Pharmacists under pressure are deviating from standard procedures to give their patients tailored care, according to a new study – feeling forced to do so because of high workloads, rigid rules and conflicting pressures from employers.
The University of Manchester study, When procedures meet practice in community pharmacies: qualitative insights from pharmacists and pharmacy support staff, funded by the UK’s National Institute for Health Research and published in BMJ Open, analysed interviews with 24 practising staff working at a range of levels in pharmacies.
Three main themes were identified in the study: the dissemination and creation of Standard Operating Procedures, complying with procedures and procedural compliance versus using professional judgement.
“Participants felt complying with all procedures at all times was an unrealistic organisational aim given the complex setting and the high workload,” the authors wrote.
“The findings highlighted a difference in work-as-done and work-as-imagined due to the sometimes unrealistic expectations placed on CP [community pharmacy] staff, in terms of the large number of detailed procedures that resulted in difficulty for staff to learn and retain all of the procedures provided.”
“I think the people who write the SOPs, they’ve never actually worked in [a branch] either,” one dispenser told the interviewers.
A locum pharmacist said that “[Staff are] presented with this massive folder [of procedures] and a lot of them are very repetitive… people will lose their attention span after five minutes… it defeats the point.”
A variety of factors affected compliance with procedures in community pharmacy, the authors noted; study participants from all roles emphasised the impact that work demands, workload and the behavioural norm within the team had on their ability to comply with procedures.
During difficult times – particularly public holidays and week beginnings and endings – complying with procedures was particularly fraught. Some participants said working in a community pharmacy on a weekend could feel like “a different job entirely,” mainly due to GP surgeries and other resources being unavailable. Insufficient staffing levels was also a problem.
“Under these circumstances, pharmacists often resorted to applying their professional judgement regarding patient safety,” the authors wrote.
“Easter weekend, the weekend before Christmas… the end of the week, Friday as well is usually very busy… sticking to the rules becomes less of a priority,” said one pharmacist at a large chain.
Large workloads are a big problem for community pharmacy, the study found.
“Many participants spoke of regularly attempting to complete several tasks at once to manage workload, leading to occasional shortcuts.
“All participants mentioned the volume of tasks they had to complete under time pressure. Pharmacists also highlighted the need to achieve service targets set by head office or area management regarding professional services such as medicines usage reviews and the new medicine service.”
The views of pharmacists tended to differ from those working in other roles when it came to the relative merits of standardised practice and the use of professional judgement in community pharmacy.
“The pharmacists appreciated that procedures were useful to an extent, and also felt that they reserved the right to bypass or deviate from procedures if they judged it necessary for the patient’s outcome,” the authors wrote.
“If somebody’s on their way to dying and the doctor’s forgotten the Midazolam CD schedule three, and forgot to put the quantity, where the figures all look clear and [the prescriber says] ‘okay, we’re on visits, we’ll be over in an hour to sign it’. Do I leave it an hour? The patient could be dead in an hour,” one independent pharmacist told the interviewers.
But some expressed concern that acting outside the procedures could expose them to the risk of disciplinary action or litigation.
“The findings from this study have important implications for pharmacy practice and policy, as they highlight the role that organisational factors have on how procedures are implemented in CP,” the authors noted.
“Factors such as pressure from the organisation regarding achieving targets or setting procedures that are difficult to follow when working out of hours can create an environment where following procedures and achieving required outputs is sometimes felt to be unachievable.
“Furthermore, the fear of being unsupported by an employer if procedures were not complied with, even if it was for patient benefit, created an additional pressure to pharmacists.
“On the other hand, this study has shown that the use of professional judgement is crucial when deciding whether to comply with a procedure.”
The authors say more work is needed in practice to realign work-as-imagined and work-as-done; one suggestion is to improve communication between staff on the frontline and management, to lessen the gap between the two, they say.