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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 309–318
What do community pharmacists do?: results from a work sampling study in London James E. Davies, Nicholas Barber and David Taylor Department of Practice and Policy, UCL School of Pharmacy, London, UK
Keywords community pharmacy; counselling; dispensing; professional practice Correspondence Dr James E. Davies, Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK. E-mail: [email protected] Received April 4, 2013 Accepted September 19, 2013 doi: 10.1111/ijpp.12083
Abstract Objective Government and professional groups within the pharmacy have sought to extend the role of pharmacists from dispensing-focused towards the provision of further pharmaceutical services. The aim of this research was to describe how pharmacists in current English community pharmacy practice spend their time using a work sampling method. Methods Ten community pharmacies across London were purposively selected. Trained observers visited one pharmacy each to record the activities of the responsible pharmacist, using a fixed-interval work sampling technique. Activities were recorded every minute, into one of 18 predefined, piloted and tested activity codes. Data were recorded for 4 h each day for 1 week at each pharmacy during 2011. Key findings A total of 12 306 observations were recorded across the pharmacies. The pharmacists spent the majority of their time assembling and labelling products (median 25.2%; quartiles 19.0, 31.0) and monitoring prescriptions for clinical appropriateness (10.6%; 8.3, 13.0). The next most prevalent activity code was rest, waiting and breaks (8.6%; 6.9, 15.3). They spent more time offering nonprescription medicines advice (6.6%; 3.5, 7.6) than prescription medicines counselling (3.8%; 2.8, 5.6). The provision of pharmaceutical services accounted for 3.2% (0.8, 7.5) of pharmacists’ time. Overall, 46.2 % (35.2, 56.2) of their time was spent on activities deemed to be ‘Professional’. Conclusions Despite repeated attempts during the last decade to shift pharmacists’ roles towards patient-care activities, on the basis of this research, community pharmacists continue to spend the majority of their time on technical dispensing (as opposed to cognitive patient-centred) tasks.
Introduction Community pharmacy in England has undergone a transition from compounding and unregulated medicines supply at the beginning of the last century to the highly regulated and automated high-volume dispensing process of today. The birth of the National Health Service (NHS) in 1948 eroded the compounding function of community pharmacists and led to a sustained increase in prescription numbers. This was accompanied by a shift of consultations about illness away from pharmacy to the free at point of use general practice setting. This was compounded by the growth of the pharmaceutical industry which created a fundamental change in the role that pharmacists provide in primary health care, from being the creators of medicines from raw drugs towards being the guardians of safe medicines supply. This role © 2014 Royal Pharmaceutical Society
change has, according to some, been accompanied by a ‘reprofessionalisation’ of community pharmacy practice[1] engendered by the concept of pharmaceutical care.[2] Government backing for the implementation of this ‘reprofessionalisation’ thesis[3] has not been confined to England.[4] Support for the extension of the pharmacists’ role has been provided by the state in many countries, including not only English-speaking nations like New Zealand and Australia but also in European States such as the Netherlands[5–7] where successive contractual negotiations have shifted their emphasis away from medicines supply towards ‘extended’ or cognitive pharmaceutical care services. In the NHS, changes to the national contractual framework for community pharmacy in England, implemented in 2005,[8] created the opportunity for community pharmacists International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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to be paid for providing medicines use review consultations. This arguably produced the first viable opportunity for community pharmacists to use their scientific and clinical skills to greater effect. The new contract, as it became known, was intended to create a sea change in practice and spur a new generation of community pharmacy practitioners.[9] The implementation of this new contractual framework provided a major impetus for role change within the community pharmacy profession. It was followed in 2008 by a significant government white paper that set out further plans to develop the contribution of pharmacists within the NHS.[3] However, it is unknown whether such policy developments have had a direct influence on practice on the ground, or whether such changes have made a positive contribution to healthcare provision.[9]
Theoretical approach It was recognised during early industrialisation that studying the work practices of individuals could improve their efficiency and in turn produce superior organisational productivity. The essence of this position has not changed, with work measurement being applied across a range of healthcare settings to improve performance and productivity. In pharmacy settings, it has been argued that ‘the benefit to the public of pharmacists’ services. . ..is dependent on the proportion of time that is devoted to pharmaceutical tasks’.[10] The benefits of work study as a management tool in pharmacies has not gone unnoticed and has been used in both the community and hospital environments around the world[11] via a range of methodological techniques.[12–14] One commonly used work-study technique is work sampling, which has previously been applied in pharmacy,[15,16] dentistry[17] and nursing.[18] Work sampling studies collect a large number of observations recorded into predefined, mutually exclusive categories, taken at either fixed or random intervals of time.[11] If a sufficient number of samples are recorded then these can be approximated to represent the proportion of time spent on each of these predefined activities. The method has been used internationally in pharmacy practice research. Relevant examples include its use in Thailand to improve the work of pharmacists in an outpatient dispensary;[19] in the UK to evaluate the impact of automated ward-based dispensing machines on nursing tasks;[20] in the USA to help design and then evaluate a redesign of an outpatient dispensary;[21] and in South Korea to evaluate the effect of a unit dose drug distribution system.[22,23] The previous applicability of the work sampling method to the community pharmacy setting made it the work-study approach of choice for this study. The aim of the research reported here was to describe how pharmacists in current community pharmacy practice in England spend their time. In particular, this research focuses © 2014 Royal Pharmaceutical Society
Results from a work sampling study in London
on the proportion of time that pharmacists spend counselling patients on their medicines in order to allow comparison with previous studies.
Methods Setting, subject and recruitment A convenience sample of pharmacists in London was invited through local contacts to take part in this study. Demographic data on these pharmacies were collected from those that showed interest. Government market research suggests that there are broadly four main types of pharmacy in England, these are described as traditional, specialist, health and beauty-led and supermarket pharmacy.[3] It has been suggested that the proportion of time dedicated to certain activities varies across these groupings and according to ownership. In order to obtain a broadly representative sample of pharmacies, a purposive framework based on these descriptors was used to identify sites from each of these categories. For pragmatic purposes, 10 research sites were selected on this basis. In line with the data for London, half of the pharmacies were selected from large multinational chains with the remainder from the independent sector.
Observers Nine third year undergraduate pharmacy students with an interest in community pharmacy research were recruited as part of their undergraduate research projects to assist in data collection. The study coordinator and students were trained to observe and record the activities of a community pharmacist using a 1-min fixed-interval work sampling technique. With this method, observers record the activity being undertaken in a particular moment at 1-min intervals. Firstly, the observers were briefed on the method, introduced to the study and provided with background material to read. Secondly, they were given a written questionnaire to assign categories of practice to gain familiarity with the coding framework. Thirdly, the observers practiced observational techniques through coding a series of videos of community pharmacists. Discrepancies between observers were discussed until observers recoded in a consistent way. Fourthly, consistency was tested with a new video in which all observers correctly assigned more than 90% of the observations (this has been used as the standard for competency in other studies[24,25]). Finally, the study coordinator also coded with the students at different times throughout the observation period to ensure over 90% consistent coding while at the study sites. The focus of data collection was on the time spent on any given task by a single pharmacist. Therefore, only one pharmacist was observed at each time point. In order to lawfully International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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conduct a retail pharmacy business, a registered pharmacist must be in charge of the registered pharmacy and be appointed as the‘responsible pharmacist’.[26] Where two pharmacists were present, the ‘responsible pharmacist’, (the one with legal responsibility for the pharmacy) was the subject of observation. However, data about the number of other staff present during each time period was collected to allow for analysis of the effects of staff on the allocation of roles, as well as the average number of prescriptions dispensed per month (Table 2). In situations where the pharmacist was performing more than one activity simultaneously, the observers made a subjective decision about which activity predominated as practiced in previous studies.[27]
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Coding framework A framework of mutually exclusive activity categories for use in this study was created by a process of reviewing other community pharmacy work studies.[10,15,28–30] These frameworks were collated, modified and altered to bring them up to date with current English community pharmacy practice and to enable comparisons between this and previous studies. A working draft of this framework was tested in two community pharmacies outside the study area. Following this pilot, the framework was revised and reviewed by three practicing community pharmacists to create 18 mutually exclusive categories (Table 1). Activities were grouped into professional, semi-professional and non-professional activities through interpretation of a previously developed framework.[16]
Sample size Sample size was calculated on the basis of time spent on patient counselling interactions. It was estimated that 8% of the pharmacist’s time would be spent counselling as previous studies have reported that 5–10% of pharmacist’s time is spent on this activity.[11,16,28] Using the equation described by McCann et al.,[16] a total of 11 310 observations would measure an activity at this frequency with an accuracy of ±5%. Using a 1-min sampling frame, 11 310 data points represents 118.5 h of observation, or 18 h and 51 min of observation per pharmacy. Pilot work demonstrated that collecting data for longer than 4 h per day was unfeasible due to observer fatigue. Therefore, observers took 5-min breaks every 30 min, giving a total time of approximately 4 h and 35 min for every 4 h of observation. A data collection matrix was created to ensure an even spread of data collection across the working week and the opening times of the pharmacy. For some pharmacies this necessitated data collection at the weekends, early morning and late evening to ensure an even spread of data. Data collection took place in March 2011. Data collection forms were used by the observers to record activities according to the coding framework. Stopwatches and digital metronomes (audible only to the observers) were used to measure the 1-min intervals. The observers remained as inconspicuous as possible to prevent their presence influencing the pharmacists’ activities. There was very limited interaction between the pharmacist and the observer, although on occasion the observer may have clarified the pharmacist’s activities at the end of an observation session. The first session of data collection at each site was discarded to allow the pharmacists to become comfortable with being observed and to help mitigate the Hawthorne effect. For this reason, observers continued to visit the same pharmacy throughout the study to ensure familiarity and to help limit any observer effect. © 2014 Royal Pharmaceutical Society
Data analysis The data were entered into Microsoft Excel and analysed with PASW Statistics 18 (SPSS Inc., Chicago, IL, USA) where the number of observations for each activity were expressed as a proportion of the total number of observations. Where the proportion of time spent on activities was found to be nonnormally distributed between the pharmacies, median and interquartile range were reported.
Ethics Participants who were invited to participate were assured of their anonymity and it was explained that the collective, as opposed to individual results would be analysed. The pharmacists all provided consent to be observed. Institution ethical approval was received (REC/B/10/03).
Results A total of 12 306 observations were recorded in 10 community pharmacies across London over a 2-week period. Data collection predominately took place Monday to Friday (n = 11886, 96.6%). However, some data were captured on Saturday (Pharmacy 2, n = 240, 1.95%) and Sunday (Pharmacy 10, n = 180, 1.46%). All of the pharmacies were open for at least the core hours of 9 a.m.–6 p.m. Monday to Friday, with data collection spread across the opening hours (Range: 7 a.m.–10:30 p.m.). Overall, seven coding categories accounted for three quarters of all pharmacists’ time (Figure 1): assembling and labelling of products (median 25.2%; quartiles 19.0, 31.0); prescription monitoring and appropriateness (10.6%; 8.3, 13.0); rest, waiting and personal time (8.6%; 4.8, 11.4); endorsing and health-related clerical work (8.7%; 4.8, 11.4); non-professional encounters (4.1%; 2.4, 11.1); counselling International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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Table 1
Results from a work sampling study in London
Coding framework
Activity
Classification
1 Prescription monitoring and appropriateness Interpretation of the prescription including checking the correctness of the dispensed item. Includes checking the indication for drug, suitability for patient, e.g. interactions with other medicines; appropriate dose of each medication; contacting the prescriber if necessary. Includes ensuring that the product is dispensed as prescribed, e.g. checking any product assembled by dispensary technicians, as well as the legality of prescription. 2 Assembly and labelling of products Includes the assembly of the product requested on the prescription and generating labels for the container of that product. The process of assembling a prescription item from receipt to the final assembly of the product, including the endorsement and filling of an individual prescription. 3 Endorsing prescriptions and clerical health-related work Includes preparing the end of month returns to the Prescription Pricing Authority, coding prescriptions etc., directly related to health provision. 4 Counselling patients on prescribed medicines Includes personally giving out the medication to the patient and providing information on disease state, medicines supplied, side effects, dose etc. 5 Non-prescription medicines counselling/responding to symptoms Includes listening to any problems, advising on problems either to patients or counter staff, recommending a non-prescription medicine or referring the patient to a General Practitioner (GP). 6 Professional encounter with non-patients Discussing new drugs with company representatives, contacting the Prescription Pricing Authority etc. 7 Health-related communication An activity or function that involves any aspect of health provision, written or verbal, that is not direct counselling to patient, including advice to GPs. 8 Provision of advanced services This relates specifically to Medicines Use Reviews 9 Provision of enhanced or other National Health Service services Conducting any additional services that are provided by the pharmacy, e.g. medicines supplied via Patient Group Direction (emergency contraception, smoking cessation advice etc.). 10 Provision of private enhanced services Conducting any additional services that are provided by the pharmacy e.g. medicines supplied via Private Patient Group Direction or paid for vaccinations. 11 Provision of services to homes As 1 and 2 but directly related to residential and nursing homes. 12 Inventory and stock control Includes stock maintenance of prescription-only medicines (dispensary) and non-prescription medicines (counter) or of non-medicinal products (perfumes/baby products etc.). 13 Staff training and education Includes any training given to new and existing staff, work experience students, e.g. formal training for dispensary staff. 14 Housekeeping Includes general maintenance and cleaning of the work place including merchandising of dispensary or non-dispensary areas. 15 Sales transactions The selling of goods between vendor and purchaser, for non-health-related products, such as perfumes. 16 Money and managerial administration Includes all clerical work such as dealing with mail, filing etc, an activity not involving any aspect of health care. Functions that the person in charge must do for the business to run effectively. Includes wages, tax returns, balancing cash at the end of the day etc. 17 Rest, waiting and personal time Includes lunch and tea breaks, resting and toilet breaks etc. or time when the pharmacist is being unproductive. 18 Non-professional encounters Includes gossip and general chat with non-professionals, e.g. talking about the weather with a customer. Advising customers on non-healthcare-related products e.g. perfumes.
Professional
© 2014 Royal Pharmaceutical Society
Semi-professional
Professional
Professional
Professional
Professional Professional
Professional Professional
Professional
Professional Non-professional
Professional
Non-professional
Non-professional Semi-professional
Non-professional Non-professional
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Percentage on Activities
50.00
40.00
30.00
20.00
10.00
Figure 1
Non-professional encounters
Rest
Money and managerial
Housekeeping
Sales transactions
Staff training
Stock control
Nursing home
Private services
Advanced services
Enhanced services
Healthcare-related communication
Professional encounters with non-patients
Counselling prescribed medicines
Counselling non-prescription medicines
Assembly and labelling of products
Endorsing and health-related clerical
Prescription monitoring and appropriateness
0.00
Box plot of activity codes.
non-prescribed medicines (6.6%; 3.5, 7.6); and counselling prescribed medicines (3.8%; 2.8, 5.6). About 25 h of the responsible pharmacists’ time is spent each week dedicated to prescription-related matters (see Table 2). Stock control activities accounted for 3.4% (2.1, 5.2) of the pharmacists’ time. Often, this was unpacking and checking the delivery and managing the stock within the pharmacy. In the two pharmacies that provided services to nursing homes, this accounted for less than a twentieth of the pharmacists’ time (5.08% and 3.83%). To facilitate interpretation activity, categories were combined under broad themes (e.g. counselling) as shown in Table 3. The two categories for counselling accounted for 12.4% (7.5, 13.3) of the pharmacists’ time. The pharmacists spent a larger proportion of their time offering counter advice on non-prescription medicines as opposed to prescription medicines. In total, the provision of clinical services accounted for about a twentieth of pharmacists’ time although the range across sites was between 0.2% and 15%. The category for extended services (which include advanced, enhanced and private services), which have been at the centre of developments in the community pharmacists’ role, were © 2014 Royal Pharmaceutical Society
found to account for the smallest proportion of pharmacists’ time (Table 3). Using the framework defined by McCann et al.,[16] the activities of the pharmacists were separated into professional, semi-professional and non-professional activities (Table 4).
Discussion This London-based work sampling study suggests that community pharmacists spend the majority of their time on supply-based processes, which account for nearly two-fifths of their working day. Pharmacists spent more time offering non-prescription medicines advice than prescription medicines counselling and less than a twentieth of their time on the provision of pharmaceutical services.
Strengths and limitations of the research Over 12 000 data points were recorded in this study. This large number of observations over a sufficient period of time was required in order to provide confidence in the inferences made from the results.[18] Yet one of the weaknesses of this International Journal of Pharmacy Practice 2014, 22, pp. 309–318
© 2014 Royal Pharmaceutical Society
3*
10
10a Manager 10b Regular 10c Locum
9a Regular 9b Regular
8a Regular
7a Owner
Female Female Male
Male Male
Male
Male
Male Male Male
Female
5b Locum
6a Manager 6b Locum 6c Locum
Female Male Male Female Female
Female Female
Female Female
Male
Pharmacist gender
4a Locum 4b Locum 4c Locum 4d Locum 5a Regular
3a Regular 3b Locum
2a Owner 2b Locum
1a regular
Pharmacist status and code
27 27 34
50 29
34
49
30 30 70
55
32 39 58 27 31
30 27
60 32
32
Pharmacist estimated age/years
0.81 0 2.36 0 0 1.6 6 1 1 0 0.4 1 1 1.82 0 1 0 0.38 0.64 0.74
0 0 1.12 0
1.93 0 0.18 0.95 0 0 2.5 0 0 0 1.81 1 0 0.36 1.17 0
Mean number of: technicians; dispensers; counter assistants; Pre-registration students*
3500
3500
4000
12 000
4000
4500
4000
4000
4000
3500
Mean monthly prescription volume/items
Supermarket
Specialist
Specialist
Traditional
Health and beauty
Supermarket
Supermarket
Specialist
Health and beauty
Specialist
Pharmacy type
Monday–Friday: 9 a.m.–8 p.m. Saturday: 9 a.m.–8 p.m.
Monday–Friday: 9 a.m.–6:15 p.m. Saturday: 10 a.m.–4 p.m.
Monday–Friday: 9 a.m.–6 p.m. Saturday: 10 a.m.–2 p.m.
Monday–Friday: 9 a.m.–7:30 p.m. Saturday: 9 a.m.–7 p.m. Sunday: 10 a.m.–2 p.m.
Monday: 8 a.m.–10:30 p.m. Tuesday–Friday: 6:30 a.m.–10:30 p.m. Saturday: 6:30 a.m.–10 p.m. Sunday: 10 a.m.–4 p.m. Monday–Friday: 9 a.m.–7 p.m. Saturday: 9 a.m.–7 p.m.
Monday–Friday: 9 a.m.–6 p.m. Saturday: 9 a.m.–6 p.m.
Monday–Friday: 9 a.m.–6 p.m. Saturday: 10 a.m.–4 p.m.
Monday–Friday: 8:30 a.m.–6:30 p.m. Saturday: 9 a.m.–1 p.m.
Monday–Friday: 9 a.m.–7 p.m. Saturday: 10 a.m.–3 p.m.
Opening hours
NB. * The data refer to the average/number of staff observed during the observational study periods and does not reflect the number of staff actually employed by a pharmacy.
2
9
3*
6
1
2*
5
8
4
4
1
2
3
7
2
2
Pharmacy
1
Number of pharmacists observed
1
Demographic data
Table 2
314 Results from a work sampling study in London
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Table 3
315
Combined activity codes
Activities (activity codes)
Median (quartiles)
Prescription related matters (1 + 2) Non-counselling communication (6 + 7 + 13 + 18) Rest waiting and personal time (17) Counselling (4 + 5) Premises (12 + 14 + 15 + 16) Health administration (3) Services (8 + 9 + 10 + 11)
39.6% (35.5, 44.5) 15.1% (13.5, 18.2) 8.6% (6.9, 15.3) 12.4% (7.5, 13.3) 8.6% (6.9, 15.3) 8.7% (4.8, 11.4) 3.2% (0.8, 7.5)
approach is that the data do not provide any detail on the quality of consultations or services; only the amount of time as a proportional estimate. Only pharmacists were observed, which may have ignored the beneficial effect of counselling that was provided by other pharmacy staff under their supervision. Fixed interval sampling, used here, is comparable to random interval sampling because of the non-cyclical nature of community pharmacists’ work.[31] Fixed-interval sampling is also simpler and cheaper because specialised random generation devices are not required. Self-reported work sampling, which has been used in other community pharmacy studies, may interrupt the workflow in the pharmacy and hence lead to poor quality data. Therefore, discrete direct observation helped to limit this bias. Pharmacy students were chosen as observers because they have been used in previous studies,[24,32] and are familiar with the work of pharmacists; an important factor in work sampling.[24] However, despite the extensive training and supervision of coding undertaken by the observers, there was still opportunity for interobserver variance in recording activities as well as the confounding factors of observer bias and the Hawthorne effect. The subjective categorisation approach adopted by the observers when the pharmacists were performing more than one activity is one example. However, it was reported that this only happened infrequently, and therefore its effects on the results should not be overstated. The observers also interacted with the pharmacists, which may have altered their practice. This was kept to a minimum and is arguably less intrusive than self-report approaches. The results suggest that a greater proportion of pharmacists’ time was spent counselling at the weekend. There was notable variation in counselling across the different days of the week.[29] Sunday saw a large amount of time apportioned to non-prescription medicines counselling, which may be due to reduced prescription numbers at the weekend and the fact that access to other healthcare settings is restricted. However, proportionally, data capture over the weekend was limited compared with other days of the week, which may have led to an overall under representation of counselling activities in the amalgamated data that considers the whole week. © 2014 Royal Pharmaceutical Society
In a similar vein, the pharmacists were only observed for short 4-h time periods. Extended pharmaceutical activities, which account for only a small proportion of the pharmacists’ time may not have been witnessed by the observers, although this does not necessarily mean that they were not taking place. Also activities, such as the time spent on endorsement of prescriptions and health-related clerical work, may have been increased by data collection taking place near the end of the month when prescriptions are sorted for submission to the pricing authority. The pharmacies were purposively selected within a convenience sample and therefore include an inherent recruitment bias in that poorly performing pharmacists are unlikely to volunteer for research. In addition, independent pharmacies were overrepresented in the sample when compared with the national picture because London has a higher proportion of independently owned pharmacies. Taking these points into consideration, the results cannot be said to be generalisable beyond the London area, especially as the sample of pharmacies was small, and those selected had below average prescription volumes when compared with national figures.
Counselling patients Time spent on counselling activities in this study was the same as the proportion observed in England in the late 1990s[24,29] and similar to that recorded in more recent work log studies,[33] suggesting little change in the proportion of time attributed to this activity. Conversely, in Northern Ireland, two studies undertaken 10 years apart found a significant reduction in the amount of time spent handing out prescriptions and counselling.[15,16] On the one hand, the proportion of time spent counselling has remained static, despite policies to encourage pharmacists to spend more time on direct patient care. Conversely, pharmacists continue to spend the same proportion of their time counselling despite a 300 million prescription item increase in workload over the last decade.[34] Overall, this suggests that the average time spent counselling per prescription item has decreased. In the research reported here, a greater proportion of time was attributed to counselling non-prescription medicines use as opposed to prescribed medicines use. Non-prescription medicines counselling is reactive and limited by the number of patients seeking advice at any one time. This sampling category covered the whole interaction, including responding to symptoms, which may require both diagnosis as well as medicines counselling advice. The increased proportions may also be a reflection that over the counter medicines are becoming more complex and require a greater degree of support.[35] By contrast, counselling patients taking prescription medicines is often proactive. Patients often collect chronic disease medication and therefore pharmacists will have multiple opportuInternational Journal of Pharmacy Practice 2014, 22, pp. 309–318
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Table 4
Results from a work sampling study in London
Activity categorisations
Activities (activity codes)
Median % (quartiles)
McCann et al.[16] (mean %)
Professional (1 + 3 + 4 + 5 + 6 + 7 + 8 + 9 + 10 + 11 + 13) Semi-professional (2 + 16) Non-professional (12 + 14 + 15 + 17 + 18)
46.2 (35.2, 56.2) 28.5 (22.7, 34.9) 23.7 (15.8, 30.0)
49 % 31% 20%
nities to counsel on prescribed medications. Indeed, patients may not need advice on every supply. US studies suggest that the likelihood that a patient will receive counselling is not related to staffing levels, automation or workload, but instead to public perceptions and expectations[36] as well as the practice habits of the pharmacists.[37] This may explain the heterogeneous and wide ranging results reported here.
Pharmaceutical services It was expected that more than a twentieth of the pharmacists’ time would be spent on advanced services as it has been reported that pharmacists have a desire to spend more time on consultation activities.[38,39] However, this observation may reflect a lack of opportunity or may be skewed by the pharmacies sampled in this study, as several did not complete a single Medicines Use Review (MUR) during the observation period. Meanwhile, national data revealed that in England approximately 50 000 MURs were completed during the study period.[40] At best, the average pharmacist would be unlikely to spend more that about 6.5 h (equivalent to a tenth of their time) each week on MURs because the mean time to complete an MUR is 51 min[41] and the NHS contractual framework for community pharmacy imposes a limit for each contractor of 400 MURs per annum (equivalent to approximately eight per week).
considerable differences in the organisation and structure of processes within the pharmacies, which may have influenced how the pharmacists apportion their time. In particular, it appeared that the willingness of the pharmacists to pass responsibilities to other staff[37,44,45] had an influence on the management of their time.
Implications for practice and policy Overall, the proportion of time attributed to each of the ‘professional’, ‘non-professional’ and ‘semi-professional’ categories remains comparable to that of previous UK-based studies (Table 4). Pharmacists continue to spend the majority of their time dispensing and checking prescriptions.[16,33] This observation is not limited to England; the dominance of this activity in pharmacist’s daily work has been reported in studies around the world.[4,38,39,46–48] The disproportionate influence of dispensing on pharmacists’ roles was described in English studies conducted in the late nineties, which concluded that the time dedicated to dispensing could be better ‘utilised’ for clinical activities.[29] This is in keeping with a series of work sampling studies conducted a decade apart in Belfast, Northern Ireland.[15,16] The evidence presented here, while limited in sample size, does suggest policies aimed at encouraging a greater proportion of pharmacists’ time to be spent on patient counselling and pharmaceutical services have failed to appreciably change pharmacists’ activities.
Rest, waiting and personal time In this study, pharmacists were observed to spend just over a tenth of their time on rest, waiting and personal activities, comparable to the 14.1% observed by Rutter et al.[24] and in keeping with the unproductive time found in other professions.[18,42] Regular rest breaks are recommended to prevent accumulation of accident risk during sustained activities.[43] Therefore, having appropriate rest breaks is an important parameter for patient safety and is beneficial to patients. The coding framework did not allow a differentiation between rest and waiting time. The observers reported that often this category was time spent waiting for others to complete tasks prior to being checked, or for access to computer terminals rather than a physical rest break. This suggests that work process within the pharmacy could be streamlined to reduce this wastage and to improve efficiency. The wide range of time observed within this category suggest some © 2014 Royal Pharmaceutical Society
Conclusions British (and international) health policy has called for better utilisation of the skills of community pharmacists building on the positive experiences of pharmacy practice in hospital settings. However, the evidence presented here suggests that overall; the proportion of time that pharmacists spend on different activities has remained fairly static over the course of the last decade. This research shows that the dispensing of prescriptions continues to dominate practice, despite the desire within the profession for role change. While accepting that practice change will be evolutionary, rather than revolutionary, at the current pace it will be many decades before community pharmacists’ skills are properly implemented into primary health care. There remains scope for community pharmacists to use appropriate process control, staffing and automation to delegate tasks in order to International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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release time for pharmaceutical care activities. The ability to move responsibility in the pharmacy and allocate pharmacists’ time to tasks that cannot be delegated requires the entrenchment of current roles and responsibilities in community pharmacy to be overcome. On this basis, further research is required to understand why the implementation of these policies have not been realised, and to further discover why pharmacists have not moved beyond the traditional dispensing role.
Declarations Conflict of interests The authors have no financial relationship with any of the organisations that might have an interest in the submitted work in the previous 3 years.
Mansoor Hashemi, Umara Uddin, Zainab Shafiq and Sarah Khan for their invaluable help in data collection and entry. We would also like to thank all of the pharmacists and their staff that took part in this study.
Authors’ contributions (ICMJE statement on authorship) JD was the lead for the research. All authors contributed to the design and development of the study and assisted in the analysis of the research. JD wrote the first draft of the paper and all authors contributed to successive drafts. All authors read and approved the final manuscript. All Authors state that they had complete access to the study data that support the publication.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgements We would like to thank Saira Aslam, Folake Olafare, Rukeya Begum, Thusanth Thayaparan, Gursharan Sira, Mohammad
References 1. Edmunds J, Calnan MW. The reprofessionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacists amongst pharmacists and General Practioners in the United Kingdom. Soc Sci Med 2001; 53: 943– 955. 2. Hepler C, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533–543. 3. Department of Health, Pharmacy in. England: Building on Strengths – Delivering the Future. (Cm 7341). London: The Stationary Office, 2008. 4. Schommer JC et al. Community pharmacists’ work activities in the United States during 2000. J Am Pharm Assoc 2002; 42: 399–406. 5. New Zealand Ministry of Health, Medicines New Zealand. Contributing to Good Health Outcomes for All New Zealanders. Wellington: Ministry of Health, 2007.
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Ethical approval The study received institutional ethical approval from the School of Pharmacy, University of London ethics committee (REC/B/10/03), plus local agreement from all pharmacies involved in the research. This committee has since been replaced by UCL ethics committee.
6. Australian Goverment & The Pharmacy Guild of Australia. The Fifth community pharmacy agreement between the commonwealth of Australia and the Pharmacy Guild of Australia. 2010. 7. Bouvy M et al. White Paper on pharmacy in the Netherlands: position on pharmacy, pharmacists and pharmacy practice, ed. R.D.P. Association. 2011: KNMP. 8. PSNC. The New Contract for Community Pharmacy. London: Pharmaceutical Services Negotiating Committee, 2004. 9. Blenkinsopp A et al. National Evaluation of the New Community Pharmacy Contract. London: Pharmacy Practice Research Trust, 2009. 10. Fisher CM et al. Study of community pharmacy practice. Part 1. Pharmacists’ work patterns. J Soc Adm Pharm 1991; 8: 15–24. 11. Savage I. The changing face of pharmacy practice – evidence from 20 years of work sampling studies. Int J Pharm Pract 1999; 7: 209–219.
12. Emmerton L, Jefferson K. Work sampling observations of community pharmacists: a review. Int J Pharm Pract 1996; 4: 75–78. 13. Rutter PM et al. Pharmacy research: the place of work measurement. Int J Pharm Pract 1998; 6: 46–58. 14. Rascati KL et al. Work measurement in pharmacy research. Am J Hosp Pharm 1986; 43: 2445–2452. 15. Bell HM et al. A self-reported work sampling study in community pharmacy practice. Pharm World Sci 1999; 21: 210–216. 16. McCann L et al. A self-reported worksampling study in community pharmacy practice: a 2009 update. Pharm World Sci 2010; 32: 536–543. 17. Marklin RW, Cherney K. Working postures of dentists and dental hygienists. J Calif Dent Assoc 2005; 33: 133–136. 18. Ampt A et al. A comparison of selfreported and observational work sampling techniques for measuring time in nursing tasks. J Health Serv Res Policy 2007; 12: 18–24.
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19. Ploylearmsang C et al. Standard time of an outpatient prescription processing at Samut Sakhon Hospital. AACP Annual Meeting, 2003. 104(Jul). 20. Ardern-Jones J et al. The impact of the introduction of a ward-based automated medicines vending unit on nursing tasks and time in the Emergency Department. Int J Pharm Pract 2009; 17: 345–349. 21. Lin AC et al. Re-engineering a pharmacy work system and layout to facilitate patient counseling. Am J Health Syst Pharm 1996; 53: 1558– 1564. 22. Ryu S et al. Evaluation of unit dose system for parenteral medication: experience of Asan Medical Center. ASHP Midyear Clinical Meeting, 2002. 37(Dec): p. intl-l-24. 23. Ryu SG, Kim JT. Unit dose system for parenteral nutrition; Implementation and evaluation. ASHP Midyear Clinical Meeting, 2003. 38(Dec): p. INTL-L-18. 24. Rutter PM et al. Validation of a subjective evaluation study using work sampling. J Soc Adm Pharm 1999; 16: 174– 185. 25. Rascati KL et al. Multidimensional work sampling to evaluate the effects of computerization in an outpatient pharmacy. Am J Hosp Pharm 1987; 44: 2060–2067. 26. General Pharmaceutical Council. Guidance for Responsible Pharmacists. London: GPhC, 2010. http://www .pharmacyregulation.org/sites/default/ files/GPhC%20Responsible%20 pharmacist%20guidance.pdf (accessed April 2013). 27. Summerfield M et al. Determining staffing requirements in institutional pharmacy. Am J Health Syst Pharm 1978; 35: 1487–1495. 28. Savage I. Time for prescription and OTC advice in independant community practice. Pharm J 1997; 258: 873– 877. 29. Rutter P et al. Subjective evaluation of how community pharmacists in Great
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30.
31.
32.
33.
34.
35.
36.
37.
38.
Britain spend their time. J Soc Adm Pharm 1998; 15: 252–261. Dupclay L, Jr et al. Analysis of grocery chain pharmacists’ work-related behaviors. J Am Pharm Assoc 1999; 39: 74–81. Dickson W. Measuring pharmacist time use: a note on the use of fixedinterval work sampling. Am J Health Syst Pharm 1978; 35: 1241–1243. Nelson AA, Jr et al. Task analysis of a pharmacist’s activities in a 45-bed rural hospital with comprehensive pharmaceutical services. Am J Hosp Pharm 1977; 34: 1063–1068. Bond C et al. The effect of the new community pharmacy contract on the community pharmacy workforce, ed. Pharmacy Practice Research Trust. Univerisity of Aberdeen, Keele Univeristy, Webstar Health. 2008. http://www.pharmacyresearchuk.org/ waterway/wp-content/uploads/ 2012/11/The_effect_of_the_new _community_pharmacy_contract _on_the_community_pharmacy _workforce.pdf (accessed November 2013). The NHS information Centre Prescribing Support Unit. Prescriptions Dispensed in the Community: England, Statistics for 1999 to 2009. London: Department of Health, 2010. Department of Health, Self Care – A Real Choice. Self Care Support – A Practical Option. London: Department of Health, 2005. Schommer JC, Wiederholt JB. Pharmacists’ perceptions of patients’ needs for counseling. Am J Hosp Pharm 1994; 51: 478–485. Angelo LB et al. Impact of community pharmacy automation on workflow, workload and patient interaction. J Am Pharm Assoc 2005; 45: 138–144. Schommer JC et al. Pharmacists’ desired and actual times in work activities: evidence of gaps from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc 2006; 46: 340–347.
39. Scott DM. 2006 North Dakota pharmacists’ wage and workload assessment. J Pharm Technol 2009; 25: 14–23. 40. NHS Prescription Services. MUR statistics. Jan 2012. 2012. http://psnc .org.uk/funding-and-statistics/nhsstatistics/mur-statistics/ (accessed November 2013). 41. Blenkinsopp A et al. Community pharmacists’ experience of providing medicines use reviews: findings from the national evaluation of the community pharmacy contractual framework. Int J Pharm Pract 2007; 15(Suppl. 2): B45– B46. 42. Westbrook JI, Ampt A. Design, application and testing of the Work Observation Method by Activity Timing (WOMBAT) to measure clinicians’ patterns of work and communication. Int J Med Inform 2009; 78S: S25–S33. 43. Tucker P et al. Rest breaks and accident risk. The Lancet 2003; 361: 680. 44. Mobach M. The general pharmacy work explored in The Netherlands. Pharm World Sci 2008; 30: 353–359. 45. Mobach MP. The counter and consultation room work explored in the Netherlands. Pharm World Sci 2008; 30: 360– 366. 46. Fleming H. No rest for the weary. Drug Top 1999; 143: 50–56. 47. Midwest Pharmacy Workforce Research Consortium. 2009 National Pharmacist Workforce Survey : final report of the 2009 national sample survey of the pharmacist workforce to determine contemporary demogrpahic and practice characteristics. Midwest Pharmacy Workforce Research Consortium: Pharmacy Manpower Project, Inc. 2010. 48. Alderman CP, Farmer C. A brief analysis of clinical pharmacy interventions undertaken in an Australian teaching hospital. J Qual Clin Pract 2001; 21: 99–103.
International Journal of Pharmacy Practice 2014, 22, pp. 309–318
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 309–318
What do community pharmacists do?: results from a work sampling study in London James E. Davies, Nicholas Barber and David Taylor Department of Practice and Policy, UCL School of Pharmacy, London, UK
Keywords community pharmacy; counselling; dispensing; professional practice Correspondence Dr James E. Davies, Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK. E-mail: [email protected] Received April 4, 2013 Accepted September 19, 2013 doi: 10.1111/ijpp.12083
Abstract Objective Government and professional groups within the pharmacy have sought to extend the role of pharmacists from dispensing-focused towards the provision of further pharmaceutical services. The aim of this research was to describe how pharmacists in current English community pharmacy practice spend their time using a work sampling method. Methods Ten community pharmacies across London were purposively selected. Trained observers visited one pharmacy each to record the activities of the responsible pharmacist, using a fixed-interval work sampling technique. Activities were recorded every minute, into one of 18 predefined, piloted and tested activity codes. Data were recorded for 4 h each day for 1 week at each pharmacy during 2011. Key findings A total of 12 306 observations were recorded across the pharmacies. The pharmacists spent the majority of their time assembling and labelling products (median 25.2%; quartiles 19.0, 31.0) and monitoring prescriptions for clinical appropriateness (10.6%; 8.3, 13.0). The next most prevalent activity code was rest, waiting and breaks (8.6%; 6.9, 15.3). They spent more time offering nonprescription medicines advice (6.6%; 3.5, 7.6) than prescription medicines counselling (3.8%; 2.8, 5.6). The provision of pharmaceutical services accounted for 3.2% (0.8, 7.5) of pharmacists’ time. Overall, 46.2 % (35.2, 56.2) of their time was spent on activities deemed to be ‘Professional’. Conclusions Despite repeated attempts during the last decade to shift pharmacists’ roles towards patient-care activities, on the basis of this research, community pharmacists continue to spend the majority of their time on technical dispensing (as opposed to cognitive patient-centred) tasks.
Introduction Community pharmacy in England has undergone a transition from compounding and unregulated medicines supply at the beginning of the last century to the highly regulated and automated high-volume dispensing process of today. The birth of the National Health Service (NHS) in 1948 eroded the compounding function of community pharmacists and led to a sustained increase in prescription numbers. This was accompanied by a shift of consultations about illness away from pharmacy to the free at point of use general practice setting. This was compounded by the growth of the pharmaceutical industry which created a fundamental change in the role that pharmacists provide in primary health care, from being the creators of medicines from raw drugs towards being the guardians of safe medicines supply. This role © 2014 Royal Pharmaceutical Society
change has, according to some, been accompanied by a ‘reprofessionalisation’ of community pharmacy practice[1] engendered by the concept of pharmaceutical care.[2] Government backing for the implementation of this ‘reprofessionalisation’ thesis[3] has not been confined to England.[4] Support for the extension of the pharmacists’ role has been provided by the state in many countries, including not only English-speaking nations like New Zealand and Australia but also in European States such as the Netherlands[5–7] where successive contractual negotiations have shifted their emphasis away from medicines supply towards ‘extended’ or cognitive pharmaceutical care services. In the NHS, changes to the national contractual framework for community pharmacy in England, implemented in 2005,[8] created the opportunity for community pharmacists International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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to be paid for providing medicines use review consultations. This arguably produced the first viable opportunity for community pharmacists to use their scientific and clinical skills to greater effect. The new contract, as it became known, was intended to create a sea change in practice and spur a new generation of community pharmacy practitioners.[9] The implementation of this new contractual framework provided a major impetus for role change within the community pharmacy profession. It was followed in 2008 by a significant government white paper that set out further plans to develop the contribution of pharmacists within the NHS.[3] However, it is unknown whether such policy developments have had a direct influence on practice on the ground, or whether such changes have made a positive contribution to healthcare provision.[9]
Theoretical approach It was recognised during early industrialisation that studying the work practices of individuals could improve their efficiency and in turn produce superior organisational productivity. The essence of this position has not changed, with work measurement being applied across a range of healthcare settings to improve performance and productivity. In pharmacy settings, it has been argued that ‘the benefit to the public of pharmacists’ services. . ..is dependent on the proportion of time that is devoted to pharmaceutical tasks’.[10] The benefits of work study as a management tool in pharmacies has not gone unnoticed and has been used in both the community and hospital environments around the world[11] via a range of methodological techniques.[12–14] One commonly used work-study technique is work sampling, which has previously been applied in pharmacy,[15,16] dentistry[17] and nursing.[18] Work sampling studies collect a large number of observations recorded into predefined, mutually exclusive categories, taken at either fixed or random intervals of time.[11] If a sufficient number of samples are recorded then these can be approximated to represent the proportion of time spent on each of these predefined activities. The method has been used internationally in pharmacy practice research. Relevant examples include its use in Thailand to improve the work of pharmacists in an outpatient dispensary;[19] in the UK to evaluate the impact of automated ward-based dispensing machines on nursing tasks;[20] in the USA to help design and then evaluate a redesign of an outpatient dispensary;[21] and in South Korea to evaluate the effect of a unit dose drug distribution system.[22,23] The previous applicability of the work sampling method to the community pharmacy setting made it the work-study approach of choice for this study. The aim of the research reported here was to describe how pharmacists in current community pharmacy practice in England spend their time. In particular, this research focuses © 2014 Royal Pharmaceutical Society
Results from a work sampling study in London
on the proportion of time that pharmacists spend counselling patients on their medicines in order to allow comparison with previous studies.
Methods Setting, subject and recruitment A convenience sample of pharmacists in London was invited through local contacts to take part in this study. Demographic data on these pharmacies were collected from those that showed interest. Government market research suggests that there are broadly four main types of pharmacy in England, these are described as traditional, specialist, health and beauty-led and supermarket pharmacy.[3] It has been suggested that the proportion of time dedicated to certain activities varies across these groupings and according to ownership. In order to obtain a broadly representative sample of pharmacies, a purposive framework based on these descriptors was used to identify sites from each of these categories. For pragmatic purposes, 10 research sites were selected on this basis. In line with the data for London, half of the pharmacies were selected from large multinational chains with the remainder from the independent sector.
Observers Nine third year undergraduate pharmacy students with an interest in community pharmacy research were recruited as part of their undergraduate research projects to assist in data collection. The study coordinator and students were trained to observe and record the activities of a community pharmacist using a 1-min fixed-interval work sampling technique. With this method, observers record the activity being undertaken in a particular moment at 1-min intervals. Firstly, the observers were briefed on the method, introduced to the study and provided with background material to read. Secondly, they were given a written questionnaire to assign categories of practice to gain familiarity with the coding framework. Thirdly, the observers practiced observational techniques through coding a series of videos of community pharmacists. Discrepancies between observers were discussed until observers recoded in a consistent way. Fourthly, consistency was tested with a new video in which all observers correctly assigned more than 90% of the observations (this has been used as the standard for competency in other studies[24,25]). Finally, the study coordinator also coded with the students at different times throughout the observation period to ensure over 90% consistent coding while at the study sites. The focus of data collection was on the time spent on any given task by a single pharmacist. Therefore, only one pharmacist was observed at each time point. In order to lawfully International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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conduct a retail pharmacy business, a registered pharmacist must be in charge of the registered pharmacy and be appointed as the‘responsible pharmacist’.[26] Where two pharmacists were present, the ‘responsible pharmacist’, (the one with legal responsibility for the pharmacy) was the subject of observation. However, data about the number of other staff present during each time period was collected to allow for analysis of the effects of staff on the allocation of roles, as well as the average number of prescriptions dispensed per month (Table 2). In situations where the pharmacist was performing more than one activity simultaneously, the observers made a subjective decision about which activity predominated as practiced in previous studies.[27]
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Coding framework A framework of mutually exclusive activity categories for use in this study was created by a process of reviewing other community pharmacy work studies.[10,15,28–30] These frameworks were collated, modified and altered to bring them up to date with current English community pharmacy practice and to enable comparisons between this and previous studies. A working draft of this framework was tested in two community pharmacies outside the study area. Following this pilot, the framework was revised and reviewed by three practicing community pharmacists to create 18 mutually exclusive categories (Table 1). Activities were grouped into professional, semi-professional and non-professional activities through interpretation of a previously developed framework.[16]
Sample size Sample size was calculated on the basis of time spent on patient counselling interactions. It was estimated that 8% of the pharmacist’s time would be spent counselling as previous studies have reported that 5–10% of pharmacist’s time is spent on this activity.[11,16,28] Using the equation described by McCann et al.,[16] a total of 11 310 observations would measure an activity at this frequency with an accuracy of ±5%. Using a 1-min sampling frame, 11 310 data points represents 118.5 h of observation, or 18 h and 51 min of observation per pharmacy. Pilot work demonstrated that collecting data for longer than 4 h per day was unfeasible due to observer fatigue. Therefore, observers took 5-min breaks every 30 min, giving a total time of approximately 4 h and 35 min for every 4 h of observation. A data collection matrix was created to ensure an even spread of data collection across the working week and the opening times of the pharmacy. For some pharmacies this necessitated data collection at the weekends, early morning and late evening to ensure an even spread of data. Data collection took place in March 2011. Data collection forms were used by the observers to record activities according to the coding framework. Stopwatches and digital metronomes (audible only to the observers) were used to measure the 1-min intervals. The observers remained as inconspicuous as possible to prevent their presence influencing the pharmacists’ activities. There was very limited interaction between the pharmacist and the observer, although on occasion the observer may have clarified the pharmacist’s activities at the end of an observation session. The first session of data collection at each site was discarded to allow the pharmacists to become comfortable with being observed and to help mitigate the Hawthorne effect. For this reason, observers continued to visit the same pharmacy throughout the study to ensure familiarity and to help limit any observer effect. © 2014 Royal Pharmaceutical Society
Data analysis The data were entered into Microsoft Excel and analysed with PASW Statistics 18 (SPSS Inc., Chicago, IL, USA) where the number of observations for each activity were expressed as a proportion of the total number of observations. Where the proportion of time spent on activities was found to be nonnormally distributed between the pharmacies, median and interquartile range were reported.
Ethics Participants who were invited to participate were assured of their anonymity and it was explained that the collective, as opposed to individual results would be analysed. The pharmacists all provided consent to be observed. Institution ethical approval was received (REC/B/10/03).
Results A total of 12 306 observations were recorded in 10 community pharmacies across London over a 2-week period. Data collection predominately took place Monday to Friday (n = 11886, 96.6%). However, some data were captured on Saturday (Pharmacy 2, n = 240, 1.95%) and Sunday (Pharmacy 10, n = 180, 1.46%). All of the pharmacies were open for at least the core hours of 9 a.m.–6 p.m. Monday to Friday, with data collection spread across the opening hours (Range: 7 a.m.–10:30 p.m.). Overall, seven coding categories accounted for three quarters of all pharmacists’ time (Figure 1): assembling and labelling of products (median 25.2%; quartiles 19.0, 31.0); prescription monitoring and appropriateness (10.6%; 8.3, 13.0); rest, waiting and personal time (8.6%; 4.8, 11.4); endorsing and health-related clerical work (8.7%; 4.8, 11.4); non-professional encounters (4.1%; 2.4, 11.1); counselling International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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Table 1
Results from a work sampling study in London
Coding framework
Activity
Classification
1 Prescription monitoring and appropriateness Interpretation of the prescription including checking the correctness of the dispensed item. Includes checking the indication for drug, suitability for patient, e.g. interactions with other medicines; appropriate dose of each medication; contacting the prescriber if necessary. Includes ensuring that the product is dispensed as prescribed, e.g. checking any product assembled by dispensary technicians, as well as the legality of prescription. 2 Assembly and labelling of products Includes the assembly of the product requested on the prescription and generating labels for the container of that product. The process of assembling a prescription item from receipt to the final assembly of the product, including the endorsement and filling of an individual prescription. 3 Endorsing prescriptions and clerical health-related work Includes preparing the end of month returns to the Prescription Pricing Authority, coding prescriptions etc., directly related to health provision. 4 Counselling patients on prescribed medicines Includes personally giving out the medication to the patient and providing information on disease state, medicines supplied, side effects, dose etc. 5 Non-prescription medicines counselling/responding to symptoms Includes listening to any problems, advising on problems either to patients or counter staff, recommending a non-prescription medicine or referring the patient to a General Practitioner (GP). 6 Professional encounter with non-patients Discussing new drugs with company representatives, contacting the Prescription Pricing Authority etc. 7 Health-related communication An activity or function that involves any aspect of health provision, written or verbal, that is not direct counselling to patient, including advice to GPs. 8 Provision of advanced services This relates specifically to Medicines Use Reviews 9 Provision of enhanced or other National Health Service services Conducting any additional services that are provided by the pharmacy, e.g. medicines supplied via Patient Group Direction (emergency contraception, smoking cessation advice etc.). 10 Provision of private enhanced services Conducting any additional services that are provided by the pharmacy e.g. medicines supplied via Private Patient Group Direction or paid for vaccinations. 11 Provision of services to homes As 1 and 2 but directly related to residential and nursing homes. 12 Inventory and stock control Includes stock maintenance of prescription-only medicines (dispensary) and non-prescription medicines (counter) or of non-medicinal products (perfumes/baby products etc.). 13 Staff training and education Includes any training given to new and existing staff, work experience students, e.g. formal training for dispensary staff. 14 Housekeeping Includes general maintenance and cleaning of the work place including merchandising of dispensary or non-dispensary areas. 15 Sales transactions The selling of goods between vendor and purchaser, for non-health-related products, such as perfumes. 16 Money and managerial administration Includes all clerical work such as dealing with mail, filing etc, an activity not involving any aspect of health care. Functions that the person in charge must do for the business to run effectively. Includes wages, tax returns, balancing cash at the end of the day etc. 17 Rest, waiting and personal time Includes lunch and tea breaks, resting and toilet breaks etc. or time when the pharmacist is being unproductive. 18 Non-professional encounters Includes gossip and general chat with non-professionals, e.g. talking about the weather with a customer. Advising customers on non-healthcare-related products e.g. perfumes.
Professional
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Semi-professional
Professional
Professional
Professional
Professional Professional
Professional Professional
Professional
Professional Non-professional
Professional
Non-professional
Non-professional Semi-professional
Non-professional Non-professional
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313
Percentage on Activities
50.00
40.00
30.00
20.00
10.00
Figure 1
Non-professional encounters
Rest
Money and managerial
Housekeeping
Sales transactions
Staff training
Stock control
Nursing home
Private services
Advanced services
Enhanced services
Healthcare-related communication
Professional encounters with non-patients
Counselling prescribed medicines
Counselling non-prescription medicines
Assembly and labelling of products
Endorsing and health-related clerical
Prescription monitoring and appropriateness
0.00
Box plot of activity codes.
non-prescribed medicines (6.6%; 3.5, 7.6); and counselling prescribed medicines (3.8%; 2.8, 5.6). About 25 h of the responsible pharmacists’ time is spent each week dedicated to prescription-related matters (see Table 2). Stock control activities accounted for 3.4% (2.1, 5.2) of the pharmacists’ time. Often, this was unpacking and checking the delivery and managing the stock within the pharmacy. In the two pharmacies that provided services to nursing homes, this accounted for less than a twentieth of the pharmacists’ time (5.08% and 3.83%). To facilitate interpretation activity, categories were combined under broad themes (e.g. counselling) as shown in Table 3. The two categories for counselling accounted for 12.4% (7.5, 13.3) of the pharmacists’ time. The pharmacists spent a larger proportion of their time offering counter advice on non-prescription medicines as opposed to prescription medicines. In total, the provision of clinical services accounted for about a twentieth of pharmacists’ time although the range across sites was between 0.2% and 15%. The category for extended services (which include advanced, enhanced and private services), which have been at the centre of developments in the community pharmacists’ role, were © 2014 Royal Pharmaceutical Society
found to account for the smallest proportion of pharmacists’ time (Table 3). Using the framework defined by McCann et al.,[16] the activities of the pharmacists were separated into professional, semi-professional and non-professional activities (Table 4).
Discussion This London-based work sampling study suggests that community pharmacists spend the majority of their time on supply-based processes, which account for nearly two-fifths of their working day. Pharmacists spent more time offering non-prescription medicines advice than prescription medicines counselling and less than a twentieth of their time on the provision of pharmaceutical services.
Strengths and limitations of the research Over 12 000 data points were recorded in this study. This large number of observations over a sufficient period of time was required in order to provide confidence in the inferences made from the results.[18] Yet one of the weaknesses of this International Journal of Pharmacy Practice 2014, 22, pp. 309–318
© 2014 Royal Pharmaceutical Society
3*
10
10a Manager 10b Regular 10c Locum
9a Regular 9b Regular
8a Regular
7a Owner
Female Female Male
Male Male
Male
Male
Male Male Male
Female
5b Locum
6a Manager 6b Locum 6c Locum
Female Male Male Female Female
Female Female
Female Female
Male
Pharmacist gender
4a Locum 4b Locum 4c Locum 4d Locum 5a Regular
3a Regular 3b Locum
2a Owner 2b Locum
1a regular
Pharmacist status and code
27 27 34
50 29
34
49
30 30 70
55
32 39 58 27 31
30 27
60 32
32
Pharmacist estimated age/years
0.81 0 2.36 0 0 1.6 6 1 1 0 0.4 1 1 1.82 0 1 0 0.38 0.64 0.74
0 0 1.12 0
1.93 0 0.18 0.95 0 0 2.5 0 0 0 1.81 1 0 0.36 1.17 0
Mean number of: technicians; dispensers; counter assistants; Pre-registration students*
3500
3500
4000
12 000
4000
4500
4000
4000
4000
3500
Mean monthly prescription volume/items
Supermarket
Specialist
Specialist
Traditional
Health and beauty
Supermarket
Supermarket
Specialist
Health and beauty
Specialist
Pharmacy type
Monday–Friday: 9 a.m.–8 p.m. Saturday: 9 a.m.–8 p.m.
Monday–Friday: 9 a.m.–6:15 p.m. Saturday: 10 a.m.–4 p.m.
Monday–Friday: 9 a.m.–6 p.m. Saturday: 10 a.m.–2 p.m.
Monday–Friday: 9 a.m.–7:30 p.m. Saturday: 9 a.m.–7 p.m. Sunday: 10 a.m.–2 p.m.
Monday: 8 a.m.–10:30 p.m. Tuesday–Friday: 6:30 a.m.–10:30 p.m. Saturday: 6:30 a.m.–10 p.m. Sunday: 10 a.m.–4 p.m. Monday–Friday: 9 a.m.–7 p.m. Saturday: 9 a.m.–7 p.m.
Monday–Friday: 9 a.m.–6 p.m. Saturday: 9 a.m.–6 p.m.
Monday–Friday: 9 a.m.–6 p.m. Saturday: 10 a.m.–4 p.m.
Monday–Friday: 8:30 a.m.–6:30 p.m. Saturday: 9 a.m.–1 p.m.
Monday–Friday: 9 a.m.–7 p.m. Saturday: 10 a.m.–3 p.m.
Opening hours
NB. * The data refer to the average/number of staff observed during the observational study periods and does not reflect the number of staff actually employed by a pharmacy.
2
9
3*
6
1
2*
5
8
4
4
1
2
3
7
2
2
Pharmacy
1
Number of pharmacists observed
1
Demographic data
Table 2
314 Results from a work sampling study in London
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Table 3
315
Combined activity codes
Activities (activity codes)
Median (quartiles)
Prescription related matters (1 + 2) Non-counselling communication (6 + 7 + 13 + 18) Rest waiting and personal time (17) Counselling (4 + 5) Premises (12 + 14 + 15 + 16) Health administration (3) Services (8 + 9 + 10 + 11)
39.6% (35.5, 44.5) 15.1% (13.5, 18.2) 8.6% (6.9, 15.3) 12.4% (7.5, 13.3) 8.6% (6.9, 15.3) 8.7% (4.8, 11.4) 3.2% (0.8, 7.5)
approach is that the data do not provide any detail on the quality of consultations or services; only the amount of time as a proportional estimate. Only pharmacists were observed, which may have ignored the beneficial effect of counselling that was provided by other pharmacy staff under their supervision. Fixed interval sampling, used here, is comparable to random interval sampling because of the non-cyclical nature of community pharmacists’ work.[31] Fixed-interval sampling is also simpler and cheaper because specialised random generation devices are not required. Self-reported work sampling, which has been used in other community pharmacy studies, may interrupt the workflow in the pharmacy and hence lead to poor quality data. Therefore, discrete direct observation helped to limit this bias. Pharmacy students were chosen as observers because they have been used in previous studies,[24,32] and are familiar with the work of pharmacists; an important factor in work sampling.[24] However, despite the extensive training and supervision of coding undertaken by the observers, there was still opportunity for interobserver variance in recording activities as well as the confounding factors of observer bias and the Hawthorne effect. The subjective categorisation approach adopted by the observers when the pharmacists were performing more than one activity is one example. However, it was reported that this only happened infrequently, and therefore its effects on the results should not be overstated. The observers also interacted with the pharmacists, which may have altered their practice. This was kept to a minimum and is arguably less intrusive than self-report approaches. The results suggest that a greater proportion of pharmacists’ time was spent counselling at the weekend. There was notable variation in counselling across the different days of the week.[29] Sunday saw a large amount of time apportioned to non-prescription medicines counselling, which may be due to reduced prescription numbers at the weekend and the fact that access to other healthcare settings is restricted. However, proportionally, data capture over the weekend was limited compared with other days of the week, which may have led to an overall under representation of counselling activities in the amalgamated data that considers the whole week. © 2014 Royal Pharmaceutical Society
In a similar vein, the pharmacists were only observed for short 4-h time periods. Extended pharmaceutical activities, which account for only a small proportion of the pharmacists’ time may not have been witnessed by the observers, although this does not necessarily mean that they were not taking place. Also activities, such as the time spent on endorsement of prescriptions and health-related clerical work, may have been increased by data collection taking place near the end of the month when prescriptions are sorted for submission to the pricing authority. The pharmacies were purposively selected within a convenience sample and therefore include an inherent recruitment bias in that poorly performing pharmacists are unlikely to volunteer for research. In addition, independent pharmacies were overrepresented in the sample when compared with the national picture because London has a higher proportion of independently owned pharmacies. Taking these points into consideration, the results cannot be said to be generalisable beyond the London area, especially as the sample of pharmacies was small, and those selected had below average prescription volumes when compared with national figures.
Counselling patients Time spent on counselling activities in this study was the same as the proportion observed in England in the late 1990s[24,29] and similar to that recorded in more recent work log studies,[33] suggesting little change in the proportion of time attributed to this activity. Conversely, in Northern Ireland, two studies undertaken 10 years apart found a significant reduction in the amount of time spent handing out prescriptions and counselling.[15,16] On the one hand, the proportion of time spent counselling has remained static, despite policies to encourage pharmacists to spend more time on direct patient care. Conversely, pharmacists continue to spend the same proportion of their time counselling despite a 300 million prescription item increase in workload over the last decade.[34] Overall, this suggests that the average time spent counselling per prescription item has decreased. In the research reported here, a greater proportion of time was attributed to counselling non-prescription medicines use as opposed to prescribed medicines use. Non-prescription medicines counselling is reactive and limited by the number of patients seeking advice at any one time. This sampling category covered the whole interaction, including responding to symptoms, which may require both diagnosis as well as medicines counselling advice. The increased proportions may also be a reflection that over the counter medicines are becoming more complex and require a greater degree of support.[35] By contrast, counselling patients taking prescription medicines is often proactive. Patients often collect chronic disease medication and therefore pharmacists will have multiple opportuInternational Journal of Pharmacy Practice 2014, 22, pp. 309–318
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Table 4
Results from a work sampling study in London
Activity categorisations
Activities (activity codes)
Median % (quartiles)
McCann et al.[16] (mean %)
Professional (1 + 3 + 4 + 5 + 6 + 7 + 8 + 9 + 10 + 11 + 13) Semi-professional (2 + 16) Non-professional (12 + 14 + 15 + 17 + 18)
46.2 (35.2, 56.2) 28.5 (22.7, 34.9) 23.7 (15.8, 30.0)
49 % 31% 20%
nities to counsel on prescribed medications. Indeed, patients may not need advice on every supply. US studies suggest that the likelihood that a patient will receive counselling is not related to staffing levels, automation or workload, but instead to public perceptions and expectations[36] as well as the practice habits of the pharmacists.[37] This may explain the heterogeneous and wide ranging results reported here.
Pharmaceutical services It was expected that more than a twentieth of the pharmacists’ time would be spent on advanced services as it has been reported that pharmacists have a desire to spend more time on consultation activities.[38,39] However, this observation may reflect a lack of opportunity or may be skewed by the pharmacies sampled in this study, as several did not complete a single Medicines Use Review (MUR) during the observation period. Meanwhile, national data revealed that in England approximately 50 000 MURs were completed during the study period.[40] At best, the average pharmacist would be unlikely to spend more that about 6.5 h (equivalent to a tenth of their time) each week on MURs because the mean time to complete an MUR is 51 min[41] and the NHS contractual framework for community pharmacy imposes a limit for each contractor of 400 MURs per annum (equivalent to approximately eight per week).
considerable differences in the organisation and structure of processes within the pharmacies, which may have influenced how the pharmacists apportion their time. In particular, it appeared that the willingness of the pharmacists to pass responsibilities to other staff[37,44,45] had an influence on the management of their time.
Implications for practice and policy Overall, the proportion of time attributed to each of the ‘professional’, ‘non-professional’ and ‘semi-professional’ categories remains comparable to that of previous UK-based studies (Table 4). Pharmacists continue to spend the majority of their time dispensing and checking prescriptions.[16,33] This observation is not limited to England; the dominance of this activity in pharmacist’s daily work has been reported in studies around the world.[4,38,39,46–48] The disproportionate influence of dispensing on pharmacists’ roles was described in English studies conducted in the late nineties, which concluded that the time dedicated to dispensing could be better ‘utilised’ for clinical activities.[29] This is in keeping with a series of work sampling studies conducted a decade apart in Belfast, Northern Ireland.[15,16] The evidence presented here, while limited in sample size, does suggest policies aimed at encouraging a greater proportion of pharmacists’ time to be spent on patient counselling and pharmaceutical services have failed to appreciably change pharmacists’ activities.
Rest, waiting and personal time In this study, pharmacists were observed to spend just over a tenth of their time on rest, waiting and personal activities, comparable to the 14.1% observed by Rutter et al.[24] and in keeping with the unproductive time found in other professions.[18,42] Regular rest breaks are recommended to prevent accumulation of accident risk during sustained activities.[43] Therefore, having appropriate rest breaks is an important parameter for patient safety and is beneficial to patients. The coding framework did not allow a differentiation between rest and waiting time. The observers reported that often this category was time spent waiting for others to complete tasks prior to being checked, or for access to computer terminals rather than a physical rest break. This suggests that work process within the pharmacy could be streamlined to reduce this wastage and to improve efficiency. The wide range of time observed within this category suggest some © 2014 Royal Pharmaceutical Society
Conclusions British (and international) health policy has called for better utilisation of the skills of community pharmacists building on the positive experiences of pharmacy practice in hospital settings. However, the evidence presented here suggests that overall; the proportion of time that pharmacists spend on different activities has remained fairly static over the course of the last decade. This research shows that the dispensing of prescriptions continues to dominate practice, despite the desire within the profession for role change. While accepting that practice change will be evolutionary, rather than revolutionary, at the current pace it will be many decades before community pharmacists’ skills are properly implemented into primary health care. There remains scope for community pharmacists to use appropriate process control, staffing and automation to delegate tasks in order to International Journal of Pharmacy Practice 2014, 22, pp. 309–318
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release time for pharmaceutical care activities. The ability to move responsibility in the pharmacy and allocate pharmacists’ time to tasks that cannot be delegated requires the entrenchment of current roles and responsibilities in community pharmacy to be overcome. On this basis, further research is required to understand why the implementation of these policies have not been realised, and to further discover why pharmacists have not moved beyond the traditional dispensing role.
Declarations Conflict of interests The authors have no financial relationship with any of the organisations that might have an interest in the submitted work in the previous 3 years.
Mansoor Hashemi, Umara Uddin, Zainab Shafiq and Sarah Khan for their invaluable help in data collection and entry. We would also like to thank all of the pharmacists and their staff that took part in this study.
Authors’ contributions (ICMJE statement on authorship) JD was the lead for the research. All authors contributed to the design and development of the study and assisted in the analysis of the research. JD wrote the first draft of the paper and all authors contributed to successive drafts. All authors read and approved the final manuscript. All Authors state that they had complete access to the study data that support the publication.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgements We would like to thank Saira Aslam, Folake Olafare, Rukeya Begum, Thusanth Thayaparan, Gursharan Sira, Mohammad
References 1. Edmunds J, Calnan MW. The reprofessionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacists amongst pharmacists and General Practioners in the United Kingdom. Soc Sci Med 2001; 53: 943– 955. 2. Hepler C, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533–543. 3. Department of Health, Pharmacy in. England: Building on Strengths – Delivering the Future. (Cm 7341). London: The Stationary Office, 2008. 4. Schommer JC et al. Community pharmacists’ work activities in the United States during 2000. J Am Pharm Assoc 2002; 42: 399–406. 5. New Zealand Ministry of Health, Medicines New Zealand. Contributing to Good Health Outcomes for All New Zealanders. Wellington: Ministry of Health, 2007.
© 2014 Royal Pharmaceutical Society
Ethical approval The study received institutional ethical approval from the School of Pharmacy, University of London ethics committee (REC/B/10/03), plus local agreement from all pharmacies involved in the research. This committee has since been replaced by UCL ethics committee.
6. Australian Goverment & The Pharmacy Guild of Australia. The Fifth community pharmacy agreement between the commonwealth of Australia and the Pharmacy Guild of Australia. 2010. 7. Bouvy M et al. White Paper on pharmacy in the Netherlands: position on pharmacy, pharmacists and pharmacy practice, ed. R.D.P. Association. 2011: KNMP. 8. PSNC. The New Contract for Community Pharmacy. London: Pharmaceutical Services Negotiating Committee, 2004. 9. Blenkinsopp A et al. National Evaluation of the New Community Pharmacy Contract. London: Pharmacy Practice Research Trust, 2009. 10. Fisher CM et al. Study of community pharmacy practice. Part 1. Pharmacists’ work patterns. J Soc Adm Pharm 1991; 8: 15–24. 11. Savage I. The changing face of pharmacy practice – evidence from 20 years of work sampling studies. Int J Pharm Pract 1999; 7: 209–219.
12. Emmerton L, Jefferson K. Work sampling observations of community pharmacists: a review. Int J Pharm Pract 1996; 4: 75–78. 13. Rutter PM et al. Pharmacy research: the place of work measurement. Int J Pharm Pract 1998; 6: 46–58. 14. Rascati KL et al. Work measurement in pharmacy research. Am J Hosp Pharm 1986; 43: 2445–2452. 15. Bell HM et al. A self-reported work sampling study in community pharmacy practice. Pharm World Sci 1999; 21: 210–216. 16. McCann L et al. A self-reported worksampling study in community pharmacy practice: a 2009 update. Pharm World Sci 2010; 32: 536–543. 17. Marklin RW, Cherney K. Working postures of dentists and dental hygienists. J Calif Dent Assoc 2005; 33: 133–136. 18. Ampt A et al. A comparison of selfreported and observational work sampling techniques for measuring time in nursing tasks. J Health Serv Res Policy 2007; 12: 18–24.
International Journal of Pharmacy Practice 2014, 22, pp. 309–318
318
19. Ploylearmsang C et al. Standard time of an outpatient prescription processing at Samut Sakhon Hospital. AACP Annual Meeting, 2003. 104(Jul). 20. Ardern-Jones J et al. The impact of the introduction of a ward-based automated medicines vending unit on nursing tasks and time in the Emergency Department. Int J Pharm Pract 2009; 17: 345–349. 21. Lin AC et al. Re-engineering a pharmacy work system and layout to facilitate patient counseling. Am J Health Syst Pharm 1996; 53: 1558– 1564. 22. Ryu S et al. Evaluation of unit dose system for parenteral medication: experience of Asan Medical Center. ASHP Midyear Clinical Meeting, 2002. 37(Dec): p. intl-l-24. 23. Ryu SG, Kim JT. Unit dose system for parenteral nutrition; Implementation and evaluation. ASHP Midyear Clinical Meeting, 2003. 38(Dec): p. INTL-L-18. 24. Rutter PM et al. Validation of a subjective evaluation study using work sampling. J Soc Adm Pharm 1999; 16: 174– 185. 25. Rascati KL et al. Multidimensional work sampling to evaluate the effects of computerization in an outpatient pharmacy. Am J Hosp Pharm 1987; 44: 2060–2067. 26. General Pharmaceutical Council. Guidance for Responsible Pharmacists. London: GPhC, 2010. http://www .pharmacyregulation.org/sites/default/ files/GPhC%20Responsible%20 pharmacist%20guidance.pdf (accessed April 2013). 27. Summerfield M et al. Determining staffing requirements in institutional pharmacy. Am J Health Syst Pharm 1978; 35: 1487–1495. 28. Savage I. Time for prescription and OTC advice in independant community practice. Pharm J 1997; 258: 873– 877. 29. Rutter P et al. Subjective evaluation of how community pharmacists in Great
© 2014 Royal Pharmaceutical Society
Results from a work sampling study in London
30.
31.
32.
33.
34.
35.
36.
37.
38.
Britain spend their time. J Soc Adm Pharm 1998; 15: 252–261. Dupclay L, Jr et al. Analysis of grocery chain pharmacists’ work-related behaviors. J Am Pharm Assoc 1999; 39: 74–81. Dickson W. Measuring pharmacist time use: a note on the use of fixedinterval work sampling. Am J Health Syst Pharm 1978; 35: 1241–1243. Nelson AA, Jr et al. Task analysis of a pharmacist’s activities in a 45-bed rural hospital with comprehensive pharmaceutical services. Am J Hosp Pharm 1977; 34: 1063–1068. Bond C et al. The effect of the new community pharmacy contract on the community pharmacy workforce, ed. Pharmacy Practice Research Trust. Univerisity of Aberdeen, Keele Univeristy, Webstar Health. 2008. http://www.pharmacyresearchuk.org/ waterway/wp-content/uploads/ 2012/11/The_effect_of_the_new _community_pharmacy_contract _on_the_community_pharmacy _workforce.pdf (accessed November 2013). The NHS information Centre Prescribing Support Unit. Prescriptions Dispensed in the Community: England, Statistics for 1999 to 2009. London: Department of Health, 2010. Department of Health, Self Care – A Real Choice. Self Care Support – A Practical Option. London: Department of Health, 2005. Schommer JC, Wiederholt JB. Pharmacists’ perceptions of patients’ needs for counseling. Am J Hosp Pharm 1994; 51: 478–485. Angelo LB et al. Impact of community pharmacy automation on workflow, workload and patient interaction. J Am Pharm Assoc 2005; 45: 138–144. Schommer JC et al. Pharmacists’ desired and actual times in work activities: evidence of gaps from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc 2006; 46: 340–347.
39. Scott DM. 2006 North Dakota pharmacists’ wage and workload assessment. J Pharm Technol 2009; 25: 14–23. 40. NHS Prescription Services. MUR statistics. Jan 2012. 2012. http://psnc .org.uk/funding-and-statistics/nhsstatistics/mur-statistics/ (accessed November 2013). 41. Blenkinsopp A et al. Community pharmacists’ experience of providing medicines use reviews: findings from the national evaluation of the community pharmacy contractual framework. Int J Pharm Pract 2007; 15(Suppl. 2): B45– B46. 42. Westbrook JI, Ampt A. Design, application and testing of the Work Observation Method by Activity Timing (WOMBAT) to measure clinicians’ patterns of work and communication. Int J Med Inform 2009; 78S: S25–S33. 43. Tucker P et al. Rest breaks and accident risk. The Lancet 2003; 361: 680. 44. Mobach M. The general pharmacy work explored in The Netherlands. Pharm World Sci 2008; 30: 353–359. 45. Mobach MP. The counter and consultation room work explored in the Netherlands. Pharm World Sci 2008; 30: 360– 366. 46. Fleming H. No rest for the weary. Drug Top 1999; 143: 50–56. 47. Midwest Pharmacy Workforce Research Consortium. 2009 National Pharmacist Workforce Survey : final report of the 2009 national sample survey of the pharmacist workforce to determine contemporary demogrpahic and practice characteristics. Midwest Pharmacy Workforce Research Consortium: Pharmacy Manpower Project, Inc. 2010. 48. Alderman CP, Farmer C. A brief analysis of clinical pharmacy interventions undertaken in an Australian teaching hospital. J Qual Clin Pract 2001; 21: 99–103.
International Journal of Pharmacy Practice 2014, 22, pp. 309–318
