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This explored how Community Pharmacy (CP) staff perceive & experience the roles of procedures within the workplace. 24 pharmacy staff (pharmacists & support staff) were interviewed.

Results:

3 main themes emerged.

1) the influence of work demands,

2) the influence staff role has on how procedures are viewed &

3) the dissemination and enforcement of SOPs.

Overall issues included the large amount of detailed procedures in CP. Staff “felt complying with all procedures at all times was an unrealistic organisational aim given the complex setting and the high workload” (p3). It’s noted that this is indicative of a gap between work-as-imagined and work-as-done where the sheer volume of procedures places staff in a difficult position to learn & retain all of the procedures.

Most staff were provided with written SOPs that they were expected to read on starting work in the CP. Again, an overload of procedures was indicated leading to procedures that were “often left on a shelf and ignored” (p3). One person noted that they couldn’t dream of being able to recall every step of every policy, nor believe anybody else could either. Expectedly, another indicated that people will often just read and sign a document & never look at it again until told to.

For the creation of SOPs, the level of involvement of CP staff varied. For smaller or independent pharmacies, heavy levels of input & involvement was evident – with some indicating the flexibility & control frontline operators had in revising written process.

This contrasted with larger pharmacy chains where little flexibility existed.

Work demands affected procedural adherence with work scheduling being mentioned by all staff types. Work surges like public holidays, weekends etc. was described by some as being an entirely different job; making procedure adherence challenging.

Job pressures involved CP staff continually completing multiple tasks at once. Compounding this effect was additional workload of service targets required by head office or area management.

Behavioural norms were also found to influence procedure adherence. Sessional pharmacists noted the pressure to conform to local practice despite inconsistencies with procedures.

Opinions varied about the merits of standardised practice & the use of professional judgement by CP staff. Pharmacists appreciated that procedures were useful to an extent but felt they reserved the right to bypass or deviate from procedures if judged necessary for the patient’s outcome.

Newly qualified pharmacists were more likely to rely on SOPs compared to experienced staff – the latter believing the reliance on SOPs as “not a realistic approach to professional practice” (p4). One pharmacist noted that using professional judgement may scare some pharmacists as they want things black & white, but part of being a professional has to be making professional decisions.

Highlighted was the situations pharmacists face which has no set guidance and where judgement was necessary. While all staff types indicated the importance of professionalism – for pharmacists professionalism was about exercising professional judgement, whereas for some support staff (nurses), more focus was on following rules. In this way, pharmacists were more similar to doctors & surgeons by seeing the need for a high degree of flexibility as opposed to “cookbook” healthcare.

On judgement, staff relied on their ability to adjust to varying conditions and adapting standardised systems to non-standard situations. This flexibility was fundamental to meet patient needs. At the same time, some pharmacists feared being unsupported by their employer for working outside of procedures and even when acting in the patient’s benefit.

On procedure use, expectedly some had an attitude that it was a tick box exercise and didn’t necessarily shape their work to a large extent. Although dispensers are required to sign that they will follow the SOPs, in certain circumstances they followed directions from the pharmacists as an alternative. Dispensers didn’t always feel that they were able to question the decision of the responsible pharmacist despite following the pharmacists’ directions while sometimes operating outside of the procedure [perhaps partially indicative of challenges around psychological safety].

On speaking out, support staff highlighted the challenges they face when following instructions that do not benefit the patient and not being able to voice their concerns; thereby impacting patient safety.

Authors: Christian E L Thomas, Denham L Phipps, Darren M Ashcroft, 2016, BMJ Open

Study link: http://dx.doi.org/10.1136/bmjopen-2015-010851

Link to the LinkedIn article: https://www.linkedin.com/pulse/when-procedures-meet-practice-community-pharmacies-from-hutchinson

Keywords: work-as-imagined, work-as-done, gap, procedures, rules, WAI, WAD