Episode 4: Pharmacy Technician Workforce Issues

In this episode of OnScript with NHA, part of the Pharmacy Podcast Network, Jeremy Sasser and Jessica Langley sit down with Dr. Shane Desselle, and Dr. Kenneth Hohmeier to discuss their research on pharmacy technician workforce issues. As the practice of pharmacy advances to become much more patient-centric, pharmacists and pharmacy technicians alike are undergoing a potentially radical change in their respective practice. While much research has been done on pharmacist workforce issues, similar research focused on pharmacy technicians has been lagging until recently. 

Drs. Desselle and Hohmeier discuss their findings related to pharmacy technicians’ self-efficacy, career loyalty, and how advancing their roles and further professionalizing of the workforce play into job satisfaction. The good news: advancing their roles not only leads to a happier workforce, but patient safety may improve by truly allowing all pharmacy personnel to practice at the top of their license.  Many pharmacists views of pharmacy technicians are shifting as they witness the positive transformation of their own practice when technicians can do more.

Read the full transcript

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This is On Script, hosted by Jeremy Sasser, a podcast publication partnership between the Pharmacy Podcast Network and National Health Career Association. Our podcast is dedicated to providing the pharmacy technician workforce with news, real life stories, and discussions that can impact personal and professional growth. Here's certified pharmacy technician and National Health Career Association content strategist, your host, Jeremy Sasser. Let's get On Script with NHA.

Jeremy Sasser:
Pharmacy Podcast Nation, very excited today to be joined by some awesome researchers, Dr. Kenneth Homeyer and Dr. Shane Desselle. They have spent much of their focus on researching pharmacy technician workforce issues, and we are very excited today to have them to just talk about the research that they are doing and kind of get a lay of the landscape in terms of pharmacy technician duties, expanded duties, what's gone on out there in other States. Of course, I'm also joined by the wonderful Jessica Langley, once again. As I said before, voice smooth as silk. We always love having her on the podcast.

Jessica Langley:
As always, I love to be here.

Jeremy Sasser:
Love to have you. So today, as you know, we always like to do a word of the day here on the On Script podcast, and I'm very fortunate to have that word given to me by Dr. Desselle today. And I'm going to have him define it, but today's word of the day is 'proletarian'. Take it away Dr. Desselle.

Shane Desselle:
Sure. And a proletarian refers to a layman, or proletarianization is of the laymen. And the reason why we thought this would be very apropos for today would be that proletarianization would in essence be the opposite of professionalization. And among the things that we're going to discuss today is the continued professionalization of pharmacy technicians in practice.

Jeremy Sasser:
That's terrific, like to go forward and not backwards. So in order to go forward, you got to know where you've been. And that's a fantastic word of the day, so let's just go ahead and jump right into it. If you gentlemen would care to give a brief description, overview of where you're at and what work you-

Jessica Langley:
Where you come from and what you're currently working on would be great.

Shane Desselle:
Sure. I'll start off again. My name is Shane Desselle, I am a professor of pharmacy at Touro University, California College of Pharmacy in Vallejo, which is not terribly far from the Bay area, and I live in Sacramento. I have been doing research of various sorts, which I'll get into momentarily as it relates to technicians and the technician profession, as has Ken. And Ken will introduce himself very shortly.

Shane Desselle:
But one of the first things I want to point out is that while I was among the first people conducting research on pharmacy technicians, I'm happy to report that it's now becoming a little bit more crowded field. It's exciting now that we actually have a couple of dozen people or more that are dedicating their research on pharmacy technician issues, where it used to be just fewer than a handful for the longest. And among the things I'm sure that'll come up as, as Ken and I discuss this matter a little bit longer today, is the fact that about 75% of the research papers on technicians that exist throughout time in the United States have actually appeared in the last five or six years.

Shane Desselle:
And so I'll let Ken introduce himself. But we've been doing research in the past on pharmacy technicians, self efficacy, preparedness to engage in new rules, and examining quality of work life issues. Because you look at historically there's been research conducted back in the 70s and 80s on pharmacist quality of work life. And I had always posed a question, what about the technicians? Shouldn't we also be interested in their stress levels, their burnout, their satisfaction, their commitment and their commitment to both their employer and to the profession in and of itself?

Shane Desselle:
We began asking the question over a decade ago. So a pharmacy is going to transition to a more patient centered model of care, that implies delegation to technicians. So if you're going to take work that was formally conducted by pharmacists and delegate it to someone else, are you not concerned then about to whom you are delegating this to? And aren't these people very important? Because you're in essence saying that they are going to be doing what pharmacists used to do. So that's why we began our intense focus on examining anything and everything that has to do with technicians' practice, including the environment in which they work, the support they get from their organizations, and how they move along in professionalization from the proletariat to the consummate white coat professional.

Kenneth Homeyer:
Yeah, very well articulated. And certainly Dr. Desselle and I share a lot of the same philosophies with pharmacy technicians and where their advancement fits within the profession. I came about my current research track in a roundabout way. I am a community pharmacist by training and practice, worked in a lot of different types of pharmacies over the years, many of which did not engage their technician workforce. And the latter of which, the last one right before I joined faculty at the University of Tennessee Health Science Center, College of Pharmacy, was one where I was able to take my technicians, and based on their skill sets and their personalities and their passions and drive, really what drove their engine. If you borrow from a great book that I love, From Good to Great. And it talks about the hedgehog concept in there.

Kenneth Homeyer:
We were able to engage those folks on a real individual level, and they were able to do great things for the pharmacy, which then elevated me to be able to do even greater things within that practice, including developing a disease state management program, expanding our compounding pharmacy lab, a whole bunch of great things. So that was on the practice side, and I had the opportunity to join faculty full-time, and really drove the research in that direction. And very early on partnering with Dr. Desselle, because he had kind of seen this coming on the horizon probably 10 to 20 years ago before most of us had.

Kenneth Homeyer:
So yeah, I would 100% agree with what's already been articulated here. The fact that we are now moving towards a professionalization of pharmacy technicians is not unlike what the profession of pharmacy went through at the turn of the 20th century, in the early 1900s when pharmacy was a trade. And there's a report out there, the Flexner Report, which said we were not professionals. And the idea of a bachelor of pharmacy degree was kind of the crazy idea at the time. And yet, look where we are now. And at that time it was physicians saying, we don't want to delegate to these paraprofessionals who are pharmacists. But I would say and argue that healthcare is better because pharmacy is engaged at a high level. I would say the same is true here for pharmacy technicians. As we engage pharmacy technicians at a higher level, as we promote within organizations to new roles and new tasks that fit with your all's passions and directions, healthcare more broadly, will improve as everybody operates at the top of their skillset.

Jeremy Sasser:
Yeah, that's terrific. And one of the things that I talk about a lot is there's a lot of distractors around this topic around worries about, well what does that mean for pharmacists? Are they going to start losing their jobs? Are we replacing pharmacists? Can technicians do it? When you strip all of that out and you really get to everyone's main objective in pharmacy, right, of patient safety and improved health outcomes, part of that is access to healthcare. And we know that most patients are frequenting their community pharmacy a lot more times in a given period of time than they are their primary care physician, if they even have one. In particular, in rural areas where tele pharmacy is now really starting to take off, to make sure that smaller communities, rural communities, have that same level of access.

Jeremy Sasser:
So, you know, really being able to expand the scope of practice for technicians to allow them to use also the technology that has really advanced in terms of final product verification, e-scribing, e-scripts coming as a lot more common nowadays than prescriptions being phoned in across the board. That's decreased errors. It's decreased diversion. So having technicians expand that scope of practice and do those more mechanical tasks, and really let pharmacists leverage their knowledge, their level of education, many of whom now are going through residency programs post-graduation to get out from behind the counter and really engage directly with patients, provide more consultative services, do more comprehensive medication reviews, things like that. Really going to help improve outcomes and improve access, I think.

Shane Desselle:
Well Jeremy, one of the words you said very early on, in your segment just a moment ago, was distraction. And I picked up on that word because distraction or distractors are things that people actually like to create when they don't understand something fully, can't wrap their arms around it, or just for whatever reason might be opposed to something. So rather than creating evidence-based arguments against something, or really evaluating something, they create distractions, they create, distractor that really take away from the central point at hand. So when you have people that, or for whatever reason, just concerned about the proliferation of technician growth of professionalization, you have people trying to muddy the waters with distractions that are not really germane to the central argument. Because the central argument, as you rightly point out, is improved quality of care and improve patient safety, because those things are the bottom line.

Shane Desselle:
The research that Ken and I have been doing, and of course our witness to other research that is going on, actually is events is over and over again that the process of delivering care has been shown to be just as safe, and oftentimes even safer when you have people like that involved. And people might say, well why would it be safer? That doesn't seem to make any sense. Well it does, because in spite of what we might think, research has also shown, and this transcends pharmacy, that people aren't good at multitasking. Okay? People are good at focusing on something.

Shane Desselle:
So if technicians are going to focus on those mechanical aspects, which allows pharmacists to focus on the non-mechanical aspects, and employ their cognitive load onto things with which they are more trained to do, and it gives technicians a more singular focus on making sure that the right drug is getting to the right patient and the right time, and so forth. And they are procuring the right drugs and preparing the drugs the right way, and taking accurate medications and histories and so forth. When people can be focused, safety actually improves.

Jeremy Sasser:
That's a great point. And I've read a lot of research papers on medication errors, and distraction always comes up. And it's not a knowledge gap, it's not that a pharmacist doesn't know how to perform a particular calculation. It's that in the middle of performing a calculation, somebody needs counsel, somebody's on the phone, you know, they're being pulled in a million different directions. I know when I was behind the counter, I oftentimes was with one pharmacist for a 12 hour shift. So if you have one individual during a 12 hour shift, regardless of what volume of scripts you're filling, and only one person can take new prescriptions, transfer prescriptions, counsel, product verify. It's just not logical when you look at workload, you know, and especially distraction.

Shane Desselle:
Well, and referring back to today's word of the day, proletarianization, which I offered as somewhat, not directly, but somewhat counter to the whole concept of professionalization. Looking at it from a pharmacist perspective, pharmacy has advanced so much in terms of its own professionalization, but still has not reached a pinnacle. And I'm sure Ken would agree with me, and I'll allow him to make some comments on that, is that the pinnacle of professionalization is delegatory authority. So when a pharmacist is allowed to design his or her own work, then that speaks greatly to autonomy, which is the ultimate in professionalization.

Shane Desselle:
We have the extraordinary pleasure and liberty to be faculty at universities. We basically design our own jobs. Nobody tells me how to teach, nobody tells me what topics to research on, nobody tells me what journals to see in my research manuscripts on. Well, that is something that faculty do enjoy, we enjoy that professional autonomy. Well I translate that to pharmacy. A pharmacist is practicing, we use the term so very frequently, the top of your license. Practicing at the top of your license means that you design your own work and delegate it to others. So if you're not delegating what you want and designing your own practice by incorporating the people who report to you, I would say then you are not yet at the top of your license and you're not a full professional yet at that time.

Jeremy Sasser:
Good point.

Kenneth Homeyer:
To kind of illustrate this point with a story, there's a chain pharmacy I work very closely with in a lot of my research. And they have within their larger operation they've got a convenient care clinic in that store, where there's also the pharmacy. And like most convenient care clinics with the nurse practitioner, the hours of operation are less than that of the pharmacy. So I was talking with one of the pharmacists who works at this company and he was telling me how the nurse practitioner community care clinic had closed for the day, this was like five o'clock on a weekend, and patients were coming up. This was recently, this was in the last month. Patients were coming up to the pharmacy saying, can you do the flu test? I know they could do it, but they're closed, can you all do the flu test?

Kenneth Homeyer:
And he had to say, no, we can't. So there is a real and growing need from patients for clinical services in their community that's convenient to access. And if our excuse for we can't provide that is, we don't have time, I think there's something wrong with the way we've designed workflow and the profession at large. To Dr. Desselle's point, delegation allows us to free up that extra time so we can say, yes, absolutely, step back here. We can take care of those services when the nurse practitioner is not on duty. And so I think there was a time where we could say, well were there things that the pharmacist would be able to do if we delegate the product distribution services? And I think that question's been asked, and now it's been answered. The answer is no. Patients want more from us as pharmacists. And so let's move to that next level.

Jeremy Sasser:
You know, in a society, in the landscape that we have right now around our complex healthcare system, and in terms of insurance and PBMs and payment, I mean that's a hot topic right now. You know, we could do five shows on DIRs and get into that. But it's a tough landscape. And so inevitably what comes up is revenue, right? Because everybody has a bottom line. I know in particular, independent pharmacies as of late have really taken a hit. There's a lot of vertical integration going on between insurers, PBMs, pharmacies, so it's really tough. Margin erosion is a real theme that's been going on for years. Kenneth, I'd be interested in your take from practicing in an independent space, what is the realistic return on investment of training up technicians to perform these things so that other streams of revenue could come in from pharmacists, provider services to patients? What does that landscape look like?

Kenneth Homeyer:
So a $1 million question, right? I mean, none of us know. So taking a step back, the issues you described are real, and I can't overemphasize how real they are because there are real pharmacies, real pharmacists, real pharmacy technicians whose jobs are on the line because things are so chaotic right now in the industry that we're in. But this isn't just a pharmacy thing, this is a healthcare thing. If you talk to physicians, if you talk to nurse practitioners, PA's, hospitals, hospital workers, we're all at sort of the cusp of major change within the industry. And I don't think anybody knows where it's going to head. We are unique in that we've got somebody like Amazon coming in and saying, we're going to disrupt the entire thing. Now, whether or not they do, it's a whole other conversation. I tend to be a little bit more cautious with my enthusiasm behind what Amazon can and cannot do within the healthcare space.

Kenneth Homeyer:
But I think the bigger picture is, delegating tasks to support personnel, to well train pharmacy technicians who want to take good care of patients allows flexibility and allows the profession to pivot in a way that right now as things are, we can't do very well. And if you look at any other industry besides healthcare, successful firms, successful organizations, are ones who can pivot quickly based on changes that happened in the marketplace. And we're still a market driven industry in healthcare, less so than most others, but we still are. And so it's in that freedom to be able to pivot to where we see the new needs are that I see the most value in advanced pharmacy technicians roles, because we don't know what the future holds.

Jessica Langley:
When we talk about some of the research that you guys are doing, can you highlight, you know, as we have all sorts of pharmacy industry individuals listening to the podcast, what are some of the most important key findings? If you can list your top two to say, I feel like this is instrumental in how not only pharmacists, but pharmacy technicians in that profession, professionalism is going to advance. What would be those top two? And then maybe you can say, that leads us to focus our future research on maybe some other topics.

Shane Desselle:
Among the things we've been looking at is a concept called self efficacy. And self efficacy, I mean, things like self esteem and self confidence are sort of transcendent, and sort of take on a global meaning for an individual. But self efficacy is derived from that, but it is particular to a situation or a task. So where we've been examining self efficacies of technicians to assume newer roles and responsibilities, and what is it that drives self efficacy? What types of people as technicians are more likely to take on certain roles? And, what about those who are not necessarily ready to take on, what sort of support, education and training do they need?

Shane Desselle:
Most recently, from a database of work that we had undertaken over the past few years, we actually could perform something called a cluster analysis. And there's no need to get into all the statistical rigmarole about what that is. But we basically identified four different strata of technicians, including some that, one cluster or stratum of technicians who were recently out, had just become certified, and had the profession commitment, ability and willingness to take on these emerging roles. Versus other technicians who could be easily trained to take them on. Versus some who would we call would be status quo technicians who actually were not that ready to take on these emerging roles.

Shane Desselle:
And so I think it's very important for us to have identified which and what types of technicians are going to help us lead into the future. If we're going to talk about this paradigm shift, we talk about pharmacists having to delegate, but we also need to identify the technicians that are most likely to embrace that new role, engage in what Dr. Homeyer and I were just talking about earlier this morning, and person environment fit. That is, fitting in their various organizations, and ascribing value to the mission of those organizations to being able to take on those new rules. So we must be able to delegate them, but we also have to find the people who are most willing to climb up on the bus and help drive it, and get us to where we're going. So that's one of the things that we've been doing to identify, having identified the antecedents to technicians embracing those new roles.

Kenneth Homeyer:
It's such an important point, and it really ties into the training and credentialing of pharmacy technicians. You can create new advanced roles like technician product verification, blood sample collection for point of care testing. All of these, medication reconciliation, we can go down the list of new and emerging things. But what we found in the research, in working with pharmacies that are doing these kinds of advanced delegation activities, that even when you open the flood gates and you say, you are legally and regulatorily allowed to do them, we still find a lot of technicians say, I'm not ready.

Kenneth Homeyer:
And part of that comes down to pharmacists really empowering and helping guide pharmacy technicians towards taking on these advanced roles. And I think the other part is helping the technicians find good programs from which to bolster the knowledge they already have. I would venture to say experience is the largest driver of being able to do most of these things, but sometimes that's not enough to build self efficacy. And so training and credentialing kind of pushes that person over the edge towards, yes, I am ready to be the person who does the final product verification. Right? That's a challenging thing, but it's also a mental thing. And so that can help overcome that barrier.

Shane Desselle:
We have a lot that we can learn, and I think finally here in the US we're starting to understand, that other countries' practices in some ways are more advanced than ours. Not in every way, and certainly not every country. But you look, for example, we're now as a group really looking to the country of Denmark. Their technicians are called pharmaconomists, they actually train for three years. Now this wouldn't be possible in the United States because of the size of our country. But they all train in one place, it's located in a little city called Allerød, a few miles North of Copenhagen. And they actually have an in-residence component to their training. They actually live, I visited that place in Allerød, they actually have dormitories and ping pong tables and things of that nature. And these folks, these pharmaconomists can do almost, not everything of course, but almost everything that a pharmacist can do.

Shane Desselle:
And I've sat and I've visited pharmacies in Denmark, whereas when you see the technicians or pharmaconomists handle these roles and responsibilities, and the pharmacist is literally sitting down with every patient that comes into the pharmacy. Because the pharmaconomist is taking care of the other patient needs, the mechanics, and even other things that go along with that. New Zealand has a designation now called a checking technician that's nationally recognized. Great Britain is taking a look at re-validating licenses for technicians in much the same way they do for pharmacists, and actually have that under a larger umbrella process under the federal government there. Which I'm not necessarily pushing federal government being involved in that though. But the point being is that we are now beginning to see what's happening in other countries, which varies tremendously.

Shane Desselle:
In other countries, particularly in what we call LMIC, is low and middle income countries, you don't have that same sort of thing, but yet with the shortage of pharmacists, technicians there are actually the key link in the supply chain. And sometimes, in say rural villages in Africa and whatnot, may be the sole source of provision for certain types of medicines on WHO's essential medicines list to provide it to that village in Africa. So different roles, different sorts of ways of practice. But United States is more so looking at other countries, and Ken can expound upon this, but you look at some States are looking at that.

Shane Desselle:
You look at Idaho, for example, where deregulation is key, not additional regulation. But the standpoint Idaho took was, rather than add a list of what technicians can do, let's just make this very, very short list of what they can't. Meaning that everything else is under the delegatory authority of the pharmacist, rather than under written rule by the Idaho State Board of Pharmacy.

Jeremy Sasser:
You know, which makes sense. If we're going to talk about, you know, pharmacists and clinical judgment, part of that is also professional judgment and knowing the technicians that they're working shoulder to shoulder with every day. I'm glad that you got there, because I just wanted to ask real quick. As you're out there in the field, I think what you talked about Dr. Homeyer is, you know, engaging technicians to do, and enabling, empowering technicians from a pharmacist standpoint to do the tasks that they can perform safely, effectively, and things that they want to do, the things they excel at.

Jeremy Sasser:
Myself, I mean, I was lucky to have a number of mentors in my career that were very empowering. At the same time, there were many times when I had to blaze my own path. I've even had to go above the head of some of the people that I report to because I'm jumping up and down asking for more responsibility, and I wasn't even given the opportunity. I kind of had to force my way in. So as you're out there discussing these topics, what kind of feedback, what kind of emotion, or what kind of reaction, I guess, do you get from practicing pharmacists who are hearing maybe some of these things kind of for the first time? I mean, is it being widely embraced? Or saying, you know, oh that'd be good in theory, but it'll never work in practice. What are you guys seeing?

Shane Desselle:
Well, the thing we're hearing is that people are generally quite supportive, and pharmacists are supportive of this. And for pharmacists to actually envisage this practice, this sort of idyllic sort of thing where they are practicing at the top of their license. What has been problematic though has been the lack of standardization in technician preparation, education and training. Certification is certainly one component to that, that is critically important. And more and more States and more employers are viewing certification as one necessary step towards trying to ensure the competence of technicians to be able to embrace these new roles. But it is not the only thing, and there are still wide variation in the quality of programming and vocational schools.

Shane Desselle:
Employers are doing a better and better job of training technicians, but they're also obviously, being that they're a specific employer, are gearing the training and education toward their particular company. Which is important, but it also precludes perhaps a little bit larger focus that could be better integrated with both certification and vocational training.

Jeremy Sasser:
Dr Homeyer, take us home.

Kenneth Homeyer:
Well, I would maybe just kind of go down that path a little bit further that Dr. Desselle just started in, and bring it home with a brief quote that came from a research project he and I collaborated on. Where we interviewed pharmacists and technicians in three states who were undergoing a pilot for tech product verification. And I'm paraphrasing the quote, but it was essentially, the pharmacist was asked, what do you like about this model? What has this model done for your pharmacy? And she responded, I cannot imagine going to practice the way I did before. Please do not take this away from me. And I think that really sums it very well. What we're seeing in the field.

Jessica Langley:
Real quick to close this out. Wonderful research, I know I've had the opportunity to have you guys send me a lot of your work once it's completed. Is there ways that other individuals can access some of your guys' research? Especially if this kind of got people really excited about the what ifs and the data that's out there. Maybe some pharmacists are like, hey, I can use this, and I'm going to take this back to my organization to use some real numbers to support change within our institution. Where can they go to find this great stuff that you guys are working on?

Shane Desselle:
Ken and I, and others, publish really in about a handful of peer reviewed journals. These include the Journal of the American Pharmacist Association, which you get access through, either through a membership in that organization or with a library or organization that does JAPHA as it's commonly known. There's also the Journal of Research and Social Administrative Pharmacy, RSAP, which is an Elsevier journal that is accessible through Science Direct.

Shane Desselle:
There is also the ASHP's journal, HHP, we published several papers in there. And there is a newer journal that is still refereed, simply called Pharmacy, and we have some papers there, and actually some more coming up. And that's actually an open access journal that is free to the public. So all of our papers, I mean every once in a while we might write something for a lay audience if we're asked to, but typically we send to either of a handful or so of peer reviewed journals that are welcoming this type of research.

Jessica Langley:
And of course we'd like to put it out there, any of our listeners want support or help in accessing some of this research or incorporating that into some of their plans, or their ideas for their organizations, we'd be happy to do some connections, hook you up with contact information for both of these amazing researchers here with us today. Just a lot of insights and a lot of due diligence in your guys' work in pharmacy industry, and technicians especially. Thank you very much for your efforts and your passion for technicians. I don't think they realize that they have people out there backing them like you, so I think that's great for them to hear.

Shane Desselle:
Yeah, thank you doctors Desselle and Homeyer, this has been fantastic. To our listeners out there, as a reminder, if you want to get ahold of us, you can email us at onscript@nhanow.com. Don't forget to subscribe through whichever platform you prefer to receive your podcasts on.

Jessica Langley:
Or just go to the Pharmacy Podcast Network and you can find On Script there as well.

Shane Desselle:
Pharmacypodcast.com, we're always there.

Jessica Langley:
Where can they find this at NHA?

Shane Desselle:
That would be found on our blog site, which is NHAnow.com-.

Jessica Langley:
Learning-leading. There you go. Perfect.

Shane Desselle:
All right. Thank you guys so much. And to our listeners out there, until you hear us again.

Jessica Langley:
There you go.

Shane Desselle:
Take care.

Kenneth Homeyer:
Thanks so much [crosstalk 00:36:14].


Thanks for listening to On Script, where we cast a spotlight on pharmacy technicians, the services they provide, and to the patients they serve. So for all the spatula warriors, TPN ninjas, and lieges of levigation, this podcast is for you. Subscribe at Apple Podcasts, Spotify, or go to Pharmacypodcast.com.