Life on the job: Pharmacists concerned about workplace quality, surveys show
Most are satisfied with the profession, but significant minority’ is not
The emergence of clinical pharmacy and managed care that dominated health care at the end of this century has left pharmacists hopeful in some ways and helpless in others. Overall, major surveys by national and regional pharmacy organizations have found a nation of dedicated professionals at the staff level who believe in their profession but have serious concerns about the quality of the workplace. For hospital pharmacy directors, just keeping staff levels full has become a major challenge.
The American Pharmaceutical Association (APhA) recently conducted a nationwide survey that examined the quality of work life. APhA sent a written questionnaire to 2,014 of its members. Nearly 1,200 usable responses were returned. Researcher Patrick McHugh, PhD, assistant professor of human resources management and human relations at George Washington University, looked at six main outcomes measures: job satisfaction, career satisfaction, organizational commitment, turnover intention, likelihood of voting for a union, and patient care issues.
The survey consisted of 108 questions. Most of them focused on quality of work life issues. Twenty-one percent of the queries asked respondents to report background and demographic data, such as how many years they had been licensed and working and whether they practiced in a retail chain/supermarket, hospital/institution, independently, or in some other setting. They were asked whether they were staff pharmacists, owners, or pharmacists in charge. Age, race, gender, educational attainment, and geographic location also were considered.
"A number of different messages emerged from the study," says McHugh. "One is that the majority is satisfied, but a significant minority is not. And that dissatisfaction is across the board, in terms of practice settings. They [pharmacists] seem to enjoy the profession itself, but they might not be happy with the way the work is organized. Pharmacists are very unsatisfied with their workloads, for example."
Overall, 74% of those responding reported a positive or higher level of job satisfaction, and about 60% indicated they probably would enroll in pharmacy school again if they were beginning college today. However, the longer a respondent had been licensed, the less willing he or she was to become a pharmacist again. Staff pharmacists and pharmacists in chain/supermarket settings also were less likely to choose pharmacy again.
Pharmacists in chain/supermarket and institutional settings reported a much lower level of overall job satisfaction than those in independent or other settings such as home health care and long-term care. Pharmacists in chain/supermarket settings also indicated a higher likelihood of turnover than those in other practice settings.
Most of the respondents said they would probably not vote for a union in their current work situation if they had the choice. However, 43% of the staff pharmacists said they would vote to unionize if they were given the opportunity.
On-the-job stress
Some concerns about the quality of pharmacists’ work life differed according to practice setting, while others were issues for all kinds of pharmacists. McHugh found, for example, that at least some respondents from all practice settings indicated they did not feel they were rewarded for doing quality work, that they lacked input into workload and staffing issues, and that they couldn’t take bathroom breaks when needed.
The latter issue was a particular problem for pharmacists in retail settings, while pharmacists in both hospital and retail settings revealed concerns about the lack of input regarding staffing.
Many job stressors are related to a pharmacist’s role within a given practice setting, says Jann Skelton, PhD, APhA senior director of professional practice development. "The real issues are control of your ultimate work life and whether you are able to be an independent decision maker. So staff or employee pharmacists are more unhappy. Employee pharmacists in retail and hospitals had similar concerns. There are stressors that may be different and setting-specific, but the level of satisfaction is often related to the role and not the setting."
McHugh agrees. "For the most part, the hospital/institutional respondents seemed to answer the same way as those working in chains. The similarities are along the lines of job satisfaction, but there are deviations in the areas of turnovers and career satisfaction. Those in the chains have a lower level of career satisfaction and also indicated they were more likely to leave their jobs."
He says chain pharmacists also had a lower rating than hospital pharmacists and independents when asked whether they think their employers are willing to hear and address their concerns. It isn’t completely clear exactly what accounts for that difference, though the survey data do give some hints.
"We asked respondents different questions about their work," says McHugh. "Things like patient contact may be a factor. Chain pharmacists indicated a higher level of patient contact than hospital pharmacists, and they had more counseling issues, so that may play a role. Also, dealing with insurance issues may be part of it. Those in chain settings have to deal with that a lot more than those in hospitals. Those things might account for some of the [contrast] in the different careers."
He says more information is needed on the details of what is affecting the work life of pharmacists, including workload, quality of work, professional discretion, patient care, and insurance complications, so professional associations can start thinking about ways to improve the quality of work life while still meeting financial and business objectives.
Overall, Skelton says she is optimistic about pharmacy’s future. "This is not a doom and gloom scenario," she says. "It [the survey] identified some key areas that need addressing and also dispelled some myths that the whole world is unhappy. That is not true. I was surprised to see it wasn’t as bad as some of what we were hearing. A lot of people have serious concerns, but a lot of people are happy."
Others who know the profession well also see a good-news, bad-news scenario unfolding in pharmacy. Pharmacists are struggling to figure out what their roles are in the changing health care environment, says Dan Albrant, PharmD, a Virginia-based health care consultant. It’s a struggle that makes many pharmacists anxious and concerned. Albrant points out that those feelings can be viewed as negatives, but they also can be seen as opportunities for introspection and constructive change.
For hospital pharmacists, reimbursement issues and changing Medicare regulations are major sources of that anxiety and concern, Albrant says. "People are wondering what the government is going to do about Medicare reimbursement and whether they are going to be locked out," he explains.
"Small hospitals are being taken over by larger corporate entities, which brings up issues about billing and reimbursement. Pharmacists have made great strides in hospitals, but they are being locked out of critical decisions regarding patient care and being able to control medications in a way that makes sense to them. Directors of hospital pharmacies are pressured to control the drug budget, but they can’t control the physicians’ behavior, and the physicians don’t have any fiduciary responsibilities to consider when they prescribe. So the pharmacists are being asked to take on responsibility for things they can’t always control," he says.
On the retail side, the new on-line pharmacies are causing concerns for pharmacists who wonder if there will still be a need for them in the community. Retail pharmacists see the demise of large chains — companies they thought were on solid ground — and wonder about their job security.
Albrant says there are more issues beneath those major ones: decreasing budgets, for example. "Decreasing budgets are behind the staffing shortages. Cutting costs results in cutting staffs. In terms of pharmacy, the costs are really on the shelves, but administrators tend to cut people since they have no control over drug costs. And they [pharmacists] are expected to meet the same standards with less staff."
There is plenty of evidence that staffing shortages are a major stressor for pharmacists. A survey conducted early last year by the American Society of Health-System Pharmacists (ASHP) found a majority of pharmacy directors are having difficulties finding qualified staff.
Nearly 90% reported a moderate to severe shortage in the availability of experienced frontline practitioners, and 70% said there was a severe to moderate shortage in the number of pharmacists available for clinical specialist positions. Nearly half of the 350 pharmacy directors polled said they had vacancies, and 30% said the vacancy rate ranges from "somewhat" to "much higher" than it was five years ago.
On the retail side, the pharmacist shortage was so severe in North Carolina last summer that some stores were reportedly closing their pharmacy counters for hours or even entire days. Ironically, retail chains complain they are losing pharmacists to managed care organizations, while health system institutions say they are losing pharmacists to retail settings.
"We are seeing an exodus of pharmacists to [retail] jobs because of the incentives. There has always been a salary gap, but now it is getting more pronounced. They are offering six figures and BMWs, and institutions simply cannot compete," Skelton says.
Despite those financial incentives, APhA’s survey consistently shows chain pharmacists have serious concerns about the quality of their work lives. Albrant says some of the responsibility for that concern lies with the pharmacists, who are choosing to practice in large chains where they may get financial rewards but don’t have a lot of input into what they do. He says it isn’t a matter of needing more pharmacists, it is a matter of getting the ones already practicing into the right places.
"It is hard to get a 22-year-old to understand they have a 40-year career ahead of them, especially when someone is waving $70,000 in their face. Everyone knows they can buy pharmacists, especially young ones. So what began as a career becomes just a job, and you end up with a group of workers who are just going in there and doing their jobs. And until you get pharmacists to say they are not going to work that way, there is nothing to stop this from happening."
Another issue pharmacists may have to take responsibility for is the way they communicate with management. "Pharmacists are not proactive," says Skelton. "They have not been trained to deal with management. They call and tell me they are so upset about something; sometimes they are even crying. So I ask them if they have discussed it with their manager, and they say no. When I ask if they can think of any solutions to their problem, they say yes, of course. So it is about learning how to identify a problem and how to share suggestions to alleviate it."
"The average pharmacist is an introvert," says Albrant. "They are highly intelligent, but they have a hard time communicating. We are telling them they have to interact with human beings and sometimes they are not psychologically equipped to do that."
Albrant says newer graduates are making strides in that area, but it is more difficult for older pharmacists.
Defining clinical roles is key
There’s little doubt that pharmacists are happier when they are able to provide patient care. That may seem obvious, but getting pharmacists into positions where they can do so is a complicated proposition.
Albrant says pharmacists excel when they are allowed to function in the caregiver role, and using pharmacists in that manner pays off in immense financial savings for the institutions that employ them. But he says pharmacists today are still called upon primarily to dispense medication, with patient care as a secondary responsibility.
"The mere act of filling a prescription is something just about anyone can do. It is just about reading and counting, which are not difficult tasks for most people. Here is a group of professionals who have gone through extensive training for a profession, many of them with as much college as a physician. And you take all these bright, well-trained people and you tell them they are going to do something relatively low-level, that is, fill prescriptions, when what they are really trained to do is put that medication in context for the patient and help them manage it. That is what pharmacists should be doing."
Another survey has found when that optimal match is made, pharmacists are much happier. As published in the American Journal of Health-System Pharmacy (Am J Health-Syst Pharm 1999; 56:1,733-1,737), the survey found "a significant positive relationship between job satisfaction and perceived utilization of skills."
Researchers Emily R. Cox, PhD, of the college of Pharmacy at the University of Arizona, and Valerie Fitzpatrick, PharmD, staff pharmacist at the University Medical Center in Las Vegas, polled pharmacists practicing in institutional and ambulatory care settings in Arizona. They found that pharmacists practicing in institutional settings felt they were using their skills more than those in ambulatory care settings, and pharmacists with management titles felt they were using their skills more than those with general staff titles. Interestingly, they also found that older pharmacists reported a higher perceived use of skills than younger ones.
"Maintaining or improving job satisfaction among pharmacists is critical to the strength of the profession, given the association between job satisfaction and turnover," they write. "As a greater number of PharmD graduates enter the work force, the profession must work to ensure that pharmacists are given the opportunity to use their skills on the job. With little evidence that pharmacists’ job duties are keeping pace with the increasing level of education, the vast majority of entry-level pharmacists may not be able to obtain positions to match their newly acquired job skills."
Albrant says the profession itself is partly responsible for the career satisfaction dilemmas pharmacists are wrestling with now. In the early part of the 20th century, it moved away from patient care to focus on distribution. More emphasis was placed on the product — the medication itself — than on the medication process. He says pharmacy is now in the process of reversing itself again, and that task can be long and difficult but by no means impossible. Professional journals are full of models and recommendations, and some of the greatest opportunities go hand-in-hand with the toughest challenges created by a health system that is in constant flux.
As the health system changes and more emphasis is placed on primary care, for example, opportunities are opening for pharmacists to use their expertise as part of a primary care team. The ASHP defines primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community."
The organization defines pharmacist roles as:
• performing patient assessment for medication-related factors;
• ordering laboratory tests for monitoring outcomes of medication therapy;
• interpreting data related to medication safety and effectiveness;
• initiating or modifying medication therapy on the basis of patient responses;
• providing information, education, and counseling to patients about medication-related care;
• documenting the care provided in patients’ records;
• identifying any barriers to patient compliance;
• participating in multidisciplinary reviews of patient progress;
• communicating with payers to resolve issues that may impede access to medication therapies;
• communicating relevant issues to physicians and other team members.
How to increase your worth
ASHP also has conducted a survey supported by Eli Lilly and Company on how pharmacists in acute care settings can make more of a contribution to patient care. The recommendations include broadening the scope of pharmacy and therapeutics committees beyond formulary management, creating computerized prescription order entry systems, and enhancing the impact of medication use evaluation studies.
Surveys have found that pharmacists are happier and make the greatest contributions when they can help manage and improve the medication process. They can do that, many experts say, by drawing on their expertise to educate both patients and prescribers.
Albrant says pharmacists don’t need the right to prescribe in order to be in a position to provide education. He calls that idea "superfluous" and says the real focus should be on whether the decision to prescribe is the best possible decision.
"They need to be with the prescriber at the time of prescription. That is where they can do the best and the most effective job. They can say a drug is or is not in the patient’s best interest and help the physician to think about things in a different way. Until pharmacists can get to the place where the decision is being made, they won’t be as effective as they have the potential to be.
"Pharmacists are helping to develop the technology systems that help guide prescribers to the right decisions," he says. "They are creating systems that help analyze data better, looking at where medication errors happen and creating safer situations even as medications are getting more toxic and more dangerous. They are also becoming more computer-literate and learning how to help patients sort through all the information out there so that they can find what they need."
Albrant says pharmacists eventually may be able to function as consultants to physicians or on the Internet.
No one says turning all these possibilities into realities will be easy. There are bound to be conflicts as pharmacists expand their roles and move into new arenas in the health care system while continuing to perform their traditional task of dispensing. New, unforeseen issues are likely to arise as well. In the meantime, those daily quality-of-work-life concerns need to be addressed.
"I think the challenge is immense," says Skelton. "When we talk about solutions, you have to take one element at a time because the issues pharmacists face are so complex. There are no easy fixes. It will take a lot of parties cooperating, and we are now building those partnerships for the first time. Pharmacists are going to have to be proactive and communicate to build those partnerships and find these solutions."
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