Pharmacy White Paper

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Columbus State Community College *

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Oct 30, 2023

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1 R ETAIL P HARMACY : A DDRESSING T URNOVER R ATES Wessley C. Monnin Franklin University English 220: White Paper Professor Rob O’Donnell October 28, 2023

2 B ACKGROUND  R ETAIL PHARMACIES PROVIDE AN EXCEPTIONALLY STRESSFUL WORK ENVIRONMENT . A DDITIONALLY , THEIR PRACTICES , PROCEDURES , AND EFFORTS ARE ALL SUBJECT TO SCRUTINY VIA THE GENERAL PUBLIC , THE CDC, AND THE FDA. P HARMACY RELATED SERVICES CONTINUE TO INCREASE IN DEMAND , MAKING PHARMACIES A CRITICAL COMPONENT OF THE HEALTHCARE ECOSYSTEM , AND PLACING AN ENORMOUS BURDEN ON PHARMACY STAFF .  R ETAIL PHARMACIES HAVE BEEN FACING INCREASES IN DEMAND , WORKLOAD , REDUCTIONS IN RESOURCES , AND INCREASES IN PATIENT DISSATISFACTION , RESULTING FROM INCREASED LEVELS OF IMPATIENCE THAT HAVE BECOME MORE NOTABLE SINCE THE BEGINNING OF THE COVID-19 PANDEMIC (J OHNSTON ET AL ., 2022). T HIS HAS CONTRIBUTED TO A RISE IN BURNOUT , INCREASING TURNOVER RATES FOR RETAIL PHARMACISTS .  R ETAIL P HARMACISTS ARE EXPECTED TO WORK LONG HOURS AND REMAIN PRESENT IN THE PHARMACY AT ALL TIMES DURING OPERATION . O VER A FIFTH OF ALL PHARMACISTS WORK IN EXCESS OF 48 HOURS PER WEEK (S ESTON ET AL ., 2013). T HEY ALSO EXPERIENCE EXTREME DIFFICULTY IN TAKING TIME OFF FOR ANY REASON AND ARE EXPECTED TO FIRMLY ADHERE TO THEIR WORK SCHEDULES . R ESULTING IN AN INCREASE IN JOB DISSATISFACTION AND DIFFICULTY IN MAINTAINING A HEALTHY WORK - LIFE BALANCE .  R ETAIL PHARMACIES ARE BECOMING INCREASINGLY BUSY . R ESEARCH SHOWS THAT THE EXPECTED AMOUNT OF WORK OUTPUT HAS BEEN CHANGING AND INCREASING OVER THE LAST FEW DECADES (L EA ET AL ., 2012). R ETENTION OF STAFF HAS ALSO BEEN STEADILY DECREASING OVER THIS PERIOD OF TIME WITH A NOTICEABLE DROP DURING THE PANDEMIC (T HIN ET AL ., 2022). T HIS HAS RESULTED IN HIGHER RATES OF BURNOUT AND THE INABILITY TO ADDRESS PHARMACY - RELATED TASKS CONSISTENTLY . T HERE HAVE ALSO BEEN NOTABLE INCREASES IN PRESCRIPTION VOLUME , VACCINATION ADMINISTRATION , AND OTHER NEWLY INCORPORATED PHARMACY TASKS (G IDMAN , 2011).  T HE REDUCTION IN STAFFING AND INCREASED WORK VOLUME , CONTRIBUTE TO HIGH ATTRITION AND HAVE LED TO INCREASED FATIGUE , BURNOUT , AND TURNOVER RATES . P HARMACY PERSONNEL WHO ARE FATIGUED , BURNT OUT , OR CONSTANTLY UNDER INTENSE STRESS AND ANXIETY ARE MORE LIKELY TO MAKE MEDICATION OR VACCINATION ERRORS WHICH CAN LEAD TO LAWSUITS , DISCIPLINE , AND ABOVE ALL PLACE THE PATIENTS ' HEALTH AT RISK .

3 O PPORTUNITY R ETAIL P HARMACIES ARE EXPERIENCING INCREASES IN STAFFING SHORTAGES , WORKLOAD , FATIGUE , AND BURNOUT , RESULTING IN SIGNIFICANT INCREASES IN TURNOVER RATES . I T IS COMMON KNOWLEDGE THAT TURNOVER RATES AND SHORT STAFFING , REGARDLESS OF INDUSTRY , CAN CAUSE STRAIN , FATIGUE , WORK OVERLOAD , BURNOUT , AND JOB DISSATISFACTION FOR EXISTING STAFF . T HESE FACTORS PLAY A ROLE IN THE DECLINE OF THE MENTAL WELL - BEING OF PHARMACY PERSONNEL (E LBEDDINI ET AL ., 2020). T HE PHARMACEUTICAL INDUSTRY HAS SHOWN A STEADY INCREASE IN WORKLOAD , AND A DECREASE IN RETENTION AND STAFFING OVER TIME (G IDMAN , 2011; T HIN ET AL ., 2022). T HIS DEMONSTRATED THAT THIS WAS ALREADY A DECLINING AREA OR PROBLEM ASSOCIATED WITH THE PROFESSION LONG BEFORE IT REACHED THE CRITICAL STATE IT IS IN NOW DUE TO THE COVID-19 PANDEMIC . N EWLY INTRODUCED SERVICES HAVE BEEN IMPLEMENTED INTO THE PHARMACY WORKPLACE TO COMBAT THE NEW WAVE OF INCREASED PHARMACY DEMAND RESULTING FROM THE COVID-19 PANDEMIC . I NCLUDING HIGHER VACCINE ADMINISTRATION , INCREASED PRESCRIPTION VOLUMES AND LEGAL CERTIFICATION FOR TECHNICIANS TO ADMINISTER VACCINATIONS . T HESE TASKS ATTRIBUTED TO A VAST INCREASE IN WORKLOAD , STRESS , FATIGUE , AND BURNOUT . A N ANALYTICAL STUDY ON THE PRIMARY CAUSE OF TURNOVER RATES WITHIN RETAIL PHARMACIES SHOWED STAFFING SHORTAGES AND WORK OVERLOAD TO BE A LEADING CAUSE OF INCREASED TURNOVER (J OHNSTON ET AL ., 2022). T HIS INCREASE IN TURNOVER RATES AMONG PHARMACY PERSONNEL CAUSES THE SAME FACTORS THAT ATTRIBUTE TO SUCH TURNOVER RATES TO INCREASE IN COMMONALITY , SUCH AS STAFFING SHORTAGES . T HIS FURTHER EXACERBATES THE SAME SHORTAGES AND RESULTS IN A REPETITION OF THE SAME ISSUES THAT RESULT IN INCREASED TURNOVER . F URTHER COMPLICATING MATTERS IS THE BURNOUT THAT IS EXPERIENCED DUE TO PROLONGED WORK OVERLOAD STEMMING FROM UNDERSTAFFING . T HIS STATE OF BURNOUT DEFINED BY EMOTIONAL , PHYSICAL , AND MENTAL EXHAUSTION RESULTING FROM PROLONGED STRESS CAN INCUR DRASTIC INCREASES IN THE TURNOVER INTENTION FROM PHARMACY PERSONNEL (D EE ET AL ., 2022). T HIS CAN RESULT IN A NEGATIVE FINANCIAL IMPACT , AS WELL AS GREATLY REDUCE THE QUALITY OF CARE AND SAFETY WITHIN THE PHARMACY SETTING . T HIS HIGH TURNOVER RATE THAT IS PLAGUING THE INDUSTRY CAUSES INCREASES IN WORKLOAD , STRESS , ERRORS , AND A DECLINE IN EFFICIENCY AND PERFORMANCE IN PHARMACY PRACTICES (T HIN ET AL ., 2022). P ROPOSING SOLUTIONS TO MITIGATE THE NEGATIVE IMPACTS OF INCREASED TURNOVER RATES NEEDS TO BE A PRIMARY GOAL OF PHARMACY LEADERS AND PHARMACEUTICAL GOVERNMENT ENTITIES . A UTOMATION OF SERVICES AS WELL AS RECOGNITION AND REWARDS FOR GOAL ACHIEVEMENT WHILE ADHERING TO CORE VALUES ARE BOTH SOLUTIONS THAT CAN MITIGATE THE CAUSES OF DECLINE IN JOB RETENTION FOR PHARMACY PROFESSIONALS . I N ESSENCE ,

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4 COMPANIES MUST ADDRESS THE OVERWHELMING WORKLOADS AND UNDERSTAFFING TO IMPROVE RETENTION RATES OF PHARMACY PERSONNEL . P HARMACEUTICAL INDUSTRY L EADERS MUST MAKE PHARMACY A BETTER PLACE TO WORK TO ENSURE RETENTION LONGEVITY .

5 Make Retail Pharmacy A Better Place to Work "I T IS DEEPLY CONCERNING TO SEE ALMOST ALL OF THOSE WORKING IN COMMUNITY PHARMACY HAVE SAID THEY ARE AT RISK OF BURNOUT …" J ANET M ORRISON , C HIEF E XECUTIVE OF THE P HARMACEUTICAL S ERVICES N EGOTIATING C OMMITTEE Retail pharmacies are experiencing high volumes of turnover at an alarming rate. Studies show between 2020-2022, that ranging up to nearly 61 percent of pharmacists were reporting intention of turnover (Thin et al., 2022). This intent was perceived as likely to be contributed to by increases in workload and a reduction in staff volume. These factors also contributed to the vast increase in burnout among pharmacy staff. In some cases, the pharmacists reporting burnout and intention of turnover were professionals with decades of experience and a high level of expertise. Demonstrating that the burnout being experienced outweighed professional allegiance toward their respective employers, which caused a decline in the quality of active pharmacy professionals. This decline resulted in a reduction of the quality of pharmacy care services (Johnston et al., 2022). The alarming attrition and burnout rate retail pharmacies are facing must be addressed at the organizational and governmental level as well as within the pharmacy community. Organizationally, companies must provide their respective retail pharmacies with funding and resources to adequately staff, train, and equip their pharmacies. Companies must explore new technologies and ideas to address staffing challenges and adapt to the ever-changing aspects of the industry, which have become more prevalent since the pandemic. They must explore ways to reduce the stress, pressure, and burnout that have become a commonality within the industry to ensure long-term staff retention. The CDC, DEA, and FDA are all entities that ensure the functionality, safety, and well-being of the pharmaceutical industry. They must continue to survey opportunities for improvement in the pharmacy environment and profession. They must also explore the areas of the industry that can benefit from additional funding, support, and organization. The policies and procedures generated by these departments are what set the blueprint for retail pharmacy operations and expectations. Managing these expectations and setting realistic goals accompanied by proper communication and leadership will ensure the prosperity of the industry.

6 Within the local pharmacy community, the corporate leaders who are responsible for pharmacy-related well-being and functionality must focus on caring for individual team members. This care and support can provide methods of retaining employees within the field, which would help reduce other factors that play a role in the retention decline among pharmacy staff. The pharmacy must provide a healthy work environment to ensure the consistent and safe dispensing of patient medications and services, and the long-term retention of pharmacy personnel. Leadership must monitor, manage, and automate areas of workload and recognize and reward adherence to personnel policies, procedures, and achievement of core values and goals. The most critical first step is to acknowledge this is a problem and seek out ways to improve for the future.

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7 Recognize and Reward Employee recognition programs can be utilized to encourage desirable outcomes and goals and provide pharmacy personnel with a sense of accomplishment. Employee recognition programs are associated with higher levels of performance and overall job satisfaction (Phillips et al., 2017). Retail pharmacy heads should implement awards that align with organizational goals and desired outcomes. For example, a pressing goal that many pharmacies are focused on during the month of October is increasing vaccination volume. An award tied to vaccine administration and intakes may motivate personnel to reach out to patients more frequently to inquire about their vaccination needs. A pharmacist/technician of the month award may encourage adherence to your corporation's core values. Reward initiative and goal achievement with personalized special recognition and reinforce the employee's importance by publicly recognizing employees who go above and beyond in expressing the core values expected of pharmacy personnel. Personalized rewards and recognition encourage feelings of appreciation, and long-term retention and allow for further advancement in the profession (Bondi et al., 2023). In addition to local pharmacy community awards, inclusion of personnel in national awards programs offered by organizations such as APhA must be ensured (The American Pharmacist Association). The American Pharmacists Association has a program called the Daniel B. Smith Practice Excellence Award which recognizes the exceptional performance of pharmacy practitioners nationally (APhA, n.d.). The APhA also provides an Immunization Champion Award that acknowledges organizations, pharmacy members and personnel that contribute to increased vaccination rates within their respective communities (Selvage, 2023). Public recognition helps to boost morale and provides the feeling of importance and value within the pharmacy community. The figure below demonstrates the overwhelming preference of public recognition within a pharmacy setting. (Bondi et al., 2023)

8 These reward initiatives may serve the overall benefit of the industry, however, be mindful of the drawbacks associated with awards and recognition programs. Placing significant emphasis on one performance metric or goal could have negative impacts on another. For example, rewarding increased prescription volume completion could cause personnel to focus solely on rapid prescription completion resulting in ignoring adherence to safety protocols that may be more time-consuming. Awarding vaccination intake volume may lead to a decrease in patient care concerning consultation and medication filling. Awarding metrics that may cause the volume of that metric to supersede what is realistically able to be balanced with other objectives has the potential to cause an unwanted decline in overall service in metrics that are un-awarded. These reward initiatives, whether global or local, improve the likelihood of long-term staff retention and may often be presented in the form of promotions, raises, or benefits. It was concluded in a study that the loss of a single healthcare professional can cost a company up to $60,000 (Bondi et al., 2023). By providing recognition and rewards to employees who promote core values, your company can ensure improvement in long-term retention, and prevent the loss of hundreds of thousands of dollars by having to consistently replace, retrain, and reintroduce new staff personnel. Pharmacy personnel leaders must balance desirable outcomes with undesirable consequences, and determine the cost-effectiveness associated with achieving desired goals and outcomes. Automate Dispensing and Filling Workload Pharmacy company leaders and government entities such as the FDA, DEA and CDC can take advantage of technology to implement ways of mitigating work overload and improve overall workflow within the pharmacy setting. A study concluded that prescription dispensing is allocated an astounding 30% of time and resources within the retail pharmacy setting, leaving little to no time to address additional professional services such as vaccinations, clinics, and consultations (Karia et al. 2022). Incorporating technology such as automated prescription filling machines in community pharmacies can drastically reduce the workload and time allocation given to just dispensing medications. This approach has already been implemented into several pharmacies across the U.S. including Walgreens in hopes to provide a means to meet increasing pharmacy service demands. This could open a significant portion of time that can then be allocated to other aspects or duties that are prevalent within the pharmacy setting. Also potentially decreasing the perception of work overload as pharmacists and technicians would be able to more efficiently address other metrics aside from dispensing, resulting in an improvement upon the level of patient care and outcomes.

9 A study that was conducted in Europe and North America showed that automation of pharmacy services, particularly in pertinence to dispensing and filling medications, resulted in up to a 37% reduction in medication errors, reduction in staffing requirements, increased productivity, and reduced stress of workload (Sng et al., 2020). This further demonstrates and supports the idea of implementing automation in areas that are eligible. This reduction in workload provides a method of more effectively managing the overwhelming workload that is present in retail pharmacies and allows the staff to engage with their customers and provide additional support services rather than being constrained by time and resource allocation to filling and dispensing services. An additional benefit of automating the filling and dispensing system is that it mitigates the stress caused by reduced staffing by alternatively increasing productivity. Pharmacies that would typically require additional staffing to address the several areas services provided, could greatly benefit from having a task that requires a third of their allocated time and resources be fully automated. This would allow them to address the additional professional pharmacy services with limited staffing availability. Thus, decreasing the perception of work overload and intention of turnover due to stress and burnout. Many studies have identified that work overload leading to burnout is a primary factor for loss of retention within the pharmaceutical industry (Lan et al., 2019). Because filling and dispensing account for a vast portion of the workload expected from pharmacy professionals, logically, reducing the allocation of efforts and resources dedicated to this one area of service could realistically provide a more stress-free environment and reduce the perception of workload intensity among pharmacy staff. Therefore, reducing the plausibility of retention decline, allowing for sufficient experienced staffing in pharmacies. Causing a domino effect that will in turn help reduce the burdens of understaffing leading to burnout and eventually turnover intention. Benefits  Reduced Workload  Reduced Stress  Reduced Burnout  More time for pharmacy professional services  Increased productivity  Reduced staffing requirement needs  INCREASED RETENTION

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10 There are potential drawbacks to consider in implementing automated technology within pharmacy environments. Incorporation and maintenance costs are all plausible drawbacks to consider. The cost of maintenance and utilization of such automated machinery and centers that utilize this machinery is expensive at best. The centers themselves require additional personnel to handle the tasks of packaging and delivering the filled medications to the local pharmacies. This would incur additional costs of staffing the centers themselves and the cost of upkeep for the automated machines if they are to ever go down. However, as stated previously, the cost of consistently losing pharmacy personnel who have experience in the field incurs a far greater cost to the industry when compared to the requirement of replacement, retraining, and the upkeep of automated machinery. The loss of one trained and experienced staff member equates to the cost of several automated filling machines, and with the rise of this issue, the costs incurred from losing personnel far outweighs the cost of implementing solutions to reduce the stress and burnout that leads to retention decline. The benefits of retention of staff far supersede the negative cost impacts that would be incurred to produce an environment that reduces the stress, burnout, and workload leading to turnover within pharmacies. P UTTING IT T OGETHER The retail pharmacy turnover rate crisis is a multi-dimensional problem that must be approached from several angles. Companies must engage current staff, executive leadership, pharmaceutical government entities, and the community. This engagement may be most effective through transparent informing of realistic expectations on a community level. This figure demonstrates the various dimensions that contribute to turnover rate increases. (Thin et al. 2021)

11  Companies need to monitor and manage expectations in pertinence to workload output.  Implementing technological advancements to mitigate workload volume which in turn will decrease stress and burnout, and increase efficiency, and staffing should be a serious consideration.  Automating services that account for high proportions of work resources and time such as filling and dispensing would greatly benefit pharmacies with consistently high workloads.  Acknowledging and rewarding staff that demonstrate core values and commitment to the company can increase productivity and feelings of value and achievement.  Government entities such as the CDC, FDA, and DEA, should reanalyze the current workload expectations of pharmacies, and consider implementing more benefits and opportunities for growth and promotions to incentivize retention.  These solutions such as promotions, increased pay, and automation of services will be implemented using tax dollars as necessary to make retail pharmacies a better place to work. Educating the community and demonstrating the benefits, both financial and societal, of retaining pharmacy personnel is crucial. The public must understand the importance of spending money and efforts on improving retail pharmacy staff retention. Pharmacy organization leaders can take these steps to make their retail pharmacies better places to work. Every pharmacy is different, so these solutions may not be applicable in every case. Your pharmacy may have automated services but no community interest in utilizing them. In such cases, you would need to focus your efforts on the community and engage them in the utilization of these services by demonstrating the positive effects it would have on their community pharmacy. If you are limited by funding, meaning you do not have the means to incorporate technology advancements and automation; then alternative methods may be required. Government entities have funded pharmacy endeavors in the past so reaching out to those entities such as the FDA and other companies for funding may spark new solutions or bring light to protocols they have in place to mitigate these issues. The turnover rate crisis can be mitigated, but must first be acknowledged, analyzed, and then acted upon by those with the ability to make changes.

12 References Johnston, K., O’Reilly, C. L., Scholz, B., & Mitchell, I. (2022). The experiences of pharmacists during the global COVID-19 pandemic: A thematic analysis using the jobs demands- resources framework. Research in Social and Administrative Pharmacy , 18 (9), 3649– 3655. https://doi.org/10.1016/j.sapharm.2022.03.018 Seston, E., & Hassell, K. (2013). British pharmacists’ work-life balance – is it a problem? International Journal of Pharmacy Practice , 22 (2), 135–145. https://doi.org/10.1111/ijpp.12040 Karia, A., Norman, R., Robinson, S., Lehnbom, E., Laba, T.-L., Durakovic, I., Balane, C., Joshi, R., & Webster, R. (2022). Pharmacist’s time spent: Space for pharmacy-based interventions and consultation time (spice)—an observational time and motion study. BMJ Open , 12 (3). https://doi.org/10.1136/bmjopen-2021-055597 Lea, V. M., Corlett, S. A., & Rodgers, R. M. (2012). Workload and its impact on community pharmacists’ job satisfaction and stress: A review of the literature. International Journal of Pharmacy Practice , 20 (4), 259–271. https://doi.org/10.1111/j.2042- 7174.2012.00192.x Thin, S. M., Nakpun, T., Nitadpakorn, S., Sorofman, B. A., & Kittisopee, T. (2022). What Drives Pharmacists’ turnover intention: A systematic review. Pharmacy Practice , 19 (4), 1–20. https://doi.org/10.18549/pharmpract.2021.4.2559 APhA. (n.d.). Daniel B. Smith Practice Excellence Award . American Pharmacists Association > Membership > Awards > Practitioner Awards: > apha-APPM Daniel B. Smith practice excellence award. https://www.pharmacist.com/Membership/Awards/Practitioner- Awards/APhA-APPM-Daniel-B-Smith-Practice-Excellence-Award Elbeddini, A., Wen, C.X., Tayefehchamani, Y. et al. (2020). Mental health issues impacting pharmacists during COVID-19. J of Pharm Policy and Pract 13 , 46. https://doi.org/10.1186/s40545-020-00252-0 Selvage, R. (2023, June 30). 2023 Immunization Champion Awards recognize significant contributions to vaccinations and public health . American Pharmacists Association. https://www.pharmacist.com/Publications/Pharmacy-Today/Article/2023-immunization- champion-awards-recognize-significant-contributions-to-vaccinations-and-public- health#:~:text=To%20celebrate%20the%20achievements%20of,vaccination%20rates %20in%20their%20communities . Bondi, D. S., Acquisto, N. M., Buckley, M. S., Erdman, G., Kerns, S. T., Nwaesei, A. S., Szymanski, T. W., Walkerly, A., Yau, A. S., & Martello, J. L. (2023). Rewards, recognition, and

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13 advancement for Clinical Pharmacists. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY , 6 (4), 427–439. https://doi.org/10.1002/jac5.1775 Sng Y, Ong CK, Lai YF. (2020). Approaches to outpatient pharmacy automation: a systematic review. European Journal of Hospital Pharmacy 2019; 26: 157-162. https://ejhp.bmj.com/content/26/3/157.abstract Lan, Y., Huang, W., Kao, C., & Wang, H. (2019). The relationship between organizational climate, Job Stress, workplace burnout, and retention of Pharmacists. Journal of Occupational Health , 62 (1). https://doi.org/10.1002/1348-9585.12079 Phillips, H., Bogdanich, I., Carter, K., Holler, J., Smith, T., Ticehurst, E. H., & Wascher, M. (2017). Commentary: Exploring novel approaches to staff rewards and recognition. Hospital Pharmacy , 52 (11), 729–731. https://doi.org/10.1177/0018578717736242 Gidman, W. Increasing community pharmacy workloads in England: causes and consequences. Int J Clin Pharm 33, 512–520 (2011). https://doi.org/10.1007/s11096- 011-9498-x Dee, J., Dhuhaibawi, N. & Hayden, J.C. A systematic review and pooled prevalence of burnout in pharmacists. Int J Clin Pharm (2022). https://doi.org/10.1007/s11096-022-01520-6