Appropriate staffing for pharmacists’ full scope of practice

For years, pharmacists have been struggling to demonstrate our value as primary care providers. Suddenly, with the COVID-19 pandemic, our role has been elevated and made much more visible. ¹ We have been relied upon to administer essential vaccines, distribute rapid test kits, provide testing and continue our regular pre-COVID duties. ² The government is realizing that pharmacy has more of a role to play in health care and that a full scope of pharmacist practice can reduce the burden on the health care system. We are being recognized for our efforts, we are getting what we’ve always wanted. It’s all good, right? Well, no. Many pharmacists have voiced concern about adequate staffing (Figure 1). Let’s look at some of the perspectives on this.

Figure 1.

Recent dialogue about the US Test and Treat initiative

What do pharmacists think?

Pharmacists are deeply concerned. A recent survey ³ showed that 72% of pharmacy professionals have considered leaving their jobs or the industry altogether, ⁴ and their mental health is suffering.

The Canadian Pharmacists Association recently conducted the Canadian Pharmacy Mental Health and Workforce Wellness Survey,^3,4 and reached 1399 Canadian pharmacy professionals. While the results of the survey will not be available until later in the year, a CPhA pre-budget consultation brief ⁴ gives some preliminary data. Almost all of those surveyed (92%) felt they were at risk of burnout, with half (51%) indicating that inadequate staffing is having a severe negative impact on their mental health. Overall, 4 in 5 of those surveyed believe their mental health and well-being is not good. ⁴ While the pandemic has certainly affected staffing levels and burnout, are there other factors at play?

The Expert Advisory Panel in a 2016 research report from the Canadian Pharmacists Association revealed that 89% of respondents felt there were too many competing priorities in the pharmacy workplace and stated there was insufficient time for pharmacy staff to provide advanced services. ⁵ It was also noted that 69% of respondents felt that there were a lack of business models to implement advanced pharmacy services in the community pharmacy setting. ⁵

The owners’ perspective

The challenge is that a pharmacist’s definition of business success is patient care, while owners or operators look at business metrics. Pharmacies are businesses; there is no business that doesn’t have projections or goals. Pharmacists will always be asked by owners or operators to achieve certain prescription counts or clinical service targets.

Most corporate pharmacy chains have a proprietary formula to determine the number of overall pharmacy staff hours for dispensing activities; this number is still largely based on total prescription count. But there is a supplementary formula used by some pharmacies for additional staffing related to clinical services, which is in addition to the standard staffing model for dispensing activities.

Furthermore, there is a real shortage of pharmacists, especially given the extra tasks and activities pharmacists have been undertaking during the COVID-19 pandemic.

So, who’s right?

It’s easy to see this issue through a negative lens; pharmacists have continued to take on more and more responsibility throughout the pandemic and many have stated they were overwhelmed and understaffed for the additional tasks and activities. We acknowledge that it has been a stressful time for everyone. It’s easy to point a finger at staffing shortages as the issue. To our surprise, these proprietary formulas do account for paid clinical services, but are these formulas appropriate? It’s important to recognize that neither of these formulas takes into account the volume of OTC questions, phone inquiries or collaborative activities with other health care professionals. This magic staffing number may also not take into account the rush of patients at the beginning and end of a work day or during the lunch hour. To our knowledge, there is no research to guide what appropriate staffing levels are; it is unfortunate that these formulas are proprietary, which precludes their evaluation by researchers.

It is also interesting to note that regulatory bodies regulate physical pharmacy space but not staffing; they simply state that staffing must be “adequate” and do not provide further guidance. The Institute for Safe Medication Practices Canada (ISMP) has an entire document that lists environmental factors, workflow and staffing patterns that routinely lead to errors and how to mitigate the risk. ⁶ They offer recommendations that can be implemented by both staff and owners on small changes; for example, they state “meal breaks not scheduled or taken” and “managers not considerate of human factors when scheduling” are common contributing factors to medication errors. ⁶ Why is this not explored during routine regulatory body audits? Especially since ISMP principles are often referred to by regulatory bodies as best practices for drug error management and avoidance.

What is the way forward?

The ongoing shortage of pharmacists is not going to change in the foreseeable future. We are not going to have the labor we need to sustain community pharmacies as they currently operate. The COVID-19 pandemic has shone a spotlight on the amazing work and reliance we have placed on our frontline pharmacists. We have been recognized by society and governments as key public health providers. So how can we balance this divide of overwhelmed pharmacists and staff shortages? Here are some points to consider:

• We need to invest time in workflow modernization (see below) and work together to create sustainable solutions. Are we managing our pharmacies properly? Are we using the right staff in the right place?

• Many pharmacies do not have or do not use the “clinical staffing formula,” instead staffing simply on the basis of prescription counts. There is no excuse for this.

• Pharmacy staffing and overall business practices are not robustly reviewed in undergraduate pharmacy programs or pharmacy management textbooks; there is also very little continuing education available on this topic.

• There is an opportunity for further research to evaluate the existing staffing formulas and define what adequate staffing entails.

A possible solution: Changes to the pharmacy workflow

Our scope of practice has changed, staffing models have changed, yet most community pharmacies still practise in an antiquated manner. It’s a tough pill to swallow, but pharmacies need to be more efficient and to leverage the skills of all pharmacy team members to create a sustainable and profitable practice. How are pharmacists supposed to provide excellent clinical services to patients if our workflow has not evolved to match the roles and services we provide?

Most pharmacies still have pharmacy assistants or technicians at the prescription intake counter. Why not have a pharmacist in that role to optimize the workflow? The pharmacist will speak directly with the patient, have the opportunity to flag any clinical issues with the prescription, make any adaptations, conduct a medication review and identify the need for routine immunizations or screen for chronic diseases.The report from CPhA revealed that 69% of respondents stated a lack of pharmacy technicians to support the provision of pharmacy advanced services. ⁵ Why is that? If a technician was hired and used to their full scope, the pharmacist could concentrate on providing clinical services and gain the revenue to pay a pharmacy technician wage.

By changing the workflow in this manner, pharmacists practise clinically and technicians are able to complete the technical aspects of pharmacy practice. This model of putting the pharmacist at intake has already been piloted and has demonstrated significant improvements in blood pressure. ⁷ Remember, excellent clinical services = patient retention = increased script count = increased staffing.

This is far from resolved, but we must address this elephant in the room. The COVID-19 pandemic has highlighted the pitfalls of continuing to ignore this issue. So let’s start talking about it. We invite your insights into your pharmacy’s staffing and your comments on this important topic.