information. Collect productivity information. Participate in quality assurance activities. Update, maintain and use information systems and dispensing technologies. Perform billing and/or accounting functions. Contribute to staff training and evaluation processes. Supervise other techs, including scheduling.
Median frequency (F)a Amb Hosp P 6 5 0.000c
Median criticality (C)b Amb Hosp P 4 4 0.083
6
5
0.000c
4
4
0.006c
6 6
4 5
0.000c 0.000c
4 4
4 4
0.668 0.114
6 5 1
5 1 1
0.000c 0.000c 0.000c
4 4 4
4 3.5 4
0.144 0.031c 0.059
1
2
0.000c
4
4
0.006c
1 6 5 5 1
1 6 4 5 1
0.650 0.719 0.175 0.005c 0.542
4 4 4 4 4
4 4 4 3 4
0.206 0.381 0.354 0.106 0.303
4.5 1
4 3.5
0.413 0.000c
4 3
4 4
0.692 0.023c
6 6 1 3
4 4 1 3
0.000c 0.000c 0.682 0.238
4 4 3 4
4 4 3 3
0.018c 0.312 0.984 0.039c
5 4 1 1
4.5 4 2 1
0.362 0.951 0.395 0.311
4 4 3 3
4 4 3 3
0.406 0.440 0.627 0.710
Abbreviations used: ID, coded role description used in figures; I.V., intravenous; Amb, ambulatory; Hosp, hospital. a Frequency: from 1 (not responsible) to 6 (daily). b Criticality: from 1 (no importance) to 4 (extremely important). c Difference in score distribution was considered statistically significant at P <0.05 using the independent samples Mann–Whitney U test. Note: Despite medians being the same, statistical significance reflects the difference in the ranked distribution for each ordinal item.
criticality and high frequency. Therefore, hospital technicians appear to self-assess roles that have high frequency but also low criticality (Figure 2, quadrant 1). A possible explanation for this observation could be related to the nature of professional roles and responsibilities in the contrasting work environments of community and hospital pharmacy practices. Technicians in hospital practices may have a wider range of possible roles that make broader and deeper use of their skills. Moreover, technicians in hospital settings may interact with many other health care providers. As a result, these technicians are more likely to see how their roles fit into the provision of those more complex pharmacy services. Concomitantly, in many community settings, technicians may see their roles in a more focused environment and, as such, perceive greater congruency between Journal of the American Pharmacists Association
criticality and frequency of tasks. Therefore, differences in levels of self-awareness may be an inherent function of technicians’ work environment and provide context for attitudes about and perceptions of their roles. This may present evidence for how to further develop the professional practice of technicians. This study also presents evidence about the congruency of technician self-assessment between perceived role frequency and role criticality. It is not clear if these perceptions would be assessed similarly by supervising pharmacists. Previous qualitative research conducted in New Zealand found that when comparing pharmacists’ views of their roles with that of pharmacist assistants, there were alignments in some respects but differences in others.23 For example, self-perceptions of pharmacist assistant roles were oriented more toward a health care j apha.org
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For example, promotion of new or alternative distribution of responsibilities8 may warrant further professionalization via education and training such that technicians can discriminate between roles performed frequently and those that are most critical to public safety. There is a link between technician perceptions and the potential for continued change. Developing a nuanced understanding of roles could be taught by highlighting the importance of accuracy compared with roles that require competence in making cognitive judgments. The pharmacy community would benefit from more evidence related to actual roles, perception of roles, and evaluation of roles and responsibilities to drive advancement in the practice environment while improving patient care and supporting public safety.
role than was perceived by pharmacists. Moreover, the idea that perceptions of pharmacy technicians are becoming oriented toward their role in health care and patient care is also supported by other research.24,25 To help further discern if this is the case, future research should evaluate pharmacists’ perceptions of the criticality of technician roles to determine if the self-justifying volume-driven effect is prevalent from the perspectives of others in pharmacy practice. Researchers could also enlist an expert panel to inform a comparator rating of priority roles that would demonstrate contextual factors beyond the perceived frequency of performing the roles. Research seeking to expand technicians’ roles will require empirical evidence to validate the actual versus perceived frequency of roles performed. From the viewpoint of stakeholders, it would be of interest to look at technicians with various educational training (e.g., certificate programs, certification-prep exams, and associate degree programs) and determine whether those differences in training translate into differences in self-assessed frequency of roles and perceptions of role criticality. As the cultural climate of pharmacy practice and the role of technicians continue to evolve, stakeholders should consider the organizational structure of practice that is desired from a broad perspective.
Limitations There are limitations with external validity; therefore, these findings cannot be generalized to other regions or states because of differences in practice regulations, including scope of practice and certification requirements. While the response rate was lower than desired, the demographic characteristics were consistent with those of studies conducted in 2008 and 2010. The 2008 study, with a similar demographic respondent profile, found 2
Quadrant 1: Low criticality High frequency
Quadrant 2: High criticality High frequency
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Adjusted SD away from mean (F*Ca) Unadjusted SD away from mean (F*C)
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-2 Criticality (C) and (Ca) on x-axis
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2 10 Quadrant 1: Low criticality High frequency
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Quadrant 2: High criticality High frequency
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7 Adjusted SD away from mean (F*Ca) Unadjusted SD away from mean (F*C)
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-2 Criticality (C) and (Ca) on x-axis
Figure 2. Dual scaling matrix: hospital/specialty settings evidence of nonrespondent bias using follow-up phone calls such that only those who were currently working in a pharmacy were most likely to respond.10 The survey instrument may not be able to discern the true differences that exist within various roles. For example, “Importance: safety/public protection” could have been interpreted in various ways. The task analysis section of the tool was not validated to actual role frequency or other sources that can assess criticality. The numbers of responses for each survey item were varied and may not reflect the total number of responses, as respondents chose to omit questions.
Conclusion This study found that technicians’ perceptions about critical roles in public safety correspond with the roles they self-assessed to perform most frequently. The model used in this study for combining the dual scaling into a weighted importance factor was useful in reducing the impact of any underlying statistical properties of the variables. The study findings suggest that there are differences in how technicians from various practice settings perceive the frequency and criticality of their roles. Not only are there differences in perception of which roles Journal of the American Pharmacists Association
are performed most often, there appear to be notable differences in how technicians, grouped by practice setting (e.g., hospital vs. ambulatory), associate the corresponding criticality of these roles. This information may be useful when considering the future professional development of the pharmacy technician workforce. References 1. Jeffery LP. Impact of the pharmacy technician upon pharmacy service in the year 2000. Drug Intell Clin Pharm. 1975;9(8):430–432. 2. Powers MF, Bright DR. Pharmacy technicians and medication therapy management. J Pharm Technol. 2008;24(6):336– 339. 3. Siemianowski LA, Sen S, George JM. Impact of pharmacy technician-centered medication reconciliation on optimization of antiretroviral therapy and opportunistic infection prophylaxis in hospitalized patients with HIV/AIDS. J Pharm Pract. 2013;26(4):428–433. 4. McGraw C, Coleman B, Ashman L, Hayes S. The role of the pharmacy technician in the skill-mixed district nursing team. Br J Community Nurs. 2012;17(9):440–444. 5. Friesner DL, Scott DM. Identifying characteristics that allow pharmacy technicians to assume unconventional roles in the pharmacy. J Am Pharm Assoc. 2010;50(6):686–697.
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6. Adams AJ, Martin SJ, Stolpe SF. “Tech-check-tech”: a review of the evidence on its safety and benefits. Am J Health Syst Pharm. 2011;68(19):1824–1833. 7. Woller TW, Ploetz PA. Expanding the role of the pharmacy technician. Top Hosp Pharm Manage. 1989;9(1):35–49. 8. Barley SR. Technicians in the workplace: ethnographic evidence for bringing work into organizational studies. Adm Sci Q. 1996;41(3):404–441. 9. Pharmacy Workforce Center. Final report of the National Pharmacist Workforce Study 2009. http://www.aacp.org/resources/research/pharmacyworkforcecenter/Pages/default. aspx. Accessed April 10, 2015. 10. Urick BY, Zgarrick D, Sobek LG. 2008 Iowa pharmacy technician compensation survey. J Iowa Pharm Assoc. 2009;65(3):48–51. 11. Quinones AC, Zgarrick DP, Pullin P. 2007 Illinois pharmacist compensation survey: part 1—overall marketplace trends. KeePosted. 2008;35(5):11–20. 12. Scott DM, Halvorson D. Assessment of pharmacy technicians’ salary, benefits, and responsibilities in North Dakota. J Pharm Technol. 2007;23(3):148–157. 13. Zgarrick D, Quinones A, Puetz K. Comparison of pharmacy technician workforce characteristics and data collection methods between two states [APhA2009 111]. J Am Pharm Assoc. 2009;49(2):237–340. 14. Dillman DA, Smyth JD, Melani Christian L. Internet, mail, and mixed-mode surveys: the tailored design method. 3rd ed. Hoboken, NJ: John Wiley & Sons; 2009. 15. Iowa Board of Pharmacy. Pharmacy technicians. http://www. state.ia.us/ibpe/pharmacy_technician. Accessed April 10, 2015.
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16. Wilson DL, Kimberlin CL, Brushwood DB, Segal R. Constructs underlying community pharmacy dispensing functions relative to Florida pharmacy technicians. J Am Pharm Assoc. 2007;47(5):588–598. 17. Muenzen PM, Corrigan MM, Smith MA, Rodrigue PG. Updating the pharmacy technician certification examination: a practice analysis study. J Am Pharm Assoc. 2006;46(1):e1–e6. 18. Raymond MR. An NCME instructional module on developing and administering practice analysis questionnaires. Educ Meas Issues Pract. 2005;24(2):29–42. 19. Kane MT, Kingsbury C, Colton D, Estes C. Combining data on criticality and frequency in developing test plans for licensure and certification examinations. J Educ Meas. 1989;26(1):17–27. 20. Champlain AF, Cuddy MM, LaDuca T. Examining contextual effects in a practice analysis: an application of dual scaling. Educ Meas Issues Pract. 2007;26(3):3–10. 21. U.S. Census Bureau. Metropolitan and micropolitan: maps of metropolitan and micropolitan statistical areas. 2013. http:// www.census.gov/population/metro/data/maps.html. Accessed April 10, 2015. 22. Hudgens J, Park T. Perceptions of pharmacy technicians and students regarding technicians as pharmacy instructors. Am J Pharm Educ. 2011;75(8):151. 23. Sheridan J, Kelly F, Basheer M, et al. Can I help you? A qualitative study of pharmacist and pharmacy assistant views on the role of pharmacy assistants in New Zealand. Int J Pharm Pract. 2011;19(4):228–235. 24. Banks J, Shaw A, Weiss MC. Walking a line between health care and sales: the role of the medicines counter assistant. Pharm J. 2005;274(7349):586–589. 25. Banks J, Shaw A, Weiss MC. The community pharmacy and discursive complexity: a qualitative study of interaction between counter assistants and customers. Health Soc Care Community. 2007;15(4):313–321.
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Pharmacy technicians’ attitudes about their roles in Iowa public safety Andrea L. Kjos and Michael T. Andreski
Andrea L. Kjos, PharmD, PhD, Assistant Professor of Social and Administrative Pharmacy, College of Pharmacy and Health Sciences, Drake University, Des Moines, IA
Abstract Objectives: To describe and apply a model for combining self-assessed frequency and criticality for pharmacy technicians’ roles and to evaluate similarities and differences between attitudes toward public safety in various practice settings. Design: Cross-sectional mail survey of randomly selected pharmacy technicians in one state. Setting: Iowa in fall 2012.
Michael T. Andreski, BSPharm, MBA, PhD, Assistant Professor of Social and Administrative Pharmacy, College of Pharmacy and Health Sciences, Drake University, Des Moines, IA Correspondence: Andrea L. Kjos, PharmD, PhD, College of Pharmacy and Health Sciences, Drake University, 2507 University Ave., Des Moines, IA 50311; andrea.kjos@ drake.edu Disclosures: The authors declare no relevant conflicts of interest or financial relationships.
Participants: 1,000 registered technicians. Intervention: Mail survey with option for online completion. Main outcome measures: Scored ratings related to perceptions of frequency and criticality of roles. Technicians rated role frequency on a scale from 1 (not responsible) to 6 (daily) and role criticality on a scale from 1 (no importance) to 4 (extremely important). A weighted relative importance score was ranked to show importance of the role considering frequency and criticality together. Results: The response rate was 25.81%. Ratings for frequency were correlated to ratings for criticality for 22 of 23 roles. A Mann–Whitney U test found a difference between ambulatory technicians and hospital technicians. A visual matrix of a dual-scaled analysis showed both groups’ role ratings to be positively linearly related. Hospital technicians showed wider discrimination in their ratings for some roles than for others.
Funding: Funding support for this study was provided by the Harris Research Endowment, Drake University College of Pharmacy and Health Sciences. Previous presentation: Annual Meeting, Iowa Pharmacy Association, June 14, 2013. Acknowledgments: Iowa Pharmacy Association for facilitating survey feedback and technical support; Hanna P. Raber and Alexandra M. Hendzel for data entry. Received July 9, 2014. Accepted for publication April 27, 2015. Published online in advance of print September 6, 2015.
Conclusion: Perceived role frequency and criticality can be considered together to contextualize the practice environment. The data suggest a relationship between perceived frequency of role performed and perception of a role’s criticality. The study found differences between how technicians from various practice settings perceive their roles. J Am Pharm Assoc. 2015;55:493–502 doi: 10.1331/JAPhA.2015.15010
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A
s pharmacy technicians’ roles evolve, it is important to understand technicians’ attitudes about their roles in patient safety. Understanding attitudes provides context for enculturation of growing expectations and may assist in professional development to ensure competence and public safety. Discussions surrounding technicians’ expanding roles have been ongoing for decades. In 1975, Jeffery hypothesized the role of the pharmacy technician in 2000, writing, “Technicians will assume, almost completely, the mechanics of prescription filling. The pharmacist’s role will be purely ‘clinical’ in this area.”1 Although technicians now have expanded roles, widespread and consistent practices remain elusive. This is attributable in part to differences in practice laws as well as organizational policy. To provide evidence to support pharmacy technician role expansion, researchers have studied the use of the technician workforce in medication therapy management and improved quality of care.2 For example, research has demonstrated that technicians have expanded their roles in medication reconciliation and in
Key Points Background: ❚❚ The pharmacy technician’s role in contemporary pharmacy practice continues to receive considerable attention. However, state practice laws and organizational policies remain inconsistent in guiding potentially evolving roles. ❚❚ Supporting professional development of technicians relies on understanding currently held perceptions and attitudes. There is a gap in the literature on how technicians perceive their current roles. ❚❚ Conducting a task analysis is one way to gather data on perceptions of the practice environment. This study used a task analysis to measure technician-assessed perceptions and attitudes about roles they perform. Findings: ❚❚ Perceived role frequency and criticality were useful in contextualizing the practice environment when conducting a task analysis. ❚❚ Roles that participating technicians perceived as critical in support of public safety in the practice environment were also the roles they self-assessed as performed most frequently. ❚❚ The specific practice setting for technicians may provide an important frame of reference for developing perceptions and attitudes about roles performed.
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assisting nurses with certain medication administration duties.3,4 Research has shown factors that predict the likelihood of technicians assuming unconventional roles are characteristics of practice settings, acceptance by pharmacists, and professional experience.5 A review of “tech-check-tech” programs reported that 12 states currently have a policy allowing for some aspect of this practice and that the published evidence on outcomes of such programs consistently support the accuracy and quality of properly implemented programs.6 It is important that the pharmacy profession supports pharmacy technicians in reaching their full potential, thereby allowing for pharmacists’ reallocation in clinical activities.6 Part of this support should be a concerted effort to fully enculturate pharmacy technicians into professional practice. This effort could include fostering professional values toward high standards of excellence in work activities, as well as an attitude of obligation toward ensuring optimal patient outcomes. As efforts to instill and enhance elements of professionalism emerge, it will be important to understand technicians’ current attitudes about and perceptions of their roles. Calls for attitude assessments when looking to expand technicians’ roles have been previously discussed.7 Such assessments could assist managers in understanding feelings and biases toward work-related functions, promote pharmacy technicians’ abilities, and help ensure a supported transition into expanded roles that are aligned with the goals of pharmacy practice. To determine attitudes of pharmacy technicians, this study examined the organizational sociology element of work8 by measuring the congruency of technicians’ perceptions of their roles. Understanding technicians’ self-assessment of the roles they perform, as well as the perceived criticality of these roles, provides context for understanding professionalism in terms of attitudes of obligation in public safety and protection. To our knowledge, no literature has been published on techniques for measuring congruency between self-assessed perceptions of frequency and criticality of roles with respect to the pharmacy workforce in general and technicians in particular.
Objectives The objectives of this study were to describe and apply a model for combining self-assessed frequency and self-assessed criticality for pharmacy technicians’ roles and to evaluate similarities and differences between attitudes toward public safety in various practice settings.
Methods As part of a longitudinal state-based technician research initiative that began in 2008, a task analysis rating assessment tool was added to a previously used technician survey in 2010 and 2012. The 2008 and subsequent surveys were derived from previous pharmacist workJournal of the American Pharmacists Association
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force studies as reported by the Pharmacy Manpower Project, Inc.9 This study’s specific survey for technicians was replicated from a survey conducted in Iowa in 2008 and 201010 and was similar to other states’ technician surveys, also based upon the Pharmacy Manpower Project.5,11–13 The entire survey tool used in 2012 is included in Appendix 1 (available under Supplemental Content on JAPhA.org). It was pretested by 20 technicians in 2010 for question clarity and comprehension of the newly added task analysis. Pretesting respondents verified their ability to understand the instructions and questions, and data collection occurred in fall 2012 using a random sample of pharmacy technicians from Iowa. The data collection process included a mixed-mode traditional mailer received by all participants with the option of online completion. The protocol followed modified elements of the Tailored Design Method, including two contacts.14 A random sample of approximately 20% of pharmacy technicians (n = 1,000), generated from a list of all Board of Pharmacy–registered Iowa technicians15 (n = 5,311), was mailed a traditional paper questionnaire. Two weeks after the initial mailing, 19 undeliverable surveys were returned; additional respondents were then randomly selected and sent a survey to replace those that could not be delivered. If these replacement surveys were returned after the 2-week period, no other replacement attempts were made. Follow-up reminders were sent 2 weeks after the initial mailing. Respondents also had the option to complete the survey online; a link was included with the mailed survey. Of the 1,019 mailed surveys, 39 were returned as undeliverable, and 980 were assumed to have reached the intended recipients. The Drake University Institutional Review Board approved this study. Student research assistants recorded and entered study data. The results presented focus specifically on responses to Question 6 of the tool (Appendix 1). The specific roles in this question were expanded into 23 roles based on the previous question’s work activity categories (e.g., “Assisting the Pharmacist in Serving Patients” and “Maintaining Medication and Inventory Control Systems”). (See survey question 5, Appendix 1.) The data herein pertain to an analytical approach summarized by the following steps: (1) conduct a dual-scaled task analysis to measure contextual effects of the practice environment, (2) rank and weight roles to quantify perception of the roles’ relative importance, and (3) develop a dualscaled analysis map matrix to visualize the data. Dual-scaled task analysis The technician workforce literature was used to create a list with 23 roles (Appendix 1).10,12,16 The 23 roles comprised 18 roles that had been included in the previously Journal of the American Pharmacists Association
conducted 2008 survey, which was based on the three major areas of assisting the pharmacist in serving patients, maintaining medication and inventory control systems, and participating in the administration and management of pharmacy practice.10 Five additional roles were added based on open-ended responses collected in 2008 and 2010. The final 23 roles were validated using a published national practice analysis of technicians in all settings17 and piloted with 20 local technicians who were contacted through the state pharmacy association and represented multiple state settings. The five added roles were (1) compound I.V. medications/fluids, (2) fill/deliver unit dose refills to hospital patients, (3) fill/deliver medication containers to nursing-home patients, (4) replenish automatic dispensing devices, and (5) supervise other techs, including scheduling. The fifth role came from open-ended feedback on previously conducted surveys, as well as responses from the pilot testers. The technicians rated the 23 roles in two ways: first, the perceived frequency of the role, performed on an ordinal scale from 1 (not responsible) to 6 (daily) (categories in Appendix 1); and second, criticality associated with how important the role was perceived to be in considering the safety and protection of the public, measured on an ordinal scale from 1 (no importance) to 4 (extremely important) (categories in Appendix 1). For the construct of criticality, “importance” was used in the survey to maintain an informal and common idiom of measurement. The structure of these dually scaled analyses was based on the example of a similar assessment for radiologic technologists.18 Ranking and weighting roles This study used a published framework to create a “multiplicative model” for combining scales.19 This provided a way to combine the measured constructs for frequency and criticality and rank the roles in order of relative importance, as well as to examine the contextual effects that may show how technicians associate frequency of roles with criticality. According to Kane et al., “The relative importance of any activity in practice will depend on the frequency of the activity and the criticality of the activity.”19 Frequency and criticality ratings were combined as a raw score, as well as with a weighted adjustment score, to control for the relative impact of each scale. The calculations used in this approach are described in Appendix 2 (available under Supplemental Content on JAPhA.org). More specifically, the weighted adjustment was calculated and transformed using an exponential model. This was done so that the relative contribution of frequency and criticality would be effectively equal. For example, this increased the weighting of activities with higher criticality ratings and decreased the weights for items with lower criticality ratings. The new calcuj apha.org
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lated relative importance score for each role could then be divided as a percentage or proportion based on the 23 roles. The weighted proportion and the adjusted weighted proportion, therefore, summed to 100 and could be ranked. Finally, because technicians’ perceptions of role frequency and criticality differed depending on practice setting, the respondents were separated by primary practice setting (community/ambulatory compared with hospital/specialty). Dual-scaled analysis mapping The data were plotted to visualize how roles related to both frequency and criticality compared with other roles. This type of plotting accords with an approach that has been used for examining contextual effects in a dual-scaled practice analysis.20 Scatterplots were created that included both the raw and adjusted weighted relative importance scores for role frequency and criticality. The data were normalized (i.e., the x and y axes, representing the difference between each role’s mean and the overall mean, were divided by the standard deviation for the overall mean of all roles). The overall mean for frequency was calculated when all role frequencies were combined and averaged, with the same done for criticality. For example, a point plotted as a zero on the x and y axes (0,0) would indicate the “average” for frequency and criticality. Thus, the figures were created to show the roles in one of four quadrants, categorized as low criticality, high frequency (quadrant 1); high criticality, high frequency (quadrant 2); low criticality, low frequency (quadrant 3); and high criticality, low frequency (quadrant 4). The raw relative importance score, as well as the adjusted relative importance, were plotted to visualize the overall impact of the adjustment on role categorization. Statistical analyses All statistical analyses were performed by the authors using IBM SPSS version 21. Spearman correlations, Mann–Whitney U tests, chi-square tests, and Fisher exact tests were performed using a critical value of alpha 0.05 to indicate statistical significance, unless otherwise noted. Correlations of the dual scale were assessed. Independent samples Mann–Whitney U tests for ordinal data were used to determine if ambulatory and hospital technicians ranked roles differently. Chi-square and Fisher exact tests were used to assess response bias.
Results Technicians provided information about work status, practice setting, position, hours worked, compensation, demographics, certification status, actual and desired roles, and ratings for frequency and criticality for specific roles. The response rate was 25.81% (253/980); respondent characteristics are included in Table 1. Of those respondents who worked primarily as a technician, 48.2% 496 JAPhA | 5 5:5 | S E P /OCT 2 0 1 5
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Table 1. Demographics for pharmacy technicians (n = 1,000) Characteristica Practice setting Independent/small (1–10 pharmacies; same ownership) Large/mass (>10 pharmacies; same ownership), mass merchandiser or supermarket Hospital Other (home infusion, mail service, etc.) Average years employed by the same employer (median; SD) Gender Female Race White/Caucasian Average age (median; SD) Education Beyond a high school diploma/GED Some college, but did not receive degree Associate’s degree Bachelor’s degree Graduate/professional degree
Response rate 89.6% (224/250) 26.4% (59/223) 42.2% (94/223) 20.1% (45/223) 11.2% (25/223) 8.1 (5.0; 8.4) 91.5% (196/214) 98.7% (208/214) 43.2% (46; 13.7) 69.0% (147/213) 36.6% (78/213) 13.1% (28/213) 14.6% (31/213) 4.7% (10/213)
a Demographic data include those respondents who indicated currently working full-time or part-time as a technician.
(108/224) were located in an urban locale, while 52.7% (516/980) of the sampling frame of invited participants was to urban-located technicians (P >0.05).21 Table 2 summarizes the findings of mean frequency and criticality ratings in all practice settings. There was a wide distribution of ratings of frequency of roles performed (mean range, 1.79–5.28). The most frequent roles performed were “receive prescription/medication orders,” “collect and communicate patient-specific information,” “process prescription and medication orders,” and “provide medication to patient or their representative.” These four roles included a mean frequency above 5.0 on the scale from 1 to 6 (Table 2). However, the responses related to criticality appeared to be skewed (mean range, 2.87–3.88 on the 1–4 scale) for all roles. A statistically significant Spearman rank-order correlation for nonparametric data was found between ratings for frequency and criticality for 22 of the 23 roles (significant at 0.01, two-tailed), with all positive correlation values ranging from 0.124 to 0.478. The only role that was not statistically significantly correlated was “maintain inventories and records, including controlled substances and investigational drugs” (Table 2). Open-ended areas in the survey instrument enabled respondents to include information about “other” roles not listed in the question. There were few responses, but those that were provided included “Medicare Part D enrollment,” “cleaning/organizing,” “giving vaccines,” “diabetes education,” and “shoe fittings.” Journal of the American Pharmacists Association
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Communicate with third-party payers. Compound I.V. medications/fluids. Fill/deliver unit dose refills to hospital patients. Fill/deliver medication containers to nursing-home patients. Identify items to be ordered. Place routine and emergency orders. Receive orders and place items into stock. Implement and monitor policies to deter theft and diversion. Maintain inventories and records, including controlled substances and investigational drugs. Replenish automatic dispensing devices. Coordinate written, electronic, and oral communication throughout the practice Update patient information. Collect productivity information. Participate in quality assurance activities. Update, maintain, and use information systems and dispensing technologies. Perform billing and/or accounting functions. Contribute to staff training and evaluation processes. Supervise other techs, including scheduling.
Role Receive prescription/medication orders. Collect and communicate patient-specific information. Assess orders for completeness, accuracy, legality and reimbursement eligibility. Process prescription and medication orders. Provide medication to patient or patient’s representative.
3.35 (171) 3.50 (204) 3.45 (192) 3.49 (207)
2.37 (224) 4.87 (223) 3.81 (223) 4.57 (225)
3.29 (189) 3.29 (187) 3.12 (182) 2.87 (166)
3.65 (223) 2.28 (222) 1.79 (224)
3.57 (197) 3.76 (200) 2.98 (178) 3.47 (191)
3.69 (198) 3.04 (168)
3.74 (221)
4.13 (224) 4.77 (223) 2.13 (218) 3.26 (225)
3.70 (224) 2.64 (221)
3.39 (191)
3.23 (159)
1.88 (223)
2.63 (224)
3.38 (198) 3.17 (158)
3.82 (203)
5.12 (222) 3.83 (223) 1.58 (221)
3.87 (200) 3.88 (205)
3.87 (211)
Mean criticalitya (C)(n) 3.83 (208)
4.41 (222) 5.08 (223)
5.28 (226)
Mean frequencya (F)(n) 5.13 (225)
0.314e 0.355e
0.298e
0.429e
0.478e 0.210e 0.356e 0.336e
0.124 0.470e
0.26e
0.342e 0.163e 0.316e 0.260e
0.300e
2.437 1.758
4.117
4.218
5.049 6.131 2.175 3.878
4.674 2.748
3.056
2.711 5.846 4.503 5.463
2.076
1.55 0.85
3.12
3.21
5.03 7.18 1.20 3.51
5.18 1.61
2.55
2.17 5.46 4.01 5.03
1.48
3.70 1.16
4.444 1.720
0.255 0.302e
8.28
6.691
7.52 8.79
9.03
W' prop. weightsa,b (100) 8.38
e
5.838 6.748
6.998
W prop. weightsa (100) 6.723
0.238e
0.242e 0.295e
0.209e
Spearman correlation (F) vs. (C) 0.260e
19 22
14
13
9 5 20 15
10 17
16
18 6 11 8
21
12 23
4
7 2
1
Ranka,b W 3
0 −1
−1
−1
0 −1 −1 2
2 −1
0
1 −1 0 −2
1
0 1
0
2 0
0
Change ranka,b (Rank W− Rank W') 0
19 23
15
14
9 6 21 13
8 18
16
17 7 11 10
20
12 22
4
5 2
1
Ranka,b W' all 3
18 21
15
16
7 6 19 13
10 20
14
17 8 12 9
23
11 22
4
5 2
1
Rankc W' amb 3
19 23
12
9
14 8 22 16
7 15
18
20 5 13 10
11
21 17
3
6 2
1
Rankd W' hosp 4
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e
Includes results of technician respondents for hospital and specialty practice settings. Weighted adjustments calculated with (a) = 3.88 as the weight-adjusted constant used to make contributions of criticality (C) and frequency (F) equal.
Correlation was statistically significant at 0.01 (two-tailed).
d
c
Includes results of technician respondents for ambulatory practice settings. Weighted adjustment conversion calculated with (a) = 4.49 as the weight-adjusted constant used to make contributions of criticality (C) and frequency (F) equal.
b
Weighted adjustment conversion calculated with (a) = 4.28, whereas (a) is the calculated weight adjustment using [Var(LnF)/Var(LnC)]1/2. This was the numerical constant used to make contributions of criticality (C) and frequency (F) equal. See Appendix 2 for equations.
a
Includes results of technician respondents in all practice settings for 2012. Frequency: from 1 (not responsible) to 6 (daily); criticality: from 1 (no importance) to 4 (extremely important).
Abbreviations used: ID, coded role description used in figures; I.V., intravenous; W prop., unadjusted proportional weight; W'prop., adjusted proportional weight; Rank W−Rank W', difference between unadjusted proportional weight and adjusted proportional weight; amb, ambulatory; hosp; hospital.
22 23
21
20
16 17 18 19
14 15
13
9 10 11 12
8
6 7
5
3 4
2
ID no. 1
Table 2. Role importance: Dual-scale results in 2012
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Ranking and weighting roles Table 2 shows the weighted proportions and adjusted weighted proportions for all roles by technicians in all settings. These proportions were ranked to show the relative importance of each role when taking into account both frequency and criticality. A change in rank description was calculated to more explicitly depict the impact of the weighted criticality adjustment on the overall relative importance of the role, compared with no weight adjustment. For example, the roles “assess orders for completeness,” “maintain inventories and records,” and “participate in quality assurance activities,” which each increased by two within the rankings, reflected the adjustment of the higher criticality score. Conversely, the role “receive orders/stock” dropped by two within the rankings (Table 2). A post hoc investigation revealed that technicians who practiced in the ambulatory or community pharmacy settings, compared with those practicing in the hospital/specialty settings, may have similar but different responsibilities as well as varying perceptions of those activities. This was reflected when the task analysis was dichotomized for technicians whose primary practice setting was community or ambulatory, compared with hospital or specialty. Although the raw weighted proportion results were not shown in the dichotomized data, Table 2 includes the weight-adjusted ranking for the roles in each type of practice setting. The ranking of the roles appeared different between ambulatory and hospital technicians’ perceptions. For example, the roles “communicate with third-party payers” and “coordinate written, electronic, and oral communication throughout the practice” were more emphasized by ambulatory practice technicians. In contrast, the roles “fill/deliver unit dose refills to hospital patients” and “information systems/dispensing technologies” were shown to have higher relative importance to hospital technicians (Table 2). Table 3 shows the statistical results for the Mann– Whitney U test distribution comparison. Frequency ratings for 12 roles and relative importance ratings for 6 roles were statistically significantly different between the two practice settings (significant at 0.05, two-tailed). Dual-scaled analysis mapping The dual-scaled analyses maps are displayed in Figures 1 and 2. The patterns of data were similar for the ambulatory and hospital technicians. Role frequency and level of criticality were linearly related in a positive direction across both groups (i.e., as technicians performed the role more often, they were more likely to perceive it as a critical role). This was consistent with the Spearman correlation reported previously. In Figures 1 and 2, the hospital group appeared to have increased discrimination between role frequency and criticality, reflected by the wider spread of data points on the scatterplot. 498 JAPhA | 5 5:5 | S E P /OCT 2 0 1 5
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More specifically, three quadrants were represented by hospital technicians, compared with two quadrants by ambulatory technicians. Figure 2 shows that certain roles (“place routine and emergency orders,” “receive orders and place items into stock,” “replenish automatic dispensing devices,” and “perform billing and/or accounting functions”) were within the quadrant of low criticality and high frequency, in contrast with ambulatory technicians. Finally, some roles of hospital technicians (“compound I.V. medications/fluids” and “identify items to be ordered”) did not follow the same linear pattern as the other roles.
Discussion Practice settings appeared to be associated with technicians’ perceptions of self-assessed frequency and criticality of roles. This finding supports that the technicians were most likely reporting on roles they were permitted to perform and that practice settings used technicians in diverse ways, such that roles performed may be directly linked to the highest patient care and administrative needs of specific practice settings. For roles more often performed, technicians perceived the criticality of performing those roles to be higher. Roles performed more often were different depending on the respondent’s practice setting. The patterns of variation among community-based technicians compared with health-system technicians have also been validated by previously reported practice analyses.17 Although we did not have an a priori hypothesis for how congruent technicians would perceive the frequency and criticality of their roles, we would have expected the dual scaling to have been less correlated or not necessarily correlated at all and the roles to populate all four quadrants of the mapping analyses as shown in Figures 1 and 2. However, the analyses showed that attitudes about roles followed a volume-driven effect—the more frequently a role was performed, the more critical it was perceived to be, which could support a hypothesis of self-justification of professional roles. Previous research supports the idea that pharmacy technicians perceive a moderate to high level of importance about most, if not all, the specific skills on which they are functionally tested for certification.22 Comparing Figures 1 and 2, we found it interesting that both groups of technicians’ roles formed a linear pattern predominately across two of the four quadrants— high criticality/high frequency and low criticality/ low frequency—thus demonstrating high congruency between the two constructs of frequency and criticality. Many technicians may have been attempting to justify the importance of their work with the self-assessed association between frequency and criticality of roles. Hospital technicians had roles that were found in three of the four quadrants, more specifically in quadrant one, representing some assessed roles with low Journal of the American Pharmacists Association
PHARMACY TECHNICIANS’ ATTITUDES ABOUT THEIR ROLES IN IOWA PUBLIC SAFETY RESEARCH
Table 3. Differences between ambulatory and hospital technicians ID no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Role Receive prescription/medication orders. Collect and communicate patient-specific information. Assess orders for completeness, accuracy, legality, and reimbursement eligibility. Process prescription and medication orders. Provide medication to patient or patient’s representative. Communicate with third-party payers Compound I.V. medications/fluids. Fill/deliver unit dose refills to hospital patients. Fill/deliver medication containers to nursing-home patients. Identify items to be ordered. Place routine and emergency orders. Receive orders and place items into stock. Implement and monitor policies to deter theft and diversion. Maintain inventories and records, including controlled substances and investigational drugs. Replenish automatic dispensing devices. Coordinate written, electronic and oral communication throughout the practice Update patient information. Collect productivity information. Participate in quality assurance activities. Update, maintain and use information systems and dispensing technologies. Perform billing and/or accounting functions. Contribute to staff training and evaluation processes. Supervise other techs, including scheduling.
Median frequency (F)a Amb Hosp P 6 5 0.000c
Median criticality (C)b Amb Hosp P 4 4 0.083
6
5
0.000c
4
4
0.006c
6 6
4 5
0.000c 0.000c
4 4
4 4
0.668 0.114
6 5 1
5 1 1
0.000c 0.000c 0.000c
4 4 4
4 3.5 4
0.144 0.031c 0.059
1
2
0.000c
4
4
0.006c
1 6 5 5 1
1 6 4 5 1
0.650 0.719 0.175 0.005c 0.542
4 4 4 4 4
4 4 4 3 4
0.206 0.381 0.354 0.106 0.303
4.5 1
4 3.5
0.413 0.000c
4 3
4 4
0.692 0.023c
6 6 1 3
4 4 1 3
0.000c 0.000c 0.682 0.238
4 4 3 4
4 4 3 3
0.018c 0.312 0.984 0.039c
5 4 1 1
4.5 4 2 1
0.362 0.951 0.395 0.311
4 4 3 3
4 4 3 3
0.406 0.440 0.627 0.710
Abbreviations used: ID, coded role description used in figures; I.V., intravenous; Amb, ambulatory; Hosp, hospital. a Frequency: from 1 (not responsible) to 6 (daily). b Criticality: from 1 (no importance) to 4 (extremely important). c Difference in score distribution was considered statistically significant at P <0.05 using the independent samples Mann–Whitney U test. Note: Despite medians being the same, statistical significance reflects the difference in the ranked distribution for each ordinal item.
criticality and high frequency. Therefore, hospital technicians appear to self-assess roles that have high frequency but also low criticality (Figure 2, quadrant 1). A possible explanation for this observation could be related to the nature of professional roles and responsibilities in the contrasting work environments of community and hospital pharmacy practices. Technicians in hospital practices may have a wider range of possible roles that make broader and deeper use of their skills. Moreover, technicians in hospital settings may interact with many other health care providers. As a result, these technicians are more likely to see how their roles fit into the provision of those more complex pharmacy services. Concomitantly, in many community settings, technicians may see their roles in a more focused environment and, as such, perceive greater congruency between Journal of the American Pharmacists Association
criticality and frequency of tasks. Therefore, differences in levels of self-awareness may be an inherent function of technicians’ work environment and provide context for attitudes about and perceptions of their roles. This may present evidence for how to further develop the professional practice of technicians. This study also presents evidence about the congruency of technician self-assessment between perceived role frequency and role criticality. It is not clear if these perceptions would be assessed similarly by supervising pharmacists. Previous qualitative research conducted in New Zealand found that when comparing pharmacists’ views of their roles with that of pharmacist assistants, there were alignments in some respects but differences in others.23 For example, self-perceptions of pharmacist assistant roles were oriented more toward a health care j apha.org
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For example, promotion of new or alternative distribution of responsibilities8 may warrant further professionalization via education and training such that technicians can discriminate between roles performed frequently and those that are most critical to public safety. There is a link between technician perceptions and the potential for continued change. Developing a nuanced understanding of roles could be taught by highlighting the importance of accuracy compared with roles that require competence in making cognitive judgments. The pharmacy community would benefit from more evidence related to actual roles, perception of roles, and evaluation of roles and responsibilities to drive advancement in the practice environment while improving patient care and supporting public safety.
role than was perceived by pharmacists. Moreover, the idea that perceptions of pharmacy technicians are becoming oriented toward their role in health care and patient care is also supported by other research.24,25 To help further discern if this is the case, future research should evaluate pharmacists’ perceptions of the criticality of technician roles to determine if the self-justifying volume-driven effect is prevalent from the perspectives of others in pharmacy practice. Researchers could also enlist an expert panel to inform a comparator rating of priority roles that would demonstrate contextual factors beyond the perceived frequency of performing the roles. Research seeking to expand technicians’ roles will require empirical evidence to validate the actual versus perceived frequency of roles performed. From the viewpoint of stakeholders, it would be of interest to look at technicians with various educational training (e.g., certificate programs, certification-prep exams, and associate degree programs) and determine whether those differences in training translate into differences in self-assessed frequency of roles and perceptions of role criticality. As the cultural climate of pharmacy practice and the role of technicians continue to evolve, stakeholders should consider the organizational structure of practice that is desired from a broad perspective.
Limitations There are limitations with external validity; therefore, these findings cannot be generalized to other regions or states because of differences in practice regulations, including scope of practice and certification requirements. While the response rate was lower than desired, the demographic characteristics were consistent with those of studies conducted in 2008 and 2010. The 2008 study, with a similar demographic respondent profile, found 2
Quadrant 1: Low criticality High frequency
Quadrant 2: High criticality High frequency
Frequency (F) on y-axis
17 3
10 12 6 21 -2
-1
16
011 0
14
20
Quadrant 3: Low criticality Low frequency
4 2
5 1
1
1
2 Quadrant 4: High criticality Low frequency
19
13 15
9
18 22
-1
23
Adjusted SD away from mean (F*Ca) Unadjusted SD away from mean (F*C)
7 8
-2 Criticality (C) and (Ca) on x-axis
Figure 1. Dual scaling matrix: Ambulatory/community settings 500 JAPhA | 5 5:5 | S E P /OCT 2 0 1 5
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PHARMACY TECHNICIANS’ ATTITUDES ABOUT THEIR ROLES IN IOWA PUBLIC SAFETY RESEARCH
2 10 Quadrant 1: Low criticality High frequency
2
Quadrant 2: High criticality High frequency
1 5 1
12
Frequency (F) on y-axis
20
4
17 21
11 -2
15
-1
0
16
Quadrant 3: Low criticality Low frequency
14 0
8
3
1
2
Quadrant 4: High criticality Low frequency
19
-1 6
13 9
22
7 Adjusted SD away from mean (F*Ca) Unadjusted SD away from mean (F*C)
18
23
-2 Criticality (C) and (Ca) on x-axis
Figure 2. Dual scaling matrix: hospital/specialty settings evidence of nonrespondent bias using follow-up phone calls such that only those who were currently working in a pharmacy were most likely to respond.10 The survey instrument may not be able to discern the true differences that exist within various roles. For example, “Importance: safety/public protection” could have been interpreted in various ways. The task analysis section of the tool was not validated to actual role frequency or other sources that can assess criticality. The numbers of responses for each survey item were varied and may not reflect the total number of responses, as respondents chose to omit questions.
Conclusion This study found that technicians’ perceptions about critical roles in public safety correspond with the roles they self-assessed to perform most frequently. The model used in this study for combining the dual scaling into a weighted importance factor was useful in reducing the impact of any underlying statistical properties of the variables. The study findings suggest that there are differences in how technicians from various practice settings perceive the frequency and criticality of their roles. Not only are there differences in perception of which roles Journal of the American Pharmacists Association
are performed most often, there appear to be notable differences in how technicians, grouped by practice setting (e.g., hospital vs. ambulatory), associate the corresponding criticality of these roles. This information may be useful when considering the future professional development of the pharmacy technician workforce. References 1. Jeffery LP. Impact of the pharmacy technician upon pharmacy service in the year 2000. Drug Intell Clin Pharm. 1975;9(8):430–432. 2. Powers MF, Bright DR. Pharmacy technicians and medication therapy management. J Pharm Technol. 2008;24(6):336– 339. 3. Siemianowski LA, Sen S, George JM. Impact of pharmacy technician-centered medication reconciliation on optimization of antiretroviral therapy and opportunistic infection prophylaxis in hospitalized patients with HIV/AIDS. J Pharm Pract. 2013;26(4):428–433. 4. McGraw C, Coleman B, Ashman L, Hayes S. The role of the pharmacy technician in the skill-mixed district nursing team. Br J Community Nurs. 2012;17(9):440–444. 5. Friesner DL, Scott DM. Identifying characteristics that allow pharmacy technicians to assume unconventional roles in the pharmacy. J Am Pharm Assoc. 2010;50(6):686–697.
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6. Adams AJ, Martin SJ, Stolpe SF. “Tech-check-tech”: a review of the evidence on its safety and benefits. Am J Health Syst Pharm. 2011;68(19):1824–1833. 7. Woller TW, Ploetz PA. Expanding the role of the pharmacy technician. Top Hosp Pharm Manage. 1989;9(1):35–49. 8. Barley SR. Technicians in the workplace: ethnographic evidence for bringing work into organizational studies. Adm Sci Q. 1996;41(3):404–441. 9. Pharmacy Workforce Center. Final report of the National Pharmacist Workforce Study 2009. http://www.aacp.org/resources/research/pharmacyworkforcecenter/Pages/default. aspx. Accessed April 10, 2015. 10. Urick BY, Zgarrick D, Sobek LG. 2008 Iowa pharmacy technician compensation survey. J Iowa Pharm Assoc. 2009;65(3):48–51. 11. Quinones AC, Zgarrick DP, Pullin P. 2007 Illinois pharmacist compensation survey: part 1—overall marketplace trends. KeePosted. 2008;35(5):11–20. 12. Scott DM, Halvorson D. Assessment of pharmacy technicians’ salary, benefits, and responsibilities in North Dakota. J Pharm Technol. 2007;23(3):148–157. 13. Zgarrick D, Quinones A, Puetz K. Comparison of pharmacy technician workforce characteristics and data collection methods between two states [APhA2009 111]. J Am Pharm Assoc. 2009;49(2):237–340. 14. Dillman DA, Smyth JD, Melani Christian L. Internet, mail, and mixed-mode surveys: the tailored design method. 3rd ed. Hoboken, NJ: John Wiley & Sons; 2009. 15. Iowa Board of Pharmacy. Pharmacy technicians. http://www. state.ia.us/ibpe/pharmacy_technician. Accessed April 10, 2015.
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16. Wilson DL, Kimberlin CL, Brushwood DB, Segal R. Constructs underlying community pharmacy dispensing functions relative to Florida pharmacy technicians. J Am Pharm Assoc. 2007;47(5):588–598. 17. Muenzen PM, Corrigan MM, Smith MA, Rodrigue PG. Updating the pharmacy technician certification examination: a practice analysis study. J Am Pharm Assoc. 2006;46(1):e1–e6. 18. Raymond MR. An NCME instructional module on developing and administering practice analysis questionnaires. Educ Meas Issues Pract. 2005;24(2):29–42. 19. Kane MT, Kingsbury C, Colton D, Estes C. Combining data on criticality and frequency in developing test plans for licensure and certification examinations. J Educ Meas. 1989;26(1):17–27. 20. Champlain AF, Cuddy MM, LaDuca T. Examining contextual effects in a practice analysis: an application of dual scaling. Educ Meas Issues Pract. 2007;26(3):3–10. 21. U.S. Census Bureau. Metropolitan and micropolitan: maps of metropolitan and micropolitan statistical areas. 2013. http:// www.census.gov/population/metro/data/maps.html. Accessed April 10, 2015. 22. Hudgens J, Park T. Perceptions of pharmacy technicians and students regarding technicians as pharmacy instructors. Am J Pharm Educ. 2011;75(8):151. 23. Sheridan J, Kelly F, Basheer M, et al. Can I help you? A qualitative study of pharmacist and pharmacy assistant views on the role of pharmacy assistants in New Zealand. Int J Pharm Pract. 2011;19(4):228–235. 24. Banks J, Shaw A, Weiss MC. Walking a line between health care and sales: the role of the medicines counter assistant. Pharm J. 2005;274(7349):586–589. 25. Banks J, Shaw A, Weiss MC. The community pharmacy and discursive complexity: a qualitative study of interaction between counter assistants and customers. Health Soc Care Community. 2007;15(4):313–321.
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