Describing interruptions, multi-tasking and task-switching in community pharmacy: a qualitative study in England

How do interruptions and distractions affect pharmacy practice? A scoping review of their impact and interventions in dispensing

BACKGROUND

Pharmacists play a crucial role in reducing medication errors, identifying 30-70 % of medication-ordering errors. However, they can also contribute to dispensing errors. Interruptions and distractions during dispensing have been known to account for approximately 9.4 % of these errors, with reported occurrences of every two to six min.

OBJECTIVE

To review existing knowledge on the impact of interruptions and distractions in pharmacy practice, including their frequency, types, and previously implemented or proposed strategies for mitigation.

METHODS

This scoping review followed the Joanna Briggs Institute (JBI) methodology and was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. A comprehensive search of Ovid Medline, Web of Science, Embase, CINAHL, and Scopus databases was conducted on June 26, 2024, November 13, 2024, and January 16, 2025. Studies were selected based on predefined inclusion and exclusion criteria. Descriptive statistics summarised study characteristics, while content analysis identified common types of interruptions and distractions, their frequency, impact, and the interventions used or recommended.

RESULTS

After removing duplicates, 7884 studies proceeded to title and abstract screening. Following the application of inclusion and exclusion criteria, 141 full-text studies were assessed, and 51 were included in the review. Pharmacists and technicians experience interruptions and distractions at varying rates, from less than 5 to more than 20 times per hour. The most common external interruptions and distractions were phone calls, face-to-face inquiries from consumers, as well as interruptions and distractions from shop staff who needed to interrupt the pharmacist to manage customer queries that were out of their scope. Internal interruptions included self-initiated task-switching, checking on staff, and non-work-related web browsing. These disruptions primarily impacted the dispensing process, pharmacists' workload, performance, well-being, and patient wait times. Few interventions have been implemented, falling into three main categories: facility modification (adjusting the physical environment), system modification (altering workflow processes), and communication adjustments (limiting direct access to pharmacists during dispensing).

CONCLUSION

There are both limited reported interventions in the pharmacy workplace, and a lack of educational initiatives at the university setting, to mitigate the impact of interruptions and distractions. These findings highlight the need to establish better foundational dispensing habits and develop methods to reduce the frequency of directly accessing the pharmacist during dispensing. Avoiding having a single pharmacist on duty at any given time and clearly defining the roles of different pharmacists during various shifts may be effective ways to reduce dispensing errors.

Community pharmacists' decision-making patterns in clinical prescription checking: A simulation-based study

Background

Community pharmacists (CPs) make a significant number of decisions on the clinical appropriateness of prescriptions daily to ensure safe and effective use of medications, in a process known as "clinical checking". The process is complex and is affected by multiple factors in practice. This study aimed to investigate the cognitive processes involved in clinical prescription checking by CPs.

Method

This qualitative study employed a purposive sampling technique to recruit a diverse sample from the population of CPs in England. Engaging in Zoom interviews, participants clinically checked three simulated prescriptions, providing concurrent verbal accounts of their thoughts. The participants' commentaries during the task were audio-recorded, transcribed verbatim, and underwent deductive thematic analysis based on Klein's recognition-primed decision-making (RPD) model.

Results

Twelve CPs from diverse backgrounds and varied working conditions were recruited and completed the online checking task. Making decisions on the clinical appropriateness of prescriptions appeared to be a multi-staged procedure whereby several levels of concerns exist, and pharmacists vary in their ability to recognise and resolve those concerns. CPs behaved in a manner similar to that described by the RPD model; they mostly engaged in pattern-recognition during clinical checking, but adopted a more analytical approach when they recognised an atypical situation. Participants showed more consistency when processing cues and expectancies; however, their subsequent actions exhibited substantial variability, coupled with a degree of hesitancy.

Conclusion

Clinical checking of prescriptions is a multifaceted process in which pharmacists employ a blend of pattern recognition and analytical thinking when making decisions. The process differs notably among pharmacists, underscoring the need to understand the factors driving these variations and any hesitancy in decision- making, as well as their potential impact on patient safety.

Development and implementation of a Community Pharmacy "Bootcamp" activity - A pilot study

OBJECTIVE

The objectives of this study are to describe 1) the implementation of and 2) student performance and perceptions during an innovative classroom activity.

METHODS

The Bootcamp was designed as an exercise in productive failure for second-year PharmD students enrolled in a community pharmacy elective course. A prescription verification exercise was introduced; however, students were intermittently interrupted with common community pharmacist tasks. To simulate these tasks (e.g.: receiving a phone call, counseling a patient, administering a vaccine, checking controlled prescription monitoring database etc.), students were directed by the instructor to perform other physical activities (e.g. walking around the classroom, doing jumping jacks, sending an email, etc.). After the activity, accuracy was assessed and each student uploaded a video reflection which were analyzed with content analysis.

RESULTS

The activity was delivered in person in 2021 and virtually in 2022 during a two-hour class period. Of the 63 students, 86 % fully completed all 12 prescription verifications in the allotted time; however, the average accuracy was 53 %. Content analysis of video reflections generated three themes: unique and fun activity, importance of attention to detail, and enhanced understanding of pharmacy workflow from the pharmacist's perspective.

CONCLUSIONS

The Community Pharmacy Bootcamp was a fun and engaging way to expose students to the realities of daily practice in the community pharmacy setting. This activity was effective in helping students discover the need for development of further skills in addition to clinical expertise. This novel activity may be adapted to other environments including integration into required coursework.

Pharmacist prescriber smoking cessation intervention during the COVID-19 pandemic

INTRODUCTION

During the pandemic, smokers who wished to access support to quit faced additional barriers. A smoking cessation service which utilized pharmacist independent prescribers working within community pharmacy was implemented. Clients received behavioral advice via a consultation with an advisor and then three consultations with a pharmacist, who prescribed varenicline, where appropriate. Consultations were by phone or video. This evaluation assessed the self-reported outcomes and experiences of clients and pharmacists.

METHODS

A mixed-methods approach was used involving both on-line questionnaires to clients and interviews with a sample of questionnaire respondents and participating prescribing pharmacists.

RESULTS

The questionnaire was completed by 85 clients with 59% reporting they had quit. Eleven clients and seven out of eight pharmacists were interviewed. Varenicline had been received by 96% of clients. The best aspects of the service reported by clients in the questionnaire and at interview were support received from the pharmacist and ease of access to varenicline. Clients regarded the service as being 'safe' to access during the pandemic. Nearly three-quarters of client respondents (72%) stated no service improvements were required. However, national supply challenges made collection of varenicline from the nominated pharmacy an issue. Some clients experienced a long wait-time before accessing the service. For pharmacists, the service offered flexibility including the opportunity to contact clients 'out of office' hours without distractions. However, not being physically in the pharmacy could result in them not being able to access the client's medicine history. Pharmacists identified that remote consultations were not ideal for all clients.

CONCLUSIONS

Pharmacist prescribers can deliver effective smoking cessation services through remote consultations. Greater flexibility would allow the service to be tailored to the client's need.

Status of Patient Safety Culture in Community Pharmacy Settings: A Systematic Review

OBJECTIVES

This systematic aimed to understand the global status using the results of survey studies based on the Community Pharmacy Survey on Patient Safety Culture and set the directions of development in terms of the patient safety culture of community pharmacies.

METHODS

Electronic searches were performed in EMBASE, MEDLINE, PubMed, and CINAHL databases by using the words "patient safety," "culture," and "community pharmacy" with synonyms or associated words in the original English language research articles published between January 1, 2012, and March 2, 2023. This systematic review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Eleven surveys from 10 countries were selected. Five studies were conducted on pharmacists, whereas 6 studies were carried out on all pharmacy staff members such as pharmacists, technicians, clerks, and pharmacy students on apprenticeship. There was a considerable variation in the positive response rates across the dimensions of all the surveys. The highest positive response score was demonstrated for "teamwork" and "patient counseling," whereas the "staffing, work pressure, and pace" dimension was essential for improving patient safety culture in community pharmacy settings. For overall rating of the pharmacy on patient safety, 84.8% of pharmacy staff members gave good, very good, or excellent as their responses.

CONCLUSIONS

Despite the differences among studies, findings of this study are expected to be used as valuable evidence to develop patient safety improvement strategies after reflecting each country's health care setting or community pharmacy practice. Furthermore, the results would offer meaningful assistance to achieve the goals of global campaigns such as the World Health Organization Patient Safety Challenge.

Australian community pharmacy service provision factors, stresses and strains: A qualitative study

Introduction

Despite the desire of pharmacists to provide new and more clinically focused services, strain on the community pharmacist workforce is a known barrier to their service provision. Causes are unclear, although the impact of increased workload, as well as broader role-related and systemic causes have been suggested.

Aims

To (1) explore the role strain, stress and systemic factors affecting Australian community pharmacists' provision of cognitive pharmacy services (CPS), using the Community Pharmacist Role Stress Factor Framework (CPRSFF), and (2) adapt the CPRSFF to the local setting.

Methods

Semi-structured interviews were conducted with Australian community pharmacists. Transcripts were analysed with the framework method to verify and adapt the CPRSFF. Thematic analysis of particular codes identified personal outcomes and causative patterns in perceived workforce strain.

Results

Twenty-three registered pharmacists across Australia were interviewed. CPS role benefits included: helping people, and increased competency, performance, pharmacy financial return, recognition from the public and other health professionals, and satisfaction. However, strain was worsened by organisational expectations, unsupportive management and insufficient resources. This could result in pharmacist dissatisfaction and turnover in jobs, sector or careers. Two additional factors, workflow and service quality, were added to the framework. One factor, "View of career importance versus partner's career", was not apparent.

Conclusion

The CPRSFF was found to be valuable in exploring the pharmacist role system and analysing workforce strain. Pharmacists weighed up positive and negative outcomes of work tasks, jobs and roles to decide task priority and personal job significance. Supportive pharmacy environments enabled pharmacists to provide CPS, which increased workplace and career embeddedness. However, workplace culture at odds with professional pharmacist values resulted in job dissatisfaction and staff turnover.

A two-agent one-machine multitasking scheduling problem solving by exact and metaheuristics

This paper studies a single-machine multitasking scheduling problem together with two-agent consideration. The objective is to look for an optimal schedule to minimize the total tardiness of one agent subject to the total completion time of another agent has an upper bound. For this problem, a branch-and-bound method equipped with several dominant properties and a lower bound is exploited to search optimal solutions for small size jobs. Three metaheuristics, cloud simulated annealing algorithm, genetic algorithm, and simulated annealing algorithm, each with three improvement ways, are proposed to find the near-optimal solutions for large size jobs. The computational studies, experiments, are provided to evaluate the capabilities for the proposed algorithms. Finally, statistical analysis methods are applied to compare the performances of these algorithms.

Instruments measuring community pharmacist role stress and strain measures: A systematic review

BACKGROUND

While macro and meso approaches to implementing public health initiatives in community pharmacies have been studied, the micro perspective of their pharmacist providers requires more inspection. Community pharmacists report increasing stress, overload, and limited control over facets of their work.1-7 Social exchange principles, e.g. role price, may help to typify pharmacist work decisions so problematic situations can be modified, thus protecting workforce health. To do so, the underlying pressures of the pharmacist role (i.e. role stresses) and indicators of systemically-caused strain (i.e. role strains) should be measurable.

OBJECTIVES

To summarise validated and reliable instruments used to measure role stress and strain among community pharmacists and evaluate compatibility in testing a theoretically-derived framework.

METHODS

In April 2020, journal articles describing reliable and validated instruments measuring role stress and strain responses among community pharmacists were identified from an online search via Scopus, Web of Science and PubMed. English-language articles after 1990 were selected; duplicates were deleted. Inclusion and exclusion criteria were used to screen title/abstracts and full texts. Reference lists were manually searched. Resultant instruments were analysed for theoretical compatibility.

RESULTS

After review, 26 separate instruments were found: seven psychological strain instruments, 14 social strain response instruments, and five role stress instruments. Role stresses were often present as facet-specific dimensions in psychological and social strain instruments. Strain instruments measuring individual evaluation of work were compatible with a social exchange approach.

CONCLUSIONS

Twenty-six reliable and validated instruments measuring role stress and role strain were found to measure negative role outcomes from the micro community pharmacist perspective. Structural measurement of role stress and resultant negative responses enable detailed examination into pharmacist roles and insights into pharmacist behaviour. Further research is required to develop additional role stress and strain instruments, and to discover pharmacist role benefits and their influence.

A participatory research approach in community pharmacy research: The case for video-reflexive ethnography

Video-reflexive ethnography (VRE) is a qualitative methodology that explores the complex nature of healthcare 'as it really is'. Its collaborative and reflexive process invites stakeholders (e.g. pharmacists and pharmacy support staff) to participate in analysing their everyday work practices as captured on video footage. Through close collaboration with practitioners and attention to their work contexts, VRE may be a useful methodology to engage a time-poor pharmacy workforce in research about themselves, encouraging more practitioner involvement in practice-based research. Aside from research, VRE has also been used effectively as an intervention to facilitate learning and change in healthcare settings, and could be effective in provoking change in otherwise resistant pharmacy environments. Much like traditional ethnographic approaches, VRE researchers have relied on being present 'in the field' to observe, record and make sense of practices with participants. The COVID-19 pandemic however, has introduced restrictions around travel and physical distancing, which has required researchers to contemplate the conduct of VRE 'at a distance', and to imagine new ways in which the methodological 'closeness' to stakeholders and their workplace contexts can be maintained when researchers cannot be on site. In this commentary, we outline the rationale for participatory methods, in the form of VRE, in pharmacy research. We describe the underlying principles of this innovative methodology, and offer examples of how VRE can be used in pharmacy research. Finally, we offer a reflexive account of how we have adapted the method for use in community pharmacy research, to adapt to physical distancing, without sacrificing its methodological principles. This paper offers not only a new methodology to examine the complexity of pharmacy work, but demonstrates also the responsiveness of VRE itself to complexity, and the potential breadth of future research applications in pharmacy both during and beyond the current pandemic.

The role of non-technical skills in community pharmacy practice: an exploratory review of the literature

BACKGROUND

Non-technical skills (NTS) are the cognitive and social skills that complement technical skills in safe and efficient practice, and include leadership, teamwork, task management, decision-making and situation awareness. Other areas within healthcare have heavily invested in producing taxonomies to aid training and assessment of NTS within their disciplines, and have found them to be essential for improving patient safety. In pharmacy, no validated taxonomy has been produced, nor has the existing literature been appraised to aid the future development of a validated taxonomy.

OBJECTIVE(S)

To examine the literature on NTS within a community pharmacy setting and establish the research conducted thus far on each NTS and how they are applied by community pharmacists.

METHODS

A literature search of six electronic databases (EMBASE, PsychINFO, Medline, SCOPUS, CINAHL Plus and HMIC) using the generic list of NTS identified in previous studies. Only empirical studies were included. Examples of behaviours or skills were extracted and categorised within each NTS.

KEY FINDINGS

Seventeen studies were identified that contained one or more examples of NTS specific to community pharmacy practice. Altogether, 16 elements were extracted. Four elements were identified within leadership and task management. A further three were identified within situation awareness and decision-making, and a final two within teamwork and communication.

CONCLUSION

A framework consisting of the skills and how they're applied has been presented which describe the NTS required by community pharmacists from the published literature. This framework can provide a foundation for further investigation into NTS use within pharmacy practice.

Factors affecting community pharmacist work: A scoping review and thematic synthesis using role theory

Many community pharmacists ideologically support recent changes to their roles in primary healthcare. However, their antithetical resistance towards practice change could have systemic causes (i.e. role stresses), which may account for increased job dissatisfaction, burnout, and job turnover in the profession. Deeper comprehension was sought using a role theory framework.

OBJECTIVE

To identify factors leading to role stresses and strain responses for community pharmacists, and to create a framework for community pharmacist role management.

METHOD

PubMed, Scopus and Web of Science databases were searched for qualitative studies identifying community pharmacist role stress and strain using scoping review methodology from 1990 to 2019. Content and thematic analysis using the framework method was performed, and themes were reported using thematic synthesis.

RESULTS

Screening of 10,880 records resulted in 33 studies identified, with 41 factors categorised into four domains: Interpersonal Interactions, Social Setting, Individual Attributes, and Extra-Role. All role stresses were present. Reported role strains suggest role system imbalance.

CONCLUSION

Community pharmacists are in a multifactorial transitional environment. Reported role stresses may be a function of past pharmacist roles and increased role expectations, amplified by many requisite interactions and individual pharmacist characteristics. Social science theories were found to be applicable to the community pharmacy setting.

A literature review of human factors and ergonomics within the pharmacy dispensing process

BACKGROUND

Within healthcare, Human Factors explores the fit between people and their working environment to improve safety, performance and wellbeing. The pharmacy setting is an area of particular interest considering the high-risk nature of the work activities in relation to dispensing errors. Internationally, the pharmacy setting is experiencing significant workforce changes, including the introduction of pharmacy technicians performing accuracy checks, and the adoption of novel technologies such as automated dispensing.

OBJECTIVE

A literature review was conducted to identify studies which have explored the pharmacy dispensing process from a Human Factors perspective.

METHODS

The databases Medline, EMBASE and PsycINFO were searched on the 27th of November 2018. All study designs were eligible for inclusion from community and hospital settings. Key study findings were extracted and reported using a descriptive narrative synthesis method.

RESULTS

Thirty-two studies were identified, with most published from 2010 onwards. The review identified that a myriad of aspects influence safety within the dispensing process; that the dispensing process is complex in nature and can be depicted in many different ways; and lastly, that deviations from intended practice appear commonplace. Most studies used two or more data collection sources, and various theories, models and frameworks were applied. Although the focus of all studies was within the wider domain of Human Factors, 14 studies did not explicitly refer to a Human Factors approach within the manuscript.

CONCLUSIONS

The complexity of the pharmacy dispensing setting suggests that adopting a Human Factors approach to explore this context is appropriate. Future Human Factors research should explore the implementation of new technology and services and focus on obtaining empirical evidence that adopting a Human Factors approach improves safety and/or efficiency within pharmacy practice. Clear guidance on how to apply the range of Human Factors approaches would help support such research and facilitate the development of sound theory.

Using an integrated information system to reduce interruptions and the number of non-relevant contacts in the inpatient pharmacy at tertiary hospital

Patient care is provided by a multidisciplinary team of healthcare professionals intended for high-quality and safe patient care. Accordingly, the team must work synergistically and communicate efficiently. In many hospitals, nursing and pharmacy communication relies mainly on telephone calls. In fact, numerous studies have reported telephone calls as a source of interruption for both pharmacy and nursing operations; therefore, the workload increases and the chance of errors raises. This report describes the implementation of an integrated information system that possibly can reduce telephone calls through providing real-time tracking capabilities and sorting prescriptions urgency, thus significantly improving traceability of all prescriptions inside pharmacy. The research design is based on a quasi-experiment using pre-post testing using the continuous improvement approach. The improvement project is performed using a six-step method. A survey was conducted in Prince Sultan Military Medical City (PSMMC) to measure the volume and types of telephone calls before and after implementation to evaluate the impact of the new system. Beforehand of the system implementation, during the two-week measurement period, all pharmacies received 4466 calls and the majority were follow-up calls. Subsequently of the integrated system rollout, there was a significant reduction (p > 0.001) in the volume of telephone calls to 2630 calls; besides, the calls nature turned out to be more professional inquiries (p > 0.001). As a result, avoidable interruptions and workload were decreased.

Traditions of research into interruptions in healthcare: A conceptual review

BACKGROUND

Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations.

OBJECTIVE

To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research.

METHODS

A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community's motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community.

RESULTS

A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities.

CONCLUSIONS

Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions.

A survey of community pharmacists’ attitudes towards mental illness

Purpose

– The purpose of this paper is to compare the pharmacy services provided to people taking psychotropic and cardiovascular medications and examine the association between pharmacists’ attitudes towards mental illness and provision of pharmacy services. The paper also considers pharmacists’ opinions of the pharmaceutical care needs of people with mental illness including their physical health.

Design/methodology/approach

– A survey instrument was sent by facsimile to a random sample of community pharmacists in England and Wales.

Findings

– Community pharmacists had generally positive attitudes towards mental illness but provided significantly fewer pharmacy services (and were less comfortable providing them) to patients taking psychotropic medications than to patients taking cardiovascular medications. Awareness of the higher prevalence of physical health conditions among people with severe mental illness was not high. Provision of pharmacy services was associated with pharmacists’ attitudes towards mental illness and comfort providing pharmaceutical care. Other factors that may contribute to these disparities in service provision are discussed.

Practical implications

– The study findings indicate the need for enhanced mental health education for pharmacy students to improve attitudes, knowledge and confidence in mental health and the inclusion of mental health in pharmacy advanced services.

Originality/value

– Few studies have examined the relationship between attitudes towards mental illness and provision of pharmacy services. This was the first study to examine the attitudes of British community pharmacists towards mental illness.