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Keywords:

  • community pharmacy;
  • job satisfaction;
  • literature review;
  • stress;
  • workload

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Objective  The objective was to identify, review and evaluate published literature on workloads of pharmacists in community pharmacy. It included identification of research involving the measurement of pharmacist workload and its impact on stress levels and job satisfaction. The review focused on literature relating to practice in the UK.

Methods  Electronic databases were searched from 1995 to May 2011. In addition, manual searches were completed for documents not available electronically. The findings were analysed with specific focus on research methodology, workload and its impact on pharmacist job satisfaction and stress levels.

Key findings  Thirteen relevant studies relating to workload in community pharmacy alone or in conjunction with job satisfaction and stress were identified. One utilised both qualitative and quantitative methods to identify differences in pharmacist workload in retail pharmacy businesses before and after the implementation of the 2005 English and Welsh community pharmacy contractual framework. This indicated that pharmacists spend most of their working day dispensing. The majority of studies suggested community pharmacists generally perceived that workload levels were increasing. Several also stated that increased workload contributed to increasing job-related stress and decreasing job satisfaction. No studies reporting dispensing rates for community pharmacies in the UK were identified and there was limited evidence concerning time devoted to non-dispensing services. One study investigated the differences between self-estimated and actual workload.

Conclusions  Whilst there is a clear perception that the type and amount of work output expected from individual community pharmacists has been changing and increasing over the last few decades, pharmacists are viewed as continuing to remain based in the dispensary. The impact of such changes to the practice of community pharmacy in the UK is poorly defined, although links have been made to increasing levels of pharmacist job dissatisfaction and stress.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Value for money in health care is essential, especially with the current downturn in the economic climate. Retail pharmacy businesses (community pharmacies) in the UK have not escaped scrutiny or funding cuts from successive governments. In England and Wales, the fee paid to community pharmacy contractors per prescription item dispensed has decreased from £1.29 in 1995 to £0.90[1,2] in 2011. Claw-backs hit community pharmacy in late 2007; the government reduced the reimbursement to pharmacy contractors for a large number of medicines for which it sets a standardised price. Moreover, since the introduction of the 2005 National Health Service (NHS) community pharmacy contractual framework in England and Wales, remuneration for pharmacy contractors changed so that less NHS income originates from the dispensing process and more from additional pharmaceutical services, many of which are clinically focused. The first suggestion of this shift occurred in the Nuffield Report in 1986.[3] This was further strengthened by initiatives such as ‘Pharmacy in a New Age’,[4–6] a Royal Pharmaceutical Society of Great Britain (RPSGB) consultation in the mid 1990s to develop a strategy for taking pharmacy into the 21st century. This expansion of the community pharmacist's role, whilst also providing better value for money, enabled patients to access services previously only available from their general practitioners (GPs). This is illustrative of the general trend of obtaining better value for public money in health care.

It is important to note that the NHS community pharmacy contractual framework (CPCF) is different in Scotland and Northern Ireland than it is in England and Wales. In Scotland and Northern Ireland, remuneration for pharmacy contractors is different; there are also different core services. In Scotland, this includes a Minor Ailments Service where certain NHS patients can be treated in their nominated pharmacy free of charge.[7] A limited minor ailments service is available in Northern Ireland, although this is not a core service.[8] This will be seen in relation to some of the literature identified.

Dispensing of Medications and Appliances

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Dispensing is a primary function of community pharmacy businesses. The number of prescription items dispensed within community pharmacies in England and Wales has been continually growing since the formation of the NHS in 1948.[9]Figure 1 illustrates the increasing numbers of prescriptions dispensed in England and Wales between 1995 and 2010 (compiled from[10,12–15]). In the financial year 2009–2010, just under 880 million prescriptions were dispensed in community pharmacies in England and Wales alone.[10] This trend is also evident in Scotland; 63.08 million prescriptions were dispensed by community pharmacies in 2001, increasing to 88.97 million in 2009–2010.[11,12] Technological progression, particularly in the last 20 years, has influenced the way pharmacists dispense; although prescription numbers have increased, original pack dispensing now dominates, with few items remaining to be ‘assembled and compounded’ in the pharmacy.

image

Figure 1. Number of prescriptions dispensed in community pharmacies in England and Wales and Number of Pharmacies in Contract, 1995–2010 (compiled from[10,12–15]).

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Sources of Work within Community Pharmacies in England and Wales

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

For most community pharmacies, a key source of income is the contract to provide NHS pharmaceutical services, and this is reliant upon government funding. In 2005, a new CPCF was introduced in England and Wales.[16] This three-tiered model, involving essential, advanced and enhanced services, greatly increased the scope of services that pharmacies can offer to the public and helped to realise some of the recommendations of the Nuffield Report[3] and Pharmacy in a New Age.[4–6] An example of a national advanced service is the Medicines Use Review (MUR). More than one million were conducted by community pharmacists in England and Wales in 2007–2008 compared with 152 854 in 2005. This represented a considerable increase in the work required of pharmacists over a short period of time.[13]

With many pharmacies reliant on the provision of NHS services for approximately 90% of their income, these services are important considerations relating to workload.[17] However, in the UK, pharmacies are private businesses and the pharmacist will not only be responsible for supervising the sale of over-the-counter (OTC) medicines, but will often have additional legal, management, administrative or ownership responsibilities. These factors have the potential to impact hugely on a pharmacist's personal workload.

The reclassification of various prescription-only medicines (POM) to pharmacy medicines (P) has provided pharmacists with a greater range of medicines to treat minor ailments. This commenced in 1983 with ibuprofen being granted P status for specified strengths and indications. Although slow to start, progression of this scheme has increased in pace with over 30 POM medicines being granted P status since the early 2000s.[18] However, the sale of these new ‘over the counter’ medicines, often for limited quantities or with restrictions on indications for legal sale, frequently requires more pharmacist time and attention to specific details. For example, the sale of Alli (an anti-obesity medicine) involves calculating a patient's body-mass index and providing detailed dietary advice. Complex consultations such as these are an additional source of workload for pharmacists specifically.

Some of the sources of work highlighted above can be delegated to support staff (such as assembling of prescriptions, filling in of MUR paperwork) whilst other work may not. This may be due to support staff not being technically or clinically competent or for legal reasons, for example the sale of specific medicines or conducting a MUR. Brown and Bellaby's[19] ethnographic research illustrates very effectively just how complex a day in the life of a community pharmacist can be and how pharmacist-specific workload can sometimes become excessive.

Importance of Research into Pharmacy Workload

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Evidence suggests that excessive workload impacts negatively on the amount and quality of advice and service provision to patients, dispensing accuracy and acts as a barrier to practice change.[20–26] Furthermore, increased workload may impact on pharmacists' stress levels and job satisfaction. Based on the fact that over 70% of UK-registered pharmacists work within the community sector,[27] the effects of workload on job satisfaction or job-related stress were also chosen to form part of this review.

Workload may be defined as the amount of work completed by a worker within a specified time frame.[28] An example of this could be the number of prescription items dispensed in an hour. For community pharmacists who are involved in many, varied tasks this will be more complex. The recent changes to community pharmacy referred to above have had an impact on pharmacists, increasing their individual workload. A simple definition of work intensification would therefore be the increase in level of workload.[29] For example, more work of similar complexity would be expected of an individual within either the same, or a shorter, time frame than previously. A further dimension to this definition may also take into account a similar amount of work than previously, but of greater complexity.

This trend for workload intensification lies not just with the pharmacy profession. There is a growing body of research into workload issues experienced by other healthcare professionals, both in the UK and overseas. In the nursing profession, the issue of workload and its impact on the quality of service provision, as well as the workforce itself is well researched.[30,31] This is also the case for the medical profession.[32–34] There has recently been an increased interest in issues relating to community pharmacist workload and its effects on the workforce, highlighted by the RPSGB launch of a workplace pressure campaign in January 2009 in response to feedback from members.[35] To date, there has been no review of the published literature on workload and its effects on pharmacists' job satisfaction and stress levels.

Aim and Objectives

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

The overall aim of this exercise was to review the state of knowledge concerning the nature of community pharmacists' workload. Two key objectives were:

  • To identify the nature of community pharmacists' workload and how this has changed since the mid 1990s.

  • To explore any association between pharmacists' workload, job satisfaction and stress.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Literature search

A search of the following electronic databases was completed: Web of Science (1995–2011), ScienceDirect (1995–2011), Medline (1995–2011), CINAHL (1995–2011), NeLM (1995–2011) and International Pharmaceutical Abstracts (1995–2011). The Pharmaceutical Journal was searched online (1999–2010). The Pharmaceutical Journal (1995–1998) and The International Journal of Pharmacy Practice (1995–2003) were searched manually by VL, as full articles were not available online previous to this. In addition, publication libraries of the Pharmacy Practice Research Trust and the RPSGB were also searched. All publication types were included in the searches. Bibliographies of articles identified as being relevant were searched manually. Search periods were set between 1995 and May 2011. These dates were chosen to include a period of 10 years before the commencement of changes introduced by the most recent community pharmacy contractual framework in England and Wales. This gave a good period to search for studies both leading up to and after these changes thus enabling comparisons to be made relating to the effect of new service provision.

Multiple databases were searched, which led to duplication of some articles. The total number of studies identified, as described in Table 1 excludes any duplicates.

Table 1. Summary of search for pharmacist job satisfaction and stress
Database/search methodSearch termsTotal number of hitsNumber of studies eligible for inclusion in review
  • *

    Denotes that duplicates of papers already identified were contained within the search – these were omitted as appropriate in the final number of papers reported above.

NeLMPharmacy OR pharmacist OR pharm AND community OR comm OR retail OR dispensing OR dispen.2201
ScienceDirect(pharmacy OR pharmacist OR pharm*) AND (community OR comm* OR retail OR dispensing OR dispens*) AND (work OR workload OR work* OR work activity OR work measurement OR task OR productivity OR busyness OR busy* OR job satisfaction OR job stress).160
International Pharmaceutical AbstractsAs above.2721
Medline/CINAHL (EBSCO Host Electronic Database)As above.1733*
Web of ScienceAs above.1892*
Manual searches (including searches of bibliographies of relevant studies)Manually searched for any studies relating to pharmacists' workload and job satisfaction or stress.xxx8
Total number of studies included in review (excluding duplicates)13

Search terms

The following were used as search terms in the form of key words and ‘free text’ searches: pharmacy; pharmacist; pharm*; community; comm.*; retail; dispensing; dispens*; work; workload; work*; work measurement; work activity; task; productivity; job satisfaction; job stress. Table 1 provides detailed information on the search terms used for each electronic database searched as well as articles found during manual searches.

Inclusion/exclusion criteria

Publications were only included in the review if they met the inclusion criteria set out in Table 2. Research that was unpublished at the time of the review was excluded as full access to such materials could not be gained. Where research was published as both conference and research papers, only the full research paper was included in the review.

Table 2. Inclusion and exclusion criteria
Inclusion criteria
Primary quantitative, qualitative or mixed method research investigating:
• Measurement AND/OR description of pharmacist workload. Papers focusing on research relating to community pharmacy in the UK.
AND/OR
• The impact of workload on community pharmacist job satisfaction and stress levels.
• All types of community pharmacies included (independent, supermarket, multiple/chain).
• Appropriate reviews of research, from 1995 onwards, relating to community pharmacist workload, with or without details of its effects on community pharmacist job satisfaction and stress.
Exclusion criteria
• Research relating to internet/mail-order pharmacies.
• Research relating only to sectors other than community pharmacy.
• Research which examines workload of pharmacy as a whole but does not allow differentiation between the workload of pharmacists and staff.
• Research that examines pharmacist job satisfaction or stress alone, and not in conjunction with workload.
• Research published pre-1995.
• Research published post-May 2011.
• Research relating to community pharmacy outside the UK.

Data abstraction

The literature search was conducted by one researcher (VL). Both VL and an academic (RR) examined titles and abstracts independently to determine which papers were relevant for review. All papers originating outside the UK were then excluded. Next, studies not investigating any aspect of community pharmacists' workload were excluded. The researcher (VL) and academic (RR) then determined from the remaining studies which were relevant for review in relation to the inclusion and exclusion criteria set out in Table 2. A custom-designed table was used to enter data from each study to ensure consistent data extraction when reviewing included papers. Data from the papers were entered into the table under the following headings: Reference; Study aims and summary; Pharmacy sector; Country in which research conducted; Sample and research methodology. Each study was also assigned a topic area: Measurement and categorisation of pharmacists' workload in the UK, pharmacist perceptions of workload and how workload impacts on pharmacists' job satisfaction and/or stress levels. Data abstraction was completed by VL and checked by RR. Included studies were then examined by all three members of the research team.

The most appropriate set of guidelines to apply to this review was considered to be the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). As the guidelines did not fully match the subject matter, the most relevant parts of PRISMA were used in the formulation of this review, excluding points 5, 11–14, 16 and 19–23 on the checklist.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

The literature search identified a total of 13 papers which related to the UK. Papers employed both qualitative and quantitative research methods; postal questionnaires, semi-structured interviews (face-to-face and telephone), observations, work-study logs and work sampling were all used in the research identified. No appropriate review papers were found. Table 3 provides a summary of the papers identified, in chronological order.[36–48]

Table 3. Summary of relevant research papers identified
StudyYearCountry of originAimsMethodKey Findings
  1. GPs, general practitioners; MUR, Medicines Use Review; NHS, National Health Service; OTC, over-the-counter; PCO, Primary Care Organisations.

Savage[36]1995UKTo investigate the effect that skilled dispensary help had on pharmacist work activities, especially the time spent advising customers on health and medicines.Direct observation of four pharmacists working in two well established independent community pharmacies over a 2-week period. One pharmacy employed a full-time dispensing technician and a counter assistant able to help in the dispensary whilst the other employed only a counter assistant who never worked in the dispensary. Pharmacists' activities were recorded every minute by a dedicated researcher.In the pharmacy where a dedicated dispensing technician was employed, the pharmacists spent 20% less time on dispensing activities and more time on the counter (14%) or resting (6%). Having a dispensing technician meant that, in a 9-h day, the pharmacists had 90 min more free time, most of which was spent on the counter. The unpredictability of pharmacy workflow means that time pharmacist time saved by a technician does not directly convert into more communication time with patients. Author concludes that to do this, pharmacists need to exert more control over their incoming workload.
Savage[37]1997UKTo investigate the time that community pharmacists spent advising customers on OTC and prescription medications and health.Over a 3-month period, two half-day observations of 18 pharmacists were completed in 15 independent pharmacies in the London and home counties area. Pharmacists had differing workloads, staff assistance and customer base.Indication of pharmacist' customer workload in events per hour – an average of 23 events per hour. These events only relate to prescriptions issues and OTC customers, not any of the additional work (such as administrative tasks) pharmacists are expected to do. The time pharmacists spend giving advice to OTC customers is longer (111 s) than that to customers with prescriptions (27 s).When prescription workload was at its highest, there was a reduction in the amount of time spent with prescription customers. Pharmacists working solo had to limit time with prescription customers and that as more products become OTC, they may have even less time available for this purpose.
Rutter et al.[38]1998UKOn a national scale, to gain baseline information about how community pharmacists spend their time.Pharmacists from one large national multiple were asked to self evaluate how they spent their time. Study used a previously tested data collection form where community pharmacists' work was placed into 16 categories. Data collection occurred over a 7-week period, each week sampling one day. Pharmacists had to fill in the form at the end of the day. Total number of participants each week ranged from 376 to 392, with a total of 1084 useable replies.The findings provide a breakdown of how several hundred community pharmacists think they spend their time. Key results include (all averages) 37.2% of time spent on dispensing, 12.18% on checking prescriptions, 12.52 on OTC advice and counselling and 4.43% on personal/break time.
Rutter et al.[39]1999UKStudy to determine the validity of previously performed research[38] utilising a work sampling technique. The previous research investigated how pharmacists in the UK spent their time using subjective evaluation.Trained observers were sent to five community pharmacies. Observations occurred on three separate days over a 6-week period. Observations were categorised in to 18 categories which were previously defined by the researchers to represent a community pharmacist's work.Dispensing was found to be the activity which pharmacists spent the most time on. The time assigned to NHS work was 57%, lower than previous estimates. Pharmacists significantly underestimated the amount of time they took as a break/personal time. Additionally, time dedicated to verbal communication (health related and non-health related) was significantly underestimated by pharmacists. However, when compared to estimates from their previous study,[38] the authors conclude subjective evaluation is more accurate than first perceived and has a place in work studies.
Bell et al.[40]1999Northern IrelandAim to find out how community pharmacists in Northern Ireland spend their time.Participants were 30 community pharmacists in the Greater Belfast area. Investigations were carried out using a work sampling technique. Pharmacists had to record what they were doing at randomly assigned times in the day.Pharmacists spent 49% of their time on professional activities (dispensing, OTC, counselling), 29% on semi-professional activities (administration, money) and 22% on non-professional activities (rest, house work). Pharmacists spent a large proportion of their time labelling and assembling medicines, a task which can easily be delegated to trained staff.
Rutter[41]2002UKComparing contrasting community pharmacies to determine if prescription volume or staffing assistance caused pharmacists' behaviour to become closer to pharmaceutical care.Staff working in four pharmacies participated. Each pharmacy had differing levels of staff and prescription workload. Over a 4-month period, the work patterns of dispensary staff were determined via direct observation, using previously determined activity categories. Observations occurred every minute over a total period 104 h.Time dedicated to pharmaceutical care related activities such as counselling on prescribed medication (range 1–6% of time) was low. Approximately 75% of the pharmacists' time was spent on the same five activities, of which dispensing was the most prominent. OTC advice given infrequently and only after referral by an assistant.
Gidman et al.[42]2007UKTo explore the effect of increased workload on female community pharmacists.Participants were 30 female community pharmacists over the age of 30 years, living in the North West of England. Face-to-face semi-structured interviews were completed with each participant.Female community pharmacists are experiencing decreased job satisfaction. This is a result of a more demanding, high pressured work environment. Authors also state there is evidence to suggest that the increase workload has led to reduced ‘health and well-being.’
Bond et al.[43]2008England and WalesTo determine the effects of the 2005 community pharmacy contractual framework on the community pharmacy workforce, with emphasis on workload and job satisfaction related issues.Mixed methodology was used. A postal survey was sent to all community pharmacies (n = 1,080) located in a stratified random sample of 10% of the Primary Care Organisations (n = 31) in England and Wales. An abridged version of this was also completed over the telephone with some pharmacists who had not initially responded to the first questionnaire. Focus groups, interviews (involving 40 community pharmacists and 22 GPs) and pharmacist work-study logs were also used.Response rate for full length postal questionnaire was 50% (543/1080) and 71% (762/1080) for the full-length postal questionnaire and the shorter telephone surveys. Response rate to the work-study log was 50% (57/114). Finding from this were extensive and not possible to summarise completely within this table. Pharmacists perceived the contractual framework to have caused an increase in personal workload and made additional demands on them. Pharmacists stated that they had seen increases in paperwork and they also did not have the time to do ‘justice to the job.’ Provision of MURs increased the likelihood of pharmacists being satisfied with their role.
Eden et al.[44]2009UKTo explore why recently qualified pharmacists chose to follow a ‘non-standard’ career path, or were contemplating doing so.A total of 12 pharmacists who had qualified in the past 5 years participated in telephone semi-structured interviews. Pharmacists were drawn from both hospital and community sectors.Pharmacists' career decisions were often influenced by workload pressures. This was the same irrespective of the sector in which participants gained early career experience in. Participants unable to deliver new pharmaceutical services they had been trained to; workload was seen to be partially responsible for this. Community pharmacists also stated lack of resources (such as staffing) as being a problem.
McCann et al.[45]2009Northern IrelandTo explore the factors that relate to job related stress in community pharmacy in Northern Ireland.Qualitative method involving one-to-one semi-structured interviews were completed with 17 community pharmacists over a period of 5 months.Key factors contributing to job stress included increasing workloads, staff were not always being adequately trained, making delegation problematic, interruptions to workflow and difficulty in taking rest breaks.
McCann et al.[46]2009Northern IrelandTo investigate levels of job satisfaction and stress in pharmacists in Northern Ireland in the context of continuing practice changes.Previously piloted and validated questionnaires were sent to all registered pharmacists in Northern Ireland. This study obviously took into account views of hospital as well as community pharmacists.The response rate to questionnaires was 39% (766/1965). Overall stress scores were found as being significantly higher in community pharmacists than hospital pharmacists. Community pharmacists found the most stressful characteristics of their jobs to be excessive workload, interruption and inadequate staffing.
McCann et al.[47]2010Northern IrelandTo investigate how community pharmacists spend their time, quantifying how much time in spent on specific activities.A total of 30 community pharmacists in 30 community pharmacies in the Greater Belfast area participated. A work sampling technique was used. Pharmacists were required to record what they were doing at 13 randomly assigned times (assigned via a bleeper device) during their working day, for 12 days.Pharmacists spent 49% of their time on professional activities (dispensing, OTC, counselling), 31% on semi-professional activities (administration, money) and 20% on non professional activities (rest, house work). Practice within Northern Ireland has changed very little if comparing the data from this study to that conducted by Bell et al.[40]
Gidman[48]2011UKTo investigate English community pharmacists' experiences of increasing workloads.Semi-structured interviews were conducted with 30 female and 29 male community pharmacists living in the North West of England over a 3-year period.Pharmacists reported that workloads were increasing within the community sector. Most participants felt this was concurrent with reduced job satisfaction and increased stress. Some evidence found to suggest that increased workloads initiated patient safety concerns.

Measurement and categorisation of pharmacists' workload in the UK

A number of studies looked at community pharmacists' workload within the UK, employing a variety of research methods. There was some evidence found which investigated both what pharmacists do during the day (categorisation of activities) and their general workload. These are summarised below.

Observational studies

Several studies employed observational methods to research pharmacists' work.[36,37,39,41] Rutter et al. reported that pharmacists spent the majority of time on dispensing, and that little time is dedicated to patient contact or pharmaceutical care. This was seen to be independent of prescription workload or staffing levels.[41] Pharmacists appeared to be placed inappropriately, completing the same tasks as dispensers. Comparisons were also made between a subjective work-study and an observational study, looking at the differences between the workload pharmacists perceived themselves to be subject to, and what they actually did.[38,39]

Interestingly, pharmacists overestimated the time spent on NHS work (70% estimated versus 57% actual) and significantly (P = 0.042) underestimated the time spent on breaks/personal time and non-health communication (P = 0.002).[39] Specific limitations of one the studies conducted by Rutter et al. relate to the fact that when pharmacists were performing more than one task at once, this was recorded in its own category.[39] It would have been useful to know which tasks they were combining. It would also have been helpful to how the total time identified as waiting or personal was allocated; was this a discrete period/s, or split throughout the day?

Savage also used direct observations in two studies to investigate time for pharmacist contact with patients in several community pharmacies.[36,37] Mean data from customer workload in 18 community pharmacies was recorded as 23 events per hour (prescription and OTC events).[37] It was also reported that there was no link between the time pharmacists spent on advice giving and the availability of dispensary help or their total customer workload.[36] It was concluded that trained dispensary help for pharmacists did not automatically translate into more time with patients; unpredictable pharmacist workflow was the main reason given for this.

Work diaries/self sampling

Work sampling or work-study logs have been used to document pharmacists' workload. A community pharmacy self reported work sampling study was carried out by Bell et al. in 1998.[40] This encompassed 30 community pharmacists in the Greater Belfast area recording their daily activities according to a list of 15 tasks pre-categorised by the researchers. Data recording occurred over a period of 10 days. One benefit of the way in which the tasks were categorised relates to the fact that the dispensing process was broken down into several categories. For example, prescription appropriateness, assembly and labelling of products and endorsing of prescriptions were all separate categories thus giving a more accurate impression of how pharmacists spent their working day. Results showed pharmacists spent a mean of 20.73% of their time assembling and labelling of products, 10.00% of their time coding and endorsing prescriptions and 9.46% handing prescriptions out and counselling patients. Rest breaks accounted for a mean of 8.58% of pharmacist time. Interestingly, staff training accounted for the least time spent on a task with a mean of 0.85%. From the results presented, the authors drew the conclusion that pharmacists were more concerned with the ‘quick and efficient’ supply of medicines to patients as opposed to patient-focused care services. Lack of time was also hypothesised as being a barrier to the provision of pharmaceutical care.

McCann et al. completed an update of the above study in 2009,[47] repeating it in 30 community pharmacies in the Greater Belfast area, utilising the same method as above, adapted slightly to account for changes in practice. Results indicated that there had not been much change since the first study in 1998. Pharmacists were still spending the majority of their time assembling and labelling products (23.24% versus 20.73%) and spending less time handing out prescriptions and counselling patients (4.84% versus 9.46%). Pharmacists who dispensed less than 1499 prescription items spent significantly more time (11.89%) on OTC advice, and responding to symptoms than those who dispensed 1500 or more prescription items per month (6.3%, P = 0.027). Work categories as set out by the authors for this study are different from those which would be set out for an English or Welsh study where the CPCF is different; this should be taken into account when comparing research in Northern Ireland with that in England and Wales. For example one category relates to minor ailments consultations (not nationally available in England and Wales), and there is no MUR category. In real terms, this may have represented differing workloads.

Mixed-method studies

Bond et al.[43] completed a mixed method study into the effects of the 2005 CPCF on pharmacy workload and pharmacist job satisfaction and stress. This was the most substantial research project on workload within the English and Welsh community pharmacy sectors to date. This was peer reviewed and published by the Pharmacy Practice Research Trust. Details of methods used are available in Table 3.

Results showed that the majority of pharmacist work time was spent dispensing prescriptions (median 51–75%). Pharmacists spent 10–25% of their working day counselling patients and up to 25% on other management tasks. The work-study log data showed similarities with this, with most time spent on dispensing prescriptions (median 50%) followed by patient counselling (median 9%). Interestingly, the work-study log figures for time spent on both tasks are lower than those from the postal survey. Approximately 59% of pharmacies were providing MURs and the average total time per MUR (including the preparation, patient consultation and subsequent paperwork) was 51 minutes. Moreover, pharmacists who were providing MURs were more likely to be providing more enhanced services compared to those who were not.

A total of 68% of respondents indicated that they had delegated more work to non-pharmacist staff since the 2005 NHS CPCF had been put in place. Only 27% of pharmacists indicated that they had delegated more work to other pharmacist staff. In total, 34% of respondents said they planned to make other staffing changes in the next year (2006–2007) because of the 2005 contract.

Pharmacists' perceptions of their own workload

One paper identified looked at pharmacists' perceptions of their own workload. The findings provided a valuable insight into this subject and suggested that the issue of workload was complex and multi-factorial. This is summarised below.

Mixed-method study

Qualitative findings from Bond et al.'s[43] case studies underlined pharmacists' own perceptions of their professional role being dominated by dispensing and checking prescriptions. However, pharmacists realised that this would have to change if they were to be able to spend more time with patients. Many of the pharmacists who participated felt that the new contract still rewarded dispensing, whilst some felt that they were being asked to do more work for the same remuneration. Also, some participants felt ‘put out’ on being asked to add more work to their already heavy workload and raised questions about whether others actually comprehended what was already part of their working day. In addition to this, some pharmacists expressed disappointment that initiatives which should help workload (such as electronic transfer of prescriptions or repeat dispensing) had not become a reality.

How workload impacts on pharmacists' job satisfaction and/or stress levels: evidence from the UK

There was evidence available to propose that workload impacted on pharmacists' job satisfaction and stress levels.[42–46,48] Both qualitative (semi-structured interviews, telephone and face-to-face) and quantitative (questionnaires) methods were employed to investigate this subject. The findings are summarised below.

Semi-structured interviews

Evidence suggested that workload pressures influenced career decisions of recently qualified pharmacists. Eden et al.[44] conducted 12 telephone semi-structured interviews with pharmacists who had qualified within the last 5 years. Results showed that regardless of the sector (hospital or community) in which the pharmacists had gained work experience, workload pressures commonly influenced career decisions. Out of 12 participants, nine began their preregistration year in hospital and three in community. Of the three community pharmacists, only one remained in full-time community employment at the time of the research. Interestingly, most of the participants (eight out of 12) held a job as a part-time community relief/locum pharmacist. Seven of these eight completed a hospital preregistration year. Workload pressures in community pharmacy were commonly linked to the need to meet specific business requirements. Community pharmacists also complained of a lack of resources (support staff in particular), meaning that their day-to-day routines ‘became monotonous and unfulfilling.’ Increased job satisfaction levels were seen when more opportunities for clinical roles were given to pharmacists. However, workload pressures meant that the time available for clinical activities was limited. The authors suggest that clearer guidance on staffing levels and provision of adequate support staff may help alleviate this problem.

Additional qualitative research by McCann et al.[45] suggested community pharmacists recognised their role has changed considerably leading to, amongst other things, increased workload which led to greater stress. Semi-structured interviews with 17 community pharmacists in Northern Ireland revealed that interruptions were also perceived contributors to job-related stress. Furthermore, participants suggested that the above, combined with a lack of breaks, could potentially lead to errors being made. Pharmacists felt that on some occasions support staff were not appropriately trained which hindered the delegation of work. Adequate rest breaks were seen as important by almost every interviewee but it was reported that these did not always materialise in practice. Isolation, professional role expansion and continuing professional development (CPD) were additional factors perceived as contributing to job stress.

Gidman et al.[42] conducted qualitative research on female community pharmacists in England with respect to role expansion and increasing workloads. The results suggested that most of the participants enjoyed various aspects of their expanded role, but found new roles difficult to realise practically alongside traditional responsibilities. Most of the participants perceived workload in the community pharmacy sector to be high and that this led to increased pressure and stress within the workplace. Pressure from inadequate staffing levels was experienced by locums, employees and proprietors. However, most felt that the greatest pressure came from an increase in their own workload and conflicting work priorities as well. Achieving an acceptable work–life balance was also perceived to be a problem by most of the participants.

Another study, published by Gidman in 2011,[48] included 29 male pharmacists being subject to the same semi-structured interviews as the female pharmacists in the Gidman et al.[42] study. Again, it was reported that pharmacists felt workloads were escalating, and that this was linked to increased stress and reduced job satisfaction. Few male participants voiced a preference for working in very busy pharmacies. It was also reported that lack of management support could be linked to workload and stress. Furthermore, some participants considered that an increase in risk of making an error might be a product of a busy community pharmacy environment in which they are often multi-tasking.

Questionnaires

Available quantitative research demonstrates a link between an excessive workload and job-related stress. McCann et al.[46] undertook quantitative research on both community and hospital pharmacists' job satisfaction and stress using a postal questionnaire. The response rate was 39% (n = 766/1965). For both community and hospital pharmacists, excessive workload and inadequate staffing levels were identified as the most influential factors on job-related stress. In addition to this, ‘mean stress scores’ were significantly higher (P < 0.05) in the community pharmacist group than the hospital pharmacist group. There was limited evidence of differences in job stress experienced by locums, employee pharmacists and employee managers compared with contractor pharmacists. Both community and hospital pharmacists perceived the top three factors contributing to stressful job situations as being: interruptions (phone calls or other) whilst carrying out normal duties; increased workload; and lack of staff.

Bond et al.[43] reported that a total of 58% of pharmacists stated they were stressed at work. The study measured workplace pressure experienced by pharmacists from specific job related factors by measurement on a scale of five (high pressure) to one (no pressure). ‘Demands from the new contract’ (mean = 3.96) were reported to provide most pressure at work closely followed by ‘actual workload’ (mean 3.89) and ‘paperwork’ (mean 3.89).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Although the number of studies relating specifically to quantifying workload in community pharmacies in the UK is limited, the evidence base is developing since the introduction of the new contract with many of the studies identified focusing on the impact of increased workload on pharmacist job satisfaction and stress. Workload was often seen as a factor impacting negatively on these.[42–46,48] Generally, the findings from some of the studies identified in this literature review suggested that community pharmacists have some difficulty with work–life balance and the increasing workloads lead to increased stress levels. There was additional evidence that community pharmacists are working longer hours than previously, because their job demands it.[43] Pharmacists perceived their own role to be dominated by the dispensing and checking of prescriptions and that their workload is, in general, high.[42,43,48] Pressure from inadequate breaks and a lack of staff were seen as problematic within the community sector.[42,44–46,48]

Strengths and limitations of this review

Literature searches were completed thoroughly and systematically. Despite this, the number of studies identified, particularly those quantifying actual workload within community pharmacies was low. Many of the studies focused more on pharmacist stress and job satisfaction. The limited number of quantitative studies identified made combining findings problematic. Consequently, the nature of this review is narrative. A formal scoring system was not applied when assessing the studies as so few had been identified, thus permitting inclusion of papers that might otherwise have been omitted. However, any obvious limitations were critically commented upon within the description of individual papers. Due to commercial sensitivity, workload-related research conducted internally by private pharmacy companies was unavailable for the review. The findings of this review may therefore be subject to publication bias.

More research is needed in the community sector to determine the level of dispensing undertaken and availability of (trained) support staff. No research was identified which benchmarks the rates of dispensing in community pharmacies in the UK. This subject may be particularly difficult to research due to commercial sensitivity. This exercise has, however, been completed in a selection of Welsh hospital pharmacies, with dispensing rates being benchmarked at an average of 9.8 items per person per hour.[49] Reported dispensing rates in community pharmacies in the USA ranged from 8.9 to 18.0 prescription items per pharmacist per hour.[50] Both of these settings differ from UK community pharmacy, and such results are not directly transferable between different environments; more research into this is needed. Two studies identified considered pharmacists' perceptions of their workload as opposed to measurement of actual workload; there is evidence to suggest there may be a difference between the two.[39,43]

There were no studies available that investigated in great detail how much time pharmacists spent on services other than dispensing (such as advanced services, enhanced services or increasingly complicated OTC medicine sales). Such information would prove useful to both policy makers and employers. Bond et al. allude to the average time spent per MUR (51 min).[43] This was useful but may also have changed as pharmacists have become more experienced at doing MURs. Savage gave an indication as to how much time pharmacists spent on OTC advice and prescription counselling.[41] It is also apparent that freeing up pharmacists' time with dispensing assistance does not automatically translate into increased customer contact time, most likely due to the unpredictability of community pharmacists' workflow.

Delegation is an important factor to consider as it may be used as tool to manage workload, and is mentioned in some of the studies identified.[43,45] Roberts et al.[51] conducted qualitative research which indicated that appropriate delegation of workload to non-pharmacist staff was seen as important for pharmacists to be able uptake new professional roles successfully. Findings suggested that pharmacists perceived delegation of tasks to non-pharmacist staff as being important for management of workload and to take on new professional roles.[43,45] Evidence from one study suggested that pharmacists in the UK were planning on increasing delegation of work to non pharmacist staff; completing a longitudinal investigation would determine if this had occurred.[43]

Further research is needed relating specifically to barriers and facilitators to delegation in the UK. This is especially relevant considering that a sizeable proportion of pharmacists' time appears to have been spent on either semi-professional or non-professional activities,[40,47] many of which could probably be delegated. Such research should not just be from pharmacists' points of view, but also the views of pharmacy staff – dispensing technicians in particular. A US study of technicians and pharmacists on this subject concluded that pharmacists and dispensing technicians both agreed that dispensing technicians should have various functions in relation to dispensing and claiming for prescriptions.[52] Technicians also supported the idea of a greater role for themselves in patient care.

Lack of trained staff, pharmacists not managing to take adequate breaks and patient safety concerns, as highlighted by some of the studies reviewed, should be of particular interest to both employers and policymakers. The case of Elizabeth Lee, an English community pharmacist who was prosecuted for a single dispensing error, in which lack of staff and breaks were factors involved, underlines the importance of such issues.[53] A study of locum pharmacists also suggested that factors which would reduce the likelihood of them returning to a pharmacy included chaotic systems of working, lack of support staff (not enough or not well trained) and poor organisation.[54] It is clear from the studies identified in this literature review, that the quantification of community pharmacists' workload is complex and differs between individual pharmacies. Employers should therefore consider not using a ‘one-size-fits-all’ approach to calculating staffing.

Increasing workloads is not an issue confined to UK community pharmacists. There are various US studies available detailing pharmacist workload and its effects on their job satisfaction or stress. These were not included in the review due to the considerable differences in practice between the UK and the USA. However, some of the findings are interesting to consider. For US pharmacists (all sectors, including community), work overload was one of the factors that most contributed to job stress for pharmacists generally.[55]

Other US research suggested that community pharmacists wanted to spend less time dispensing and on business management and more time on consultation and drug-use management. This was true of community pharmacists working in both chain and independent pharmacy settings.[56] Results from another study showed that prescriptions dispensed personally by community pharmacists had increased since the year 2000.[57] Svarstad et al. also reported that increased community pharmacy busyness reduced the likelihood of any pharmacist communication to patients (talking to patients, oral information giving, assessment of understanding).[58]

Limitations of research methods employed in identified papers

Papers identified used a range of methods to research the subjects of pharmacist workload, job satisfaction and stress. Various limitations are to be noted. Two studies used questionnaires to collect information from pharmacists.[43,46] Questionnaires in all the studies identified were previously validated. However, non-response bias has the potential to affect study outcomes on the basis that non-responders may be characteristically different to those who do respond. McCann et al. stated that non-response bias in their quantitative study[46] (questionnaire response rate 39%) should not be overlooked. Bond et al. followed up non-responders over the telephone, giving a high overall response rate (71%) helping to reduce possible bias.[43]

The use of work diaries or subjective evaluation as a method of recording pharmacists' work patterns was reported by several of the studies identified. Participants' perception of time spent on certain aspects of their jobs was skewed, intentionally or unintentionally. One study reported differences between actual work completed and estimated work, some of the differences having statistical significance.[39]

Observational studies were used in some of the research described in this review. Observations are subject to the Hawthorne effect, where participants modify their behaviour in response to being observed.[59] Although quantifying the Hawthorne effect in such studies remains difficult, observations are still key for investigating pharmacists' workload, especially given the differences in perceived workload and actual workload identified in this review.[39]

Much of the data presented in this review were collected several years prior to the introduction of the 2005 CPCF in England and Wales. Only seven out of the 13 studies identified were post 2005; three of these were in Northern Ireland where the contractual framework is different to England and Wales. Due to the separate pressures provided by the contract changes in England and Wales there is now a growing need to conduct more studies or repeat studies completed prior to contractual changes to determine whether anything has changed. There was already some evidence to suggest that changes were beginning to take place after the introduction of the CPCF, even in 2006. Further changes may have occurred in the past 5 years; indeed, additional contractual changes occurred in late 2011 with the introduction of the New Medicines Service.[60]

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

The research identified is a base for determining community pharmacists' workload and understanding how it impacts on job satisfaction and stress. The evidence for specifically quantifying levels of workload or work intensity in the community pharmacy sector after the introduction of the 2005 CPCF is limited. Whilst there is a clear perception that the amount of work output expected from individual community pharmacists has been changing and increasing over the last few decades, pharmacists are viewed as continuing to remain based in the dispensary despite attempts to introduce more clinical aspects to their roles. The impact of such changes to the practice of community pharmacy in the UK is poorly defined, although links have been made to increasing levels of pharmacist job dissatisfaction and stress.

In the light of concern over maintaining the pharmacist workforce levels, and as a result of the demand for increased utilisation of pharmacist based services within the NHS, there is a need to broaden the evidence base relating to community pharmacists' workload. It is likely that the evidence base for workload in community pharmacy will be greater in the future.

Declarations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References

Conflict of interest

The Authors declare that they have no conflicts of interest to disclose.

Funding

This review received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Acknowledgements

This work was supported by Medway School of Pharmacy, Chatham, Kent, UK as part of a PhD programme.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Dispensing of Medications and Appliances
  5. Sources of Work within Community Pharmacies in England and Wales
  6. Importance of Research into Pharmacy Workload
  7. Aim and Objectives
  8. Method
  9. Results
  10. Discussion
  11. Conclusion
  12. Declarations
  13. References