<%BANNER%>

Professional Expertise and Pharmacy Technicians


PAGE 1

PROFESSIONAL EXPERTISE AND PHARMACY TECHNICIANS By DEBBIE LOUISE WILSON A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2004

PAGE 2

Copyright 2004 by DEBBIE LOUISE WILSON

PAGE 3

This work is dedicated to my life partner R. Scott Smith. Thank you for encouraging me.

PAGE 4

iv ACKNOWLEDGMENTS I would like to acknowledge the P.A. Foote Grant in Health Outcomes for making this work possible through the provision of the $5000 grant. I would like to thank the Pharmacy Technician Certification Board for providing the list of CPhTs free of charge. I would like to thank David Brushwood for the funds and support to execute the focus group of pharmacists and pilot studies that were crucial to the development of the questionnaire. I would like to thank the Department of Pharmacy Health Care Administration for its support.

PAGE 5

v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES.............................................................................................................ix LIST OF FIGURES..........................................................................................................xii CHAPTER 1 INTRODUCTION........................................................................................................1 Objectives..................................................................................................................... 2 Background...................................................................................................................2 Significance..................................................................................................................5 2 LITERATURE REVIEW.............................................................................................8 Practice and Regulation of Pharmacy Technici ans in the United States of America...8 History of Pharmacy Technicians.........................................................................8 Credentialing of Pharmacy Technicians..............................................................10 Current Practice of Pharmacy Technicians.........................................................13 Empirical Studies of the Optimal Fu nction of Pharmacy Technicians.......................18 Studies at the National Level...............................................................................18 Studies at the State Level....................................................................................20 Evaluations of Performance of Pharmacy Technicians..............................................22 Community Dispensing Study.............................................................................22 Institutional Tech-Check-Tech Studies...............................................................23 Court Judgment...................................................................................................24 Technology and Pharmacy Technicians..............................................................24 Summary.....................................................................................................................25 3 THEORETICAL FRAMEWORK OF PROFESSIONAL EXPERTISE...................26 Overview.....................................................................................................................26 Description of the Theoretical Fram ework of Professional Expertise........................27 Knowledge...........................................................................................................28 Clinical Reasoning and Judgment.......................................................................29 Movement............................................................................................................30 Virtues.................................................................................................................31

PAGE 6

vi Adapted Framework of Expert Practice for Pharmacy...............................................31 Knowledge and Skills..........................................................................................32 Reasoning and Judgment.....................................................................................33 Patient Assessment and Education......................................................................34 Virtues.................................................................................................................34 Research Questions.....................................................................................................35 Conclusion..................................................................................................................36 4 METHODOLOGY.....................................................................................................37 Introduction.................................................................................................................37 Subjects....................................................................................................................... 37 Study Variables and Operati onalization of Constructs...............................................38 Instrument Development.....................................................................................38 Original Item Pool...............................................................................................38 Focus Group........................................................................................................38 Pretests.................................................................................................................41 Data Collection Procedures........................................................................................50 Questionnaire.......................................................................................................51 The Community Pharmacy Technician Use Questionnaire.........................51 Instrument Validation.................................................................................................52 Analyses......................................................................................................................5 5 Descriptive Analyses...........................................................................................55 Confirmatory Factor Analysis.............................................................................56 Exploratory Factor Analysis................................................................................58 Internal Consistency Reliability..........................................................................59 Inter-Factor Correlations.....................................................................................59 Within-Group Comparisons of Summated Scores by Type of Experience.........60 Response Bias......................................................................................................61 Sample Size Estimation..............................................................................................61 Summary.....................................................................................................................61 5 RESULTS...................................................................................................................63 Questionnaire Response..............................................................................................63 Descriptive Data.........................................................................................................64 Work Experience.................................................................................................64 Pharmacist Reported Pharmacy Tec hnician Supervisory Experience.................64 Pharmacist Reported Type of Ph armacy Technician Supervised........................65 Pharmacy Technician Reported Credentials.......................................................65 Item Level Descriptive Data................................................................................67 Analyses......................................................................................................................6 9 Chi-Square Tests.................................................................................................69 Confirmatory Factor Analysis....................................................................................72 Exploratory Factor Analysis.......................................................................................74 Pharmacist data....................................................................................................74 Pharmacist Model Development.........................................................................76

PAGE 7

vii Six-factor pharmacist model........................................................................76 Five-factor pharmacist model.......................................................................78 Four-factor pharmacist model......................................................................79 Pharmacist Model Selection................................................................................81 Pharmacy Technician Data..................................................................................81 Pharmacy Technician Model Development........................................................83 Five-factor technician model........................................................................83 Four-factor technician model.......................................................................85 Pharmacy Technician Model Selection...............................................................87 Comparison of Models Generated for the Two Groups.............................................87 Internal Consistency Reliability.................................................................................87 Pharmacist Data...................................................................................................87 Clinical pharmacy knowledge tasks.............................................................87 Tasks and functions typical of pharmacy technicians in current practice factor.......................................................................................................88 Pharmacy information evaluation and management skills factor................89 Pharmacist only tasks as specified by law factor.........................................90 Technician Data...................................................................................................90 Tasks and functions typical of pharmacy technicians in current practice factor.......................................................................................................90 Clinical pharmacy knowledge tasks factor...................................................91 General drug knowledge factor....................................................................92 Pharmacist only tasks as specified by law factor.........................................92 Inter-Factor Correlations............................................................................................93 Factor Correlations within the Pharmacist Model...............................................93 Factor Correlations within th e Pharmacy Technician Model..............................94 Within-Group Comparisons of Summated Scores by Type of Experience................95 Pharmacist Group Comparisons..........................................................................96 Work experience..........................................................................................96 Pharmacist reported pharmacy technician competency...............................97 Supervision of PTCB certif ied pharmacy technicians.................................97 Supervision of pharmacy technicians with AA in pharmaceutical sciences99 Pharmacy Technician Group Comparisons.......................................................100 Work experience........................................................................................100 Education....................................................................................................101 Training......................................................................................................102 Additional certifications.............................................................................103 Comparison of Early and Late Responders..............................................................105 6 DISCUSSION...........................................................................................................109 Introduction...............................................................................................................109 Response Rate...........................................................................................................109 Descriptive Data.......................................................................................................110 Group Differences by Items......................................................................................112 Confirmatory Factor Analysis..................................................................................116 Exploratory Factor Analyses....................................................................................118

PAGE 8

viii Data Driven Models..........................................................................................119 Factor Correlations Within Models...................................................................123 Model Differences Between Groups.................................................................124 Within-Group Comparisons of Summated scores by Type of Experience.......124 Model Comparisons with Proposed Model.......................................................125 Limitations................................................................................................................127 Suggestions for Future Research..............................................................................128 Conclusion................................................................................................................128 APPENDIX A INITIAL COVER LETTER SENT TO PHARMACIST SUBJECTS.....................130 B INITIAL COVER LETTER SENT TO TECHNICIAN SUBJECTS......................132 C FOLLOW-UP COVER LETTER SENT TO ALL SUBJECTS...............................134 D PHARMACIST QUESTIONNAIRE.......................................................................136 E PHARMACIST QUESTIONNAIRE.......................................................................141 F CONFIRMATORY FACTOR ANLAYSIS WITH COMPLETE DATA PROGRAM146 G CONFIRMATORY FACTOR ANLAYSIS WITH MISSING DATA PROGRAM148 LIST OF REFERENCES.................................................................................................152 BIOGRAPHICAL SKETCH...........................................................................................158

PAGE 9

ix LIST OF TABLES Table page 2-1 Pharmacy Techni cian Designations Used................................................................14 2-2 Pharmacy Technician Credentials Ma ndated by States (includes the District of Columbia, Guam and Puerto Rico)..........................................................................14 2-3 Pharmacy Technician Func tions in the Hospital Setting.........................................16 2-4 Pharmacy Technician Functi ons in the Ambulatory Setting....................................17 4-1 Item Means from First Testing.................................................................................42 4-2 Item Means from Second Testing............................................................................43 4-3 Item Analysis for the Patient Assessm ent and Education Scale on the Pre-tests.....45 4-4 Item Analysis for the Knowledge and Skills Scale on the Pre-tests........................47 4-5 Item Analysis for the Reasoning a nd Judgment Scale on the First Pre-test.............48 4-6 Item Analysis for the Virtues Scale on the First Pre-test.........................................49 5-1 Reported Community Work Expe rience of Subjects in Sample..............................64 5-2 Item Means from the Pharmacist Group (n=314) and the Pharmacy Technician Group (n=449) on The Community Pharm acy Technician Use Questionnaire.......68 5-3 Dichotomized Means from the Pharmacist Group (n=315) and Pharmacy Technician Group (n=448) on the Items of The Community Pharmacy Technician Use Questionnaire....................................................................................................71 5-4 Eigenvalues for Factors Extr acted from the Pharmacist Data..................................74 5-5 Pattern Matrix for 6-Factor Model from the Pharmacist Data.................................76 5-6 Pattern Matrix for 5-Factor Model from the Pharmacist Data.................................78 5-7 Pattern Matrix for 4-Factor Model from the Pharmacist Data.................................80 5-8 Eigenvalues for Factors Extr acted from the Technician Data..................................82

PAGE 10

x 5-9 Pattern Matrix for 5-Factor Model from the Technician Data.................................84 5-10 Pattern Matrix for 4-Factor Model from the Technician Data.................................85 5-11 Item Analysis for the Clinical Pharmacy Knowledge Tasks Factor........................88 5-12 Item Analysis for the Tasks and Functions Typical of Pharmacy Technicians in Current Practice Factor.............................................................................................89 5-13 Item Analysis for the Pharmacy Information Evaluation and Management Skills Factor........................................................................................................................8 9 5-14 Item Analysis for the Pharmacist On ly Tasks as Specified by Law Factor.............90 5-15 Item Analysis for the Tasks and Functions Typical of Pharmacy Technicians in Current Practice Factor.............................................................................................91 5-16 Item Analysis for the Clinical Pharmacy Knowledge Tasks Factor........................91 5-17 Item Analysis for the General Drug Knowledge Factor..........................................92 5-18 Item Analysis for the Pharmacist On ly Tasks as Specified by Law Factor.............93 5-19 Factor Correlations from the Pharmacist Model (n=314)........................................94 5-20 Factor Correlations from the Pharmacy Technician Model (n=449).......................95 5-21 Correlations between the Factors and the Number of Years Practicing as a Licensed Pharmacists (n=295).................................................................................................96 5-22 Correlations between the Factors and Pharmacist Reported Pharmacy Technician Competency (n=299)................................................................................................97 5-23 Factors Means for Pharmacist Who Have and Have Not Supervised a PTCB Certified Pharmacy Technician................................................................................98 5-24 Comparison of Means on Factors Dependent on Whether or Not the Pharmacist Has Supervised a PTCB Certified Pharmacy Technician........................................98 5-25 Factors Means for Pharmacist Who Have and Have Not Supervised a Pharmacy Technician with an AA in Pharmaceutical Sciences................................................99 5-26 Comparison of Means on Factors Dependent on Whether or Not the Pharmacist Has Supervised a Pharmacy Technician with an AA in Pharmaceutical Sciences100 5-27 Correlations between the Factors and the Number of Years Working as a Pharmacy Technician (n=400)................................................................................................101

PAGE 11

xi 5-28 Factors Means for Pharmacy Technicians Who Reported Having and Reported Not Having Some Education Beyond a GED or High School Diploma.......................101 5-29 Comparison of Means on Factors Dependent on Whether or Not the Pharmacy Technician Reported Having Education Beyond a GED or High School Diploma102 5-30 Factors Means for Pharmacy Technicians Who Reported Having and Reported Not Having Some Training Be yond On-The-Job Training...........................................103 5-31 Comparison of Means on Factors Dependent on Whether or Not the Pharmacy Technician Reported Having Trai ning Beyond On-The-Job Training..................103 5-32 Factors Means for Pharmacy Technicians Who Reported Having and Reported Not Having Pharmacy Certificates in Addition to PTCB Certification........................104 5-33 Comparison of Means on Factors Dependent on Whether or Not the Pharmacy Technician Reported Having Pharmacy Certificates in Addition to PTCB Certification............................................................................................................104 5-34 Dichotomized Means from the Earl y Responding Pharmacist Group (n=206) and Late Responding Pharmacist Group (n=108) on the Items of The Community Pharmacy Technician Use Questionnaire..............................................................105 5-35 Dichotomized Means from the Earl y Responding Technician Group (n=249) and Late Responding Technician Group (n=200) on the Items of The Community Pharmacy Technician Use Questionnaire..............................................................107

PAGE 12

xii LIST OF FIGURES Figure page 3-1 Model of Expert Practice for Physical Therapy (Adapted from Jensen et al., 1999)27 4-1 Model Targeted in the Confirmatory Factor Analysis.............................................54 5-1 Scree Plot of the Eigenvalues for the Factors Extracted from Pharmacist Data......75 5-2 Scree Plot of the Eigenvalues for the Factors Extracted from Technician Data......83

PAGE 13

xiii Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PROFESSIONAL EXPERTISE AND PHARMACY TECHNICIANS By Debbie Louise Wilson December 2004 Chair: Carole Kimberlin Cochair: David Brushwood Major Department: Pharmacy Health Care Administration Pharmacy technicians are often defined as performing tasks not requiring professional judgment. The framework of professional expertise as described in the Model of Expert Practice in Physical Therapy is similar to the construct of professional judgment as used in pharmacy. The model constructs used in this investigation were: (1) Patient Assessment and Education, (2) Knowledge and Skills, (3) Reasoning and Judgment, and (4) Virtues. Pharmacists and Pharmacy Technician Certification Board certified technicians working in community pharmacy in Florida were included. Data on pharmacist and technician’ beliefs were collected with a self-administered mail questionnaire. Chisquare tests on dichotomized items were used to check for differences in the beliefs of the two groups on each item. Pharmacist and pharmacy technicians’ beliefs on the tasks that a capable community pharmacy technician should perform relevant to a framework of

PAGE 14

xiv professional expertise were examined using confirmatory factor analysis (CFA) with LISREL. A total of 503 pharmacists and 569 technicians responded (response rate 27%). The chi-square tests found that the pharmacist and technician beliefs differed on 16 of 26 items. For eight items, pharmacists believed that technicians should not perform the tasks. Technicians, however, believed that technicians should perform six of the eight tasks, including “assess a patient’s actual medication use” and “educate patients on the appropriate use of their medications”. The CFA found that pharmacist and technician beliefs on the tasks did not fit the proposed framework. Following CFA, exploratory factor analysis found that both groups had two factors that were conceptually the same with only one or two items loading differently on each factor: (1) clinical pharmacy knowledge tasks, and (2) tasks and functions typical of pharmacy technicians in current practice. A third factor (“pharmacist-only tasks as specified by law”) had identical item loadings on the factors. The beliefs of the pharmacists and pharmacy technicians on the items did not fit the proposed framework. Technicians were more likely than pharmacists to agree that technicians should perform a broader range of tasks and to believe that technicians should perform tasks requiring specialized drug knowledge or a professional relationship with patients.

PAGE 15

1 CHAPTER 1 INTRODUCTION This study examined the beliefs of pharmacists and pharmacy technicians about the tasks pharmacy technicians should perform in the community pharmacy workforce. Pharmacy technicians are already an important part of the pharmacy workforce. Today pharmacy technicians are performing tasks that were previously only performed by licensed pharmacists. Pharmacy technicians are not licensed and credentialed as pharmacists are. Technician functions are not clearly defined in state regulations. Minimal educational requirements are often not specified by states. Pharmacy technicians serve under the supervision of pharmacists. As a result, the tasks that a pharmacy technician is allowed to perform are, for the most part, determined by the individual supervising pharmacist and vary not only from site to site, but from pharmacist to pharmacist within a site. Indeed pharmacy technicians may be performing tasks that they should not perform. Because each individual pharmacist who supervises a pharmacy technician has a primary role in determining what functions that technician can perform, it is important to study pharmacists’ beliefs about what functions a pharmacy technician should be able to perform. Since pharmacy technicians are the group of interest it is important to study their beliefs about this as well.

PAGE 16

2 Objectives The objectives of this research are to 1. develop and validate an instrument to measure beliefs of pharmacists and pharmacy technicians about the functions pharmacy technicians should perform in community practice, 2. describe the beliefs of pharmacists and pharmacy technicians about the functions pharmacy technicians should perform in community practice, 3. examine the differences that exist between pharmacists’ and pharmacy technicians’ beliefs about the functions that pharmacy technicians should perform in community practice, and arrive at a clearer understanding of what role a pharmacy technician should play in pharmacy practice as judged by a consensus of the beliefs of both pharmacists and technicians. Background The regulation of the pharmacy technician role in the dispensing process varies by state. The practice of pharmacy technicians also varies from site to site with tasks being delegated to pharmacy technicians by pharmacists (The Council on Credentialing in Pharmacy [CCP], 2000). The CCP (2000) defines a pharmacy technician as “an individual who, under the supervision of a licensed pharmacist, assists in pharmacy activities not requiring the professional judgment of the pharmacist.” The American Society of Health-Systems Pharmacists (ASHP) Manual for Pharmacy Technicians (1998) also uses the concept of professional judgment to differentiate the types of tasks that pharmacists and technicians can perform. ASHP has defined a pharmacy technician as “someone who, under the

PAGE 17

3 supervision of a licensed pharmacist, assists in various activities of the pharmacy department not requiring the professional judgment of the pharmacist.” The American Society of Hospital Pharmacists (ASHP) Task Force on Technical Personnel in Pharmacy defined the term as “someone who, under the supervision of a licensed pharmacist, assists in various technical activities of the pharmacy department that do not require the immediate judgment of a pharmacist” (ASHP, 1987). Some definitions of ‘pharmacy technician’ do not use the term professional judgment. Another definition offered by the ASHP Task Force is “individuals who are employed as pharmacy support personnel in an organized health-care setting working under the supervision of a licensed pharmacist and assisting in the preparing, distributing, or administering of medications” (ASHP, 1989). Those definitions that use the term professional judgment seem to be best received. Araque and Latiolais (1985) had Ohio hospital pharmacy directors rate four definitions of ‘pharmacy technician’ developed from the pharmacy literature. The highest rated definition was someone who under the supervision of a licensed pharmacist assists in the nonprofessional and nonjudgmental aspects of preparing and dispensing medications. Such duties include maintaining patient records; setting up, packaging, and labeling medication doses; filling and dispensing routine orders for stock supplies for patient-care areas; maintaining drug inventories; adding drugs to parenteral fluids and similar manipulations. (Araque and Latiolais, 1985, 75) The lowest rated definition was: an individual who has received an associate degree in hospital pharmacy technology which includes academic training in a junior college and formal hospital training/education including lecture and laboratory assignments. (Araque and Latiolais, 1985, 75) Using ‘professional judgment’ as a means to define what pharmacy technicians are not capable of doing does not clearly define wh at they are or should be capable of doing.

PAGE 18

4 In fact it is possible that even technical pharmacy tasks require some amount of judgment that is specific to pharmacy and thus require professional judgment. It has been suggested that some functions that pharmacy technicians are now being assigned may require some “higher level of judgment” (ASHP, 2003). Whitney editorialized this position in 1986: To say that all technicians are not allowed to make judgments is imprecise and illogical. . The word nonjudgmental creates ill will by suggesting that there is no opportunity for technicians to ever make judgments. This is just not the truth in actual practice. . nothing but absolute futility will be accomplished by attempting to restrict technicians to nonjudgmental tasks. . Pharmacists must recognize technicians are not only capable of making judgments but that they are involved in them now on a daily basis. Job descriptions must be written for technicians that do not limit them to nonjudgmental or nonprofessional duties. . (Whitney, 1986, 193-194) Pharmacists may perform any of the tasks involved in the normal practice of pharmacy, while technicians may perform only a subset of those tasks. Pharmacists are overqualified to perform many tasks involved in the dispensing process. Using them to perform such tasks inhibits them from providing services, which they are uniquely qualified to provide. Using the term professi onal judgment in defining what a technician is not or cannot do does not help us understand what tasks pharmacy technicians should be performing. The role of the pharmacy technician is in flux and an understanding is needed. The main concern for the practice of pharmacy technicians revolves around two issues: the tasks that pharmacy technicians should ideally perform in community pharmacy are vaguely defined, and pharmacy technicians are taking on more of the tasks traditionally involved in the practice of pharmacy. Beginning a process to reach

PAGE 19

5 consensus on the tasks that pharmacy technicians should perform in community pharmacy is warranted. Significance “The Final Report of the ASHP Task Force on Technical Personnel in Pharmacy” (1989) called for a consensus on pharmacy technicians, including consensus on the use of the term “pharmacy technician,” as well as on “the role, functions, core competencies, training, supervision, and recognition” of pharmacy technicians. So far this has not happened. Pharmacy organizations and some st ates have defined ‘pharmacy technician’, but they do so differently (Wilson, 2004). Also many define ‘pharmacy technician’ by use of the term ‘professional judgment’ (Wilson, 2004). The term ‘professional judgment’ in the definitions vaguely describe s the tasks that pharmacy technicians may or may not perform. Vaguely describing the tasks that pharmacy technicians may or may not perform does not help develop a consensus in the use of pharmacy technicians in community practice. Understanding the tasks that pharmacy technicians should perform is important for optimizing the use of pharmacy technicians. Historically pharmacy technicians were regularly employed in hospital pharmacies before they began being employed widely in community practice (ASHP, 1981). In addition, the use of pharmacy technicians in hospitals has been better described and appropriate tasks delineated than has the use of pharmacy technicians in community pharmacy settings. This is due largely to the American Society of Health-Systems Pharmacy’s efforts when the society was the American Society of Hospital Pharmacy. However, today there are many more pharmacy technicians in community pharmacy than there are in hospital pharmacy (ASHP, 1994; Greenberg, 1981; Hogan, 1985; Health Resources and Services Administration [HRSA], 2000; Meade, 1994). According to the

PAGE 20

6 United States Department of Labor (USD L) Bureau of Labor Statistics (BLS) 211,000 pharmacy technicians held jobs in 2002 in the United States (USDL, 2004). Two-thirds of these were in retail (USDL, 2004). Understanding the tasks that pharmacy technicians should perform in community pharmacy is needed. The pharmacy technician role is expanding due to increased demand for pharmacy services (APhA and ASHP, 1996; ASHP, 2003; Cooksey et al., 2002). Kalman et al. (1992) found that by expanding the role of pharmacy technicians along with instituting a comprehensive quality control program in a hospital setting, the pharmacy department was able to increase distribution and clinical services with a minor increase in personnel. However, expansions of the pharmacy technici an role should include only those tasks and all of those tasks that a pharmacy technician should perform. An understanding of the tasks that both pharmacists and pharmacy technicians believe pharmacy technicians should perform in community pharmacy will help guide this expansion. An understanding of the tasks that it is believed pharmacy technicians should perform in community pharmacy will also allow for better use of pharmacists. Pharmacy technicians can be best used in performing tasks they are qualified to perform and that pharmacists are overqualified to perform. The demand for pharmaceutical care and for pharmaceuticals continues to increase more quickly than the number of pharmacists. The use of pharmacists to perform technical functions “results in a dilution of pharmaceutical talents and limits the scope of pharmaceutical services provided” (ASHP, 1987). An understanding of the types of tasks it is believed that pharmacy technicians should perform in community pharmacy will help policy makers define the term ‘pharmacy technician’ in community practice, and mandate appropriate credentialing and

PAGE 21

7 education standards for pharmacy technicians working in community practice. An understanding of the tasks that a pharmacy technician should perform will aid in optimizing the actual use of pharmacy technicians. A consensus of beliefs about the tasks that a pharmacy technician should perform is crucial to the proper education and credentialing of pharmacy technicians. The education and credentialing of pharmacy technicians should provide pharmacy technicians with the skills that they need when performing pharmacy technician tasks. Thus policy makers and educators need to have a clear understanding of the types of tasks that pharmacy technicians should perform in community pharmacy.

PAGE 22

8 CHAPTER 2 LITERATURE REVIEW This chapter describes the current practice of pharmacy technicians, history of the use of pharmacy technicians and studies measuring the performance of pharmacy technicians. The practice of pharmacy techni cians varies by state. This study focuses specifically on Florida pharmacy technicians. For that reason the practice of pharmacy technicians in Florida and of the rest of the United States are described here and compared. Practice and Regulation of Pharmacy Techni cians in the United States of America History of Pharmacy Technicians The use of technicians in American pharmacy is relatively new. Originally pharmacists worked alone or with a pharmacist apprentice. Supportive personnel began assisting pharmacists in the mid-1940’s (Raehl et al., 1992). In 1981, supportive personnel were used in all states in hospital pharmacy settings and in 36 states in community pharmacy settings (ASHP, 1981). Until 1991, eight states did not allow pharmacy technicians in community pharmacy settings (ASHP, 1985; Fitzgerald et al., 1991). In 1999 a study performed by Drug Topics magazine found that “virtually all chain and hospital pharmacies employ pharmacy technicians (Drug Topics, 1999). In 1991, 25 states reported legally recognizing pharmacy technicians (Fitzgerald et al, 1991). Fifteen states reported activity to recognize pharmacy technicians (Fitzgerald et al, 1991). Of the 25 states that did not report legally recognizing pharmacy technicians, 23 states reported that pharmacy technicians were in use in pharmacy

PAGE 23

9 practice (Fitzgerald et al, 1991). In 1991, six states did not refer to pharmacy technicians in their state laws (Fitzgerald et al, 1991). Today only one state does not refer to pharmacy technicians in its state laws (National Association of Boards of Pharmacy [NABP], 2003). Initially pharmacy technicians were not regulated. Once introduced, the regulation of pharmacy technicians increased over time. In 1981, three states had educational requirements for pharmacy technicians (ASHP, 1981). In 1985, five had such requirements (ASHP, 1985). In 1991, 25 states had training requirements for pharmacy technicians (Fitzgerald, 1991). In 1992, 17 states required one or more qualifications for pharmacy technicians (Raehl et al, 1992). At that time, the types of requirements included some in-service training (n=6), that pharmacy technicians be highschool graduates (n=5), three months of on-the-job training (n=4), that the pharmacy technician be 18 years of age or older (n=3), institutional training (n=3), no criminal record (n=2), and registration (n=2) (Raehl et al, 1992). In 1992, Raehl et al., (1992) did not find any requirements for pharmacy technicians in 34 states. Pharmacy technician licensure has been opposed due to the fear that licensing pharmacy technicians will lead to a category of practitioners who will want to expand their scope of practice (Ukens, 1996). In 1985, one third of states required a pharmacist-to-technician ratio (ASHP, 1985). In 1992, 18 states (36%) required a pharmacist-to-technician ratio (Raehl et al., 1992). It has been suggested that ratios be dropped in exchange for a pharmacist’s opinion on how many pharmacy technicians that pharmacist can adequately supervise, but there is concern that employers, for economic reasons, will schedule more pharmacy technicians than could be adequately supervised (Ukens, 1996). Today, pharmacy

PAGE 24

10 technicians are regulated to a larger extent and in more states than in the past. Those current regulations are described in the next section on credentialing. In addition to increased regulation of pharmacy technicians, specialized pharmacy technician positions are being created. Such new specialty positions include Ambulatory Care Infusion Pharmacy Technicians (ASHP, 2000), Clinical Pharmacy Technicians (Koch, 1998), Data Analyst Pharmacy Technician (Ervin et al., 2001), and Investigational Drug Services Pharmacy Technicians (Wilson, 2001). More specialization will probably emerge over time. Credentialing of Pharmacy Technicians Pharmacists and pharmacy technicians’ beliefs about the tasks that pharmacy technicians can optimally perform may be affected by the current practice of pharmacy technicians. The language of credentialing of pharmacy technicians is meaningful and specific. For those reasons, the current practice of pharmacy technicians in the US and the language of credentialing are described here. The current number of practicing pharmacy technicians is unknown. Since 1995, 122,397 pharmacy technicians have been nationally certified (PTCB, 2003). In 1996, the number of pharmacy technicians in practice was estimated to be 150,000 (APhA & ASHP, 1996). By 2000, the number was estimated to be 247,000 (Cooksey et al., 2002). In 1994 prior to the establishment of the Pharmacy Technician Certification Board, 26% of pharmacy technicians were certified as a pharmacy technician by a pharmacy organization (ASHP, 1994). The percentage of all pharmacy technicians that are Nationally Certified Pharmacy Technicians in practice is not known. The number of currently practicing pharmacy technicians is thought to be considerably larger than both the number of Nationally Certified Pharmacy Technicians and of the number estimated to

PAGE 25

11 be in practice in 1996. The number of PTCB certified pharmacy technicians in Florida is 9,082, the second highest in the nation (PTCB, 2003). The terminology of credentialing is meaningful. According to the Council on Credentialing in Pharmacy (2000), "credentialing is the process by which an organization or institution obtains, verifies, and assesses a pharmacist's qualifications to provide patient care services." This definition could be generalized to the process by which an organization or institution obtains, verifies, and assesses a practitioner's qualifications to provide the professional services of that practice. A credential is "documented evidence" of a person's "qualifications." Pharmacy technicians' credentials include diplomas, certificates, certifications, and licenses (Wilson, 2003). The distinctions between these are described below. Pharmacy technicians can pursue formal education programs that grant diplomas or certificates of completion. Often, technicians are trained by their employers either formally or informally. Some employers offer certificates of completion for their technician training programs. It is unknown how many such programs exist. The ASHP is the accreditation body for pharmacy technician training programs. In 2002 there were 88 accredited programs (ASHP, 2002). It is suggested in the 2003 White Paper on Pharmacy Technicians that all training programs should be accredited. The Pharmacy Technician Certifica tion Board (PTCB) offers voluntary certification to pharmacy technicians. According to the Council on Credentialing in Pharmacy (2000), certification is the "voluntary process by which a nongovernmental agency or association formally grants recognition to a [person] who has met certain predetermined qualifications specified by that organization." Since the PTCB was

PAGE 26

12 founded, 122,397 people have received PTCB certification (PTCB, 2003). Additional specialization certificates are available to Certified Pharmacy Technicians (CPhT) through the National Pharmacy Technician Association (NPTA) (NPTA, 2002). While certification is voluntary, licensure is not. The CCP (2000) defines a license as a "credential issued by a state or federal body that indicates that the holder is in compliance with minimum mandatory governmental requirements necessary to practice in a particular profession or occupation" and licensure as the "process of granting a license.” Registration indicates state licensure. Accord ing to the CCP (2000), the term registered is used to describe a person "who has met state requirements for licensure and whose name has been entered on a state registry of practitioners who are licensed to practice in that jurisdiction" (CCP, 2000). In May of 2000, the National Association of Boards of Pharmacy (NABP) proposed a national competence assessment for pharmacy technicians. The resolution urged state boards to use the proposed national competence assessment program as a criterion for pharmacy technicians practicing in a state (ASHP, 2000). Such a criterion would not be voluntary. An NABP research team assessed the PTCE to see if the examination could be used for an NABP competency assessment program for pharmacy technicians or if the NABP needed to establish its own. The assessment led to the NABP signing an agreement with the PTCB in February 2002 that made the NABP a full partner and member of the PTCB Board of Governors. According to the agreement, the NABP Executive Director/Secretary will now chai r the PTCB Certification Council (NABP, 2002).

PAGE 27

13 Current Practice of Pharmacy Technicians The regulation of pharmacy technicians' designation, credentials and tasks varies by state. In 1991, only 25 states recognized pharmacy technicians, and only 12 states clearly defined such personnel in their rules and regulations (Fitzgerald et al., 1991; Raehl et al., 1992). According to the NABP 2003-2004 Survey of Pharmacy Law today Ohio is the only state—of the 50 states, the District of Columbia, Guam, and Puerto Rico—that does not address the use of pharmacy technicians in its state statutes or regulations (NABP, 2003). Wilson (2004) found that 43 states define pharmacy technician in their state statutes and regulations. Florida does not define pharmacy technicians but does have a statute on pharmacy technicians. Florida’s stat ute is similar to a definition of a pharmacy technician in that it describes how pharmacy technicians can be used (Wilson, 2004). The statute details that a licensed pharmacist may delegate certain tasks to pharmacy technicians, that pharmacy technicians perform those delegated tasks under the direct supervision of a licensed pharmacist, and that the ratio of pharmacy technician to pharmacist is 1:1 unless permission is obtained for more with the maximum being 3:1. The majority of the 50 states (74%) use the designation pharmacy technician (NABP, 2003). Among the 50 states, 10 designations are used, of which five are used in only one state each. Like the majority of states, the designation used in Florida is pharmacy technician (NABP, 2003) (Table 2-1). Thirty-five (70%) states either license, register, certify, require PTCB Certification, and/or have pharmacy technici an training or educational requirements. Two additional states have proposed some such sort of credentialing requirements. One other state reports that a pharmacist must notify the board of technician employees.

PAGE 28

14 Florida has no such requirements (NABP, 2003). Thirty-two states reported that the board can revoke, deny or suspend technician registration (NABP, 2003) (Table 2-2). Table 2-1. Pharmacy Technician Designations Used Designation Number Ancillary Personnel 1 Pharmaceutical Technician 1 Pharmacy Personnel 1 Pharmacy Technician 37 Registered Pharmacy Technician 2 Supportive Personnel 3 Technician 1 Unlicensed Person 2 Unlicensed Personnel, Unlicensed Assistant 1 Total 50* *One state does not address the use of pharmacy technicians in its state statutes or regulations (NABP, 2003) Table 2-2. Pharmacy Technician Credentials Mandated by States (Includes the District of Columbia, Guam and Puerto Rico) Credential Number Unspecified Certification 4 PTCB Certification 2 License 7 Permit 1 Enrolled 1 Register 23* Training 28** *Data for one state was missing **One state responded no to requiring traini ng but had specific training requirements detailed in the notes (NABP, 2003) Despite the low number of states reporting certification requirements in the NABP survey, a review of all of the data including the notes revealed that many more than six states mention certification. According to the PTCB, 21 states have PTCB certification in their regulations (PTCB, 2003). The NABP (2003) survey data did not clearly reflect this. It seems that some states use the term “certification” interchangeably with “PTCB certification.” Certification wa s mentioned in entries for 18 states, and

PAGE 29

15 PTCB certification was mentioned in entries fo r 12 states. Fifteen states’ entries and notes report that certification allows for expanded duties, and twelve states’ entries and notes report that PTCB certification allows for expanded duties. Additionally, three states’ entries and notes report that training allows for expanded duties. Florida was not one of these states (NABP, 2003). According to the NABP, 27 states require training of pharmacy technicians (NABP, 2003). Mississippi indicated that training wa s not required, but a footnote in the NABP 2001-2002 Survey of Pharmacy Law detailed the state’s training requirements. Florida does not have training requirements for pharmacy technicians (NABP, 2003). Eight states (16%) require continuing e ducation (CE) of pharmacy technicians. (NABP, 2003). One requires six hours of in-service training per year. Two note that PTCB CE requirements are required or that PTCB certification must be maintained. PTCB certification requires 20 hours of CE every two years, one of which must be in pharmacy law (PTCB, 2003). Five states reported that CE requirements had to be met annually with an average of seven hours per year (low=3, high=10). Three states reported that CE requirements had to be met biennially with an average of 13 hours per two years (low=8, high=20). Requirements for three states were unknown. One state required that a minimum of four hours of the state’s required 10 hours be live. Florida does not require CE of pharmacy technicians (NABP, 2003). Five states reported having technician exam requirements. Some reported that PTCB certification was required (n=3), that PTCB certification was one way to become registered (n=1), that PTCB certification or another board approved exam was required (n=2), that PTCB certification was necessary for reciprocity (n=1), and that PTCB

PAGE 30

16 certification and a state law exam were necessary (n=1). Florida has no exam requirements (NABP, 2003). Thirty-seven states have maximum technician to pharmacist ratios in ambulatory care settings (NABP, 2003). The highest ratio allowed in an ambulatory care setting is 4:1; the lowest is 1:1. Those with a maximum ratio of 1:1 allow for variances. Thirtyseven states have maximum technician to pharmacist ratios in institutional care settings. The highest ratio allowed in an institutional care setting is 5:1; the lowest is 1:1. In seven states a ratio of more pharmacy technicians to pharmacists is permitted if certification or education achievements of the technicians as required by the board are met. Florida’s highest ratio in community and hospital settings is 3:1 (NABP, 2003). Table 2-3. Pharmacy Technician Functions in the Hospital Setting Yes No Not Addressed If PTCB certified Missing Accept Called in Prescriptions from Physician’s Office 6 42 1 1 0 Enter prescriptions into Pharmacy Computer 50 0 0 0 0 Can Technicians Check the Work of Other Technicians? 8 41 0 0 1 Call Physician for Refill Authorization 39* 11** 0 0 0 Compound Medications for Dispensing 43 3 1 1 2 Transfer Prescriptions via Telephone 6*** 42 0 0 2 *One state reports that techs may not call about controlled substances **One state reports that techs may call but not receive authorization ***Two states report this acceptable if the technician is “certified” (NABP, 2003) The pharmacy technician functions in hospital and ambulatory settings show little variation. In nearly all states pharmacy technicians may enter prescriptions into pharmacy computers. In Florida pharmacy technicians may do this. In nearly all states

PAGE 31

17 pharmacy technicians may not accept called in prescriptions from a physician’s office. In Florida pharmacy technicians may not accept called in prescriptions from a physician’s office. The most disagreement among the states about what pharmacy technicians may do is whether or not they are allowed to call physicians’ offices for refills. In Florida pharmacy technicians may do this. Few states allow pharmacy technicians to transfer prescriptions. In Florida pharmacy technici ans may not transfer prescriptions (NABP, 2003) (Table23 and Table 2-4). Table 2-4. Pharmacy Technician Functions in the Ambulatory Setting Yes No Not Addressed but Discouraged If PTCB certified Missing Accept Called in Prescriptions from Physician’s Office 7* 39 1 1 0** Enter prescriptions into Pharmacy Computer 50*** 0 0 0 0 Can Technicians Check the Work of Other Technicians? 5 44 0 0 1 Call Physician for Refill Authorization 33 4 0 1 2 Compound Medications for Dispensing 43 8 1 0 0 Transfer Prescriptions via Telephone 6 42 0 0 2 *Three states report this acceptable if the technician is “certified” **Two states report pilot programs are underway ***May key in but not enter (NABP, 2003) There is little variation in allowing tech-check-tech. Eight states allow it in institutional settings and five in ambulatory settings. Three additional states report reviewing or studying tech-check-tech. In Fl orida pharmacy technicians may not perform the final check (NABP, 2003). Since it is hard to check a compounded product to ensure that the appropriate ingredients have been used in the correct quantities, many states do not permit pharmacy technicians to compound in either the ambulatory setting or the

PAGE 32

18 institutional setting or both. Florida allows pharmacy technicians to compound in both settings (Table2-3 and Table 2-4). Empirical Studies of the Optimal Function of Pharmacy Technicians Studies of the practice of pharmacy technicians have been described, but are somewhat dated. These works are descriptive and cover a range of issues including functions and prevalence of pharmacy technicians. The works tend to focus on the hospital settings since many of the studies were conducted by the American Society of Health-Systems Pharmacists (ASHP). These works range in date of publications from the early eighties to the late nineties. Studies at the National Level The American Society of Health-Systems Pharmacists (ASHP) conducted national surveys of pharmacy technician practice in hospitals and community settings in 1981 (Greenberg, 1981) and in 1985 (Hogan, 1985). Hogan (1985) found that of the 41 ASHP’s affiliated state chapter presidents who responded, all indicated that their states allowed pharmacy technicians to be used in hospital settings, and all but eight indicated that their states allowed pharmacy technicians to be used in community settings. The respondents indicated that all but five of the 25 functions Hogan assessed were permitte d in at least 30% of the 41 states. Those functions that were permitted in at least 30 states included (1) inventory management tasks, such as unit does packaging and labeling, bulk compounding of medications, and bulk reconstitution of injectable medications; (2) Processing of medication orders, including receiving written drug orders, filling new orders, typing labels, physical and written maintenance of medication profiles, reconstitution, compounding and delivery of non controlled substances; (3) handling of controlled substances such as the delivery of

PAGE 33

19 controlled substances to patient care areas, and the maintenance of records. The five tasks that were not so commonly permitted were: (1) the extemporaneous compounding of medications (n=25); (2) receiving telephone orders (n=6); (3) receiving oral orders (n=4), (4) transcribing oral orders (n=5), and (5) handling information requests (n=17). Stolar (1981) conducted a national survey of pharmacy technician practice in hospitals (Stolar, 1981). Stolar (1981) found that according to the directors of pharmacy at 462 of 808 randomly selected American hospitals the mean length of employment for a hospital pharmacy technician was 3.9 years. Of 674 respondents, 75.4% used pharmacy technicians, with the highest percentage of use (94.6%) of pharmacy technicians occurring in hospitals with 300 to 499 beds, and the lowest percentage of use (56.6%) occurring in hospitals with less than 100 beds. Of the technician-user hospitals, 43.8% indicated that they were in need of additional technicians, with the highest occurrence (64.1%) among hospitals with more than 500 beds. The most common reason (66%) given by hospitals reporting technician need was insufficient funds to hire more pharmacy technicians. Thirty percent of technician-user hospitals reported having several levels of pharmacy technicians with the incidence increasing with hospital bed size. The 1991-1994 Scope of Pharmacy Practice Project described the functions that pharmacy technicians perform in different settings in all states (ASHP, 1994; Meade, 1994). The study found that the pharmacy technicians interviewed spent 26% of their time collecting, organizing, and evaluating information; 21% of their time developing and managing medication distribution and st ock; and 7% of their time providing drug

PAGE 34

20 information and education. This study was used to develop the Pharmacy Technician Certification Examination (Muenzen et al., 1999). A Drug Topics/Hospital Pharmacist Report survey of more than 600 pharmacists nationwide found that the most common task performed by pharmacy technicians is to ring up customers’ purchases (96%). Other top duties included stock/update shelves (94%), place medications into vials (91%), perform clerical duties (89%), place prescription label on container (85%), and enter prescriptions into pharmacy computer (84%). The least common duties were prepare medications in cards for nursing homes (28%), blister-pack medications for future use (26%), compound medications for dispensing (22%), and accept called-in prescriptions from physician’s office (13%). These results are presented in aggregate despite the setting specific (community versus hospital setting) nature of many of these tasks (Drug Topics, 1999). The Pharmacy Practice News’ survey found that in 2003 among most pharmacies surveyed pharmacy technicians performed the following duties: repackaging (93%), phones (93%), parts of filling process (91%), and inventory/purchasing (90%) (Pharmacy Practice News, 2003). The least common duties were drug administration (4%), patient interaction (7%), reimbursement (28%), and parts of checking process (30%). Studies at the State Level A few studies have surveyed the prevalence and function of the pharmacy technicians in more localized areas. The employment and responsibilities of technicians in hospital and community pharmacies in South Carolina has been described (Ballington et al., 1990). Ballington et al., (1990) found that 100% of hospital pharmacy directors (n=78) reported using pharmacy technicians and 63% of community pharmacist respondents (n=613) reported using pharmacy technicians. The most commonly reported

PAGE 35

21 community pharmacy technician activity was receiving prescriptions from patients (60%), and the least was filling nursing home medication carts (2%). The low frequency of the latter is probably confounded by the fact that few community pharmacies perform such a task. The least commonly reported community pharmacy technician activity that is typical of community pharmacy practices was compounding (7%). The most commonly reported hospital pharmacy technician activity was delivering and returning medications (87%), and the least was chemotherapy (9%). The meaning of chemotherapy was not defined but the implied meaning is preparing or compounding chemotherapeutic agents, a dangerous task. The pharmacy activities that pharmacists delegate to technicians in Tennessee has been described (Phillips et al., 1988). Phillips et al.(1988) found that in Tennessee the dispensing task most frequently delegated to pharmacy technicians in community pharmacies was to file the completed drug order (83% of 767 community pharmacies) and in hospital pharmacies was delivering drugs (95.1% of 153 hospital pharmacies). The supportive task most frequently delegated to pharmacy technicians in community pharmacies and hospital pharmacies was to stock shelves with drug items (84.7% in community, 98.6 in hospital). Ten percent of the respondents reported permitting five activities that were required by the Tennessee Board of Pharmacy to be performed only by a pharmacist: (1) affix label to container, (2) certify written drug order, (3) compound topical preparations, (4) receive telephone drug order, and (5) reconstitute needed amount of drug. The most common therapy-related activity delegated by the respondents to pharmacy technicians was recommending nonprescription products to patients (57.7% community, 23.3% hospital).

PAGE 36

22 Evaluations of Performance of Pharmacy Technicians Evaluations of the performance of pharmacy technicians suggest that appropriately and well-trained pharmacy technicians can perform technical pharmacy services at a cost savings compared to pharmacists. Such studies include studies of ambulatory dispensing (count and pour) and tech-check-tech. The studies suggest that use of trained pharmacy technicians in the dispensing process allows pharmacists more time to spend on clinical activities as well as saves money. Community Dispensing Study McGhan et al., (1983) compared pharmacist and pharmacy technician dispensing of prescriptions in an ambulatory care setting. Pharmacists and pharmacy technicians were randomly assigned prescriptions to fill. A pharmacist performed the final check. The five pharmacists in the study were highly experienced having between four and 19 years of experience. At the time, technician dispensing was uncommon although this is no longer the case. In order to obtain approval for the study from the state board, the authors had to train the pharmacy technicians. The technicians participated in a fourweek training program. The study found that pharmacists spent significantly less time filling prescriptions than the pharmacy technicians (1.86 minutes per prescription versus 2.11). Pharmacy technicians in the study filled more prescriptions than pharmacists in the study (1011 prescriptions versus 881) with fewer errors (44 technician errors versus 48 pharmacist errors). A chi-square analysis of the errors was insignificant. The pharmacists were found to spend more time counseling patients per counseling session after the introduction of pharmacy technician dispensing (2.89 minutes per counseling session versus 3.88 minutes).

PAGE 37

23 Institutional Tech-Check-Tech Studies In a systematic review of the literature, Wilson (2003) found 11 studies in 10 publications that evaluated tech-check-tech. In the two studies that Wilson (2003) found which compared the accuracy rates of pharmacists and pharmacy technicians checking the same samples, the results disagreed. In one the pharmacists were more accurate, in the other the technicians were more accurate. In the two studies that Wilson found that had error detection rates of pharmacists and pharmacy technicians checking different samples, the pharmacists did not detect as many errors as the technicians did. Wilson found that overall the studies did not compare the differences between the ability of pharmacists and technicians to check for accuracy, but that they compared the effects of training on the technicians’ ability to check for accuracy relative to pharmacists who did not receive training. One study reported that testing its intervention was its goal. Two had no intervention. Wilson concluded that educational training on checking can increase accuracy of checking unit-dose dispensing which might be appropriate for technicians. The use of tech-check-tech may be used to increase pharmacists time providing clinical services and to reduce dispensing costs. In 1996 the California Board of Pharmacy ruled against the practice of tech-check-tech, which had been in use at many of the state’s institutions for years (Gebhart, 1997). Institutional administrators suggest this resulted in reduction in clinical services by pharmacists, along with increased costs due to pharmacists performing the final dispensing check (Gebhart, 1997). In addition to helping fulfill the workforce shortage in pharmacy, technicians could provide costeffective drug-dispensing services. Pharmacists’ salaries are higher than technicians’. A cost comparison of technicians and pharmacists checking refills for unit dose medication

PAGE 38

24 and IV admixture refills based on a pharmacist average salary of $25.69/hour (CAN) ($17.21 1994 USD) and a senior pharmacy tec hnician average salary of $18.23/hour (CAN) ($12.21 1994 USD) plus benefits found a net savings estimated at $21,421 (CAN) ($14352.07 1994 USD) (per year by using technicians to check the final product (Klammer & Ensom, 1994). The American dollar estimates were calculated by multiplying the amounts time .67, which was the estimate for conversion generated by a web based conversion calculator for target dates between January 01, 1994 and June 01, 1994 (International Currency Converter, 2004). Court Judgment In 2002 a jury awarded the family of an infant who apparently suffered neurological damage from an overdose of a medication (Young, 2002). The error was initially made by a technician and not caught by the pharmacists prior to dispensing. The award was brought against two of the hospital’s pharmacists, and the technician, but not the hospital. Technology and Pharmacy Technicians As discussed above training may be effective in reducing error in tech-check-tech. Also effective may be technology. Technology such as unit-of-use packaging and barcodes could be used to enhance the error detection rate of tech-check-tech. The use of scanners and barcodes in checking medication cassettes has been found to increase accuracy, increase the speed of checking, and to allow the final verification to transfer from a pharmacist to a pharmacy technician (Meyer et al., 1991). Unit-of-use packaging has been found to save pharmacists time, increase accuracy, and increase the use of pharmacy technicians in the dispensing process (Lipowski et al., 2002).

PAGE 39

25 Due to a lack of published empirical studies that model the optimal function of pharmacy technicians, this chapter has presented the current function of pharmacy technicians in the US, and will follow with a description of a model of professional expertise that was used to examine pharmacy technicians’ tasks and role in pharmacy. Summary The practice of pharmacy technicians in the United States is relatively new. While studies have worked to describe the current use of pharmacy technicians little work has explored what tasks pharmacy technicians should perform. This work investigates pharmacist and pharmacy technician beliefs on what tasks or functions pharmacy technicians should perform for Florida. The credentialing of pharmacy technicians is inconsistent among the 50 states. Pharmacy technician credentials should reflect the skills and qualities that pharmacy technicians need in order to best serve patients. Such a skills and qualities should be assessed within a framework. This work not only explores the types of tasks that Florida pharmacists and pharmacy technicians believe that pharmacy technicians should perform, but also explores skills and qualities that those tasks are associated with. The literature contains evaluations of pharmacy technician performance on prescription entry in community pharmacy and tech-check-tech in hospitals. Future evaluations of pharmacy technician performance could be also evaluate pharmacy technician performance and their cost effectiveness of performing the tasks or types of tasks that pharmacists and pharmacy technicians believe pharmacy technicians should perform.

PAGE 40

26 CHAPTER 3 THEORETICAL FRAMEWORK OF PROFESSIONAL EXPERTISE This chapter discusses the theoretical framework of professional expertise that was used in this study. Using theoretical framework to address the questions posed by this research allowed the work to go beyond a basic descriptive state. If no theoretical framework were available the groundwork of developing a framework would be needed before an instrument to evaluate the tasks and functions of pharmacy technicians within a context of professional expertise could be developed. The domains of functions filled by professionals such as pharmacists and pharmacy technicians need to be evaluated in terms of the beliefs of those professionals. Pharmacist and pharmacy technician beliefs on the tasks and functions that a pharmacy technician should do need to be evaluated within a theoretical framework that logically fits those tasks and functions. Overview The way the term professional judgment is used to define pharmacy technicians and those tasks that pharmacy technicians can and can not do suggests that in the pharmacy context, the term is being used to describe a level of expertise or some ‘tool kit’ of knowledge and skills. Examination of the literature revealed no work in pharmacy describing a conceptual foundation for professional judgment. Related work examining pharmacists’ perceptions of their “professional responsibility” in patient care has been conducted (Planas et al., 2001). Work in other health care fields has defined and examined related concepts of “expertise” and “expert practice”. The Jensen, Gwyer, Shepard and Hack Model of Expert Practice in Physical Therapy examines the domains

PAGE 41

27 of “expertise” in physical therapy and seems to offer a foundation for examining expert or professional practice in pharmacy (Jensen et al., 1999; Jensen et al., 2000). For that reason the Jensen Model of Expert Practice is adapted to pharmacy in this work. Description of the Theoretical Framework of Professional Expertise Jensen et al. (1999) used the Grounded Theory Approach to study expertise. They studied clinical expertise in four clinical specialty areas in physical therapy: geriatric, neurology, orthopedic and pediatric practice (Jensen et al., 1999; Jensen et al., 2000). The study identified four dimensions of professional expertise: knowledge, clinical reasoning and judgment, movement, and virtues (Figure 3-1). The framework was specific for physical therapy but seems to capture the nature of professional expertise for all health care fields. In the following section, the framework is described as Jensen et al. (1999) described it. Then it is adapted to describe the professional expertise of pharmacy practice. Figure 3-1. Model of Expert Practice for Phys ical Therapy (Adapted from Jensen et al., 1999) Philosophy of practice Knowledge Virtues Movement Clinical Reasoning

PAGE 42

28 Knowledge One dimension of professional expertise involves the sources and types of knowledge experts use in clinical practice. Knowledge involves the knowledge of practice procedure specific to the professional’s practice. It is continually developing. It is multidimensional and focuses on the patient. This knowledge goes beyond the expert’s professional education, and involves continued learning. Experts have a “deep understanding” of their field, and they work to increase that understanding. The first year out of school, I immediately felt like I had to go back to things I learned in physical therapy school and refile everything, because everything I learned was from one perspective and I need to immediately pull it out by diagnosis. . .I realized when I did that what I had for any given diagnosis was incomplete. . so I went to the library and started looking up spinal bifida or any diagnosis and just pouring through the articles. This was a completely different type of learning and I just loved it. (Jensen et al., 2000, 35) Experts are reflective. They seek answers to problems that patients are having. When an intervention fails, experts try to understand why. Knowledge includes a reflective process where the professional gains new knowledge from experience. Experts learn from mistakes and from successes through reflection. I was at this clinic doing what I had learned in school and from a long-term course, and what I would find is that pa tients I would treat and could not help would go to see another practitioner. Then, in 2 or 3 months, I would see them and they would say they saw this practitioner and were helped in 1 or 2 visits. I said to myself, “I have to find out what that person is doing.” (Jensen et al., 2000, 35) The patient is an important and trusted source of knowledge. Knowledge of the patient beyond the health problem or mechanism of the problem is important. This knowledge includes understanding the patients’ support system, work and home

PAGE 43

29 activities, and other health problems and therapies. Experts consider the skill of listening to patients as essential to evaluation. It is important for an expert to understand a patient’s problem in order to teach the patient how to manage the problem. You get a lot of good information. . .You just let your patients talk and give it to you as they want it to come out. (Jensen et al., 2000, 35) Clinical Reasoning and Judgment Another dimension of professional expertise is the clinical-reasoning and judgment or decision-making method experts use when collaborating with providers, patients and caregivers. It is used in problem solving. It is patient centered. Clinical reasoning is a process the expert uses to solve the problems that patients challenge them with. Experts’ services include figuring out solutions to patients’ problems. It is a collaborative process with the patient. I feel I spend the majority of time explaining to people what the problem is and then teaching them the ideas behind the therapy and then getting them to help me design their exercise program. They do all the work. When they come back, I check their progress. The more I explain to them the idea behind the intervention, the more they buy into it. (Jensen et al., 2000, 38) Clinical reasoning and judgment involves practical reasoning and moral reasoning. Still, experts are not afraid to take risks. You learn to teach yourself. You need to ask questions, to think about what you are doing. I can see 2 people with a vestibular injury, and their test results look the same. And these 2 people are completely different in terms of how they’re doing with treatment. Why is that? How can I explain that? Trying to figure it out helps you to begin to identify the problem, and that makes for good scientific inquiry. (Jensen et al., 2000, 38) Clinical reasoning is patient specific. The expert focuses on the patient. The expert values the activities or goals of the patient. Clinical reasoning is a collaborative process between the expert and the patient. It focuses on what is happening to the patient

PAGE 44

30 functionally. The professional has to consider the patient’s diagnosis, needs and goals in evaluating and developing an intervention. The diagnosis [medical] itself is not as important as functionally what am I seeing that is happening. I like to know the diagnosis, especially when it comes to fractures and other conditions. .,but what is the reason their mobility is jeopardized? Is it a little bit of arthritis? Is it a little bit of neurological problems? Is it a little bit of stenosis? (Jensen et al., 2000, 38) Movement Another dimension of professional expertise is the process of evaluating a patient’s problem and teaching the patient how to manage the problem. In physical therapy the evaluation is done through the assessment of movement. The problem itself is movement. The solving of a problem is done by teaching the patient how to move. The therapist also uses movement of his own body to do these things. The physical therapist must make an assessment of the patient’s movement Movement is a tool for problem assessment and data gathering. Experts must interact with patients in order to obtain the information that they need to evaluate the patients’ problems. I have to feel what the patient is doing. Somebody will say, ‘Well, what do you think is wrong?’ or ‘what can I do to make his gait better?’ and I say, ‘Well, I don’t know, let me feel.’ And then I can say, ‘There’s not enough weight shift. You need to facilitate this aspect of the movement and so on.’ (Jensen et al., 2000, 38) Experts seek to make the intervention patient specific. Experts must obtain information to develop interventions that patients can manage. [From video observation] You see here I am allowing the patient to move the way she wants to move. [Patient is going down stairs by leaning forward using both handrails and descending step over step.] I have had patients who have never gone up their stairs step over step with alternating legs, so I’m not going to teach them something new. (Jensen et al., 2000, 39)

PAGE 45

31 Virtues Another dimension of professional expertise is the virtue of caring. Experts value their clinical practice and their patients. Experts are intrigued by their practice. They have high motivation and internal drive. Experts set high standards for themselves. They are driven to stay current in their field. They are driven to do what is best for the patient. I look at the patient as being a mystery. I love to get a new patient because it is a new problem to solve. It is exciting, and if it wasn’t, I wouldn’t be practicing today. (Jensen et al., 2000, 39) Experts value their patients. They communicate a sense of caring for and commitment to their patients. Experts do not judge their patients, they seek to solve the patients problem. Part of an expert’s professional role is as an advocate for the patient. Experts spend time working to obtain the best care and resources for patients. They may have to deal with providers, caregivers or payers to do this. I have spoken with the MD at the rehab center who is following the patient and told her about the discharge from home care and my anticipation that she would be followed by outpatient therapy. The MD said she would write the prescription. Then I made a follow-up call to the secretary. The patient did not have the prescription yet from the MD. So a week and one half later, I made another contact with the physician, and she wrote it then while I was with her. Then I checked with the secretary, and she still didn’t have the prescription. Now, I am going to have to call the MD again. (Jensen et al., 2000, 39) Adapted Framework of Expert Practice for Pharmacy The Jensen et al., 1999 Model of Expert Practice in Physical Therapy is made up of four dimensions: knowledge, clinical reas oning and judgment, movement, and virtues. Jensen’s framework is specific for physical therapy but can be adapted to represent professional expertise for all health care fields.

PAGE 46

32 The dimension of movement in the framework captures the need of the physical therapist to move the patient to evaluate the problem. The therapist must then guide the patient in how to move in order to solve the problem. This dimension of movement can be viewed as comprising patient assessment and education. In this way the expert must communicate with the patient in order to understand the problem, determine how to make a patient specific intervention and then to teach the changes involved to the patient. The focus of movement is redefined in order to apply the model to the context of pharmacy practice. The four dimensions of the adapted model are (1) knowledge and skills, (2) reasoning and judgment, (3) patient assessment and education, (4) and virtues. Knowledge and Skills One dimension of professional expertise involves the sources and types of knowledge pharmacy professionals use in pharmacy practice. Knowledge involves the knowledge of practice procedure specific to the professional’s practice. It is continually developing. It is multidimensional and focuses on the patient, product and service. Pharmacy practice is a rapidly cha nging field. New drugs, devices, knowledge and techniques are developed. Pharmacy professionals must update their knowledge and skills regularly to keep abreast of the profession. Educational articles, presentations, on site experience, fellow professionals, reference books, package inserts, the Internet and training sessions are means of acquiring new knowledge in pharmacy practice. The patient is a trusted source of information. When a pharmacy professional notices that a patient is refilling a prescription 14 days early, he asks the patient about his use of the drug. The patient is the one who has the most knowledge about his use of his medicines and pharmacy professionals use that source.

PAGE 47

33 Pharmacy professionals often have to speak to third party payers, other health care providers and other pharmacies to obtain information they need to properly care for a patient. When something does not make sense they follow up on it to ensure proper patient care. Pharmacy professionals are themselves a trusted source of knowledge. Other health care providers and patients consult with pharmacy professionals when making decisions or seeking solutions to problems. Reasoning and Judgment Another dimension of professional expertise in pharmacy practice is the clinicalreasoning and judgment or decision-making experts use when collaborating with providers, patients and caregivers. It is used in problem solving. It is patient centered. Pharmacy practice involves a great deal of problem solving. Pharmacy professionals are often relied on as a safety net to catch errors or potential problems that a patient may have with a drug therapy. Other health care professionals and patients rely on and expect pharmacy professionals to catch and prevent potential problems. Pharmacy professionals must evaluate drugs and their potential use during the dispensing process. It is often in the reading of prescriptions that problems come to light and must be solved. Pharmacy professionals must then consider alternatives and solutions. Pharmacy professionals use reasoning and judgment to provide patient care. Pharmacists talk to patients about their drugs and disease and try to help the patients predict problems of adherence and use ahead of time. Patients often seek pharmacy professionals to help them solve problems with their therapy or condition. Patients often

PAGE 48

34 seek the pharmacists to ask questions about the appropriateness of their therapy, alternative therapy, or side effects. Patient Assessment and Education Another dimension of professional expertise is the process of evaluating a patient’s problem and teaching the patient how to manage the problem. Recall that in physical therapy, the evaluation is done through the assessment of movement. For pharmacy this construct is the more general one of patient assessment and education. Pharmacy professionals assess information about patient therapy. This information is used to help in the dispensing process and in assessing the need for interventions in order to meet therapeutic goals. Assessments come in many forms. Pharmacy personnel must assess if the patient prefers generics, and if they have drug allergies. Pharmacists must assess if the patient has potential problems with taking the medication. They also must evaluate potential problems that may be hidden from patient knowledge such as interactions with over-the-counter drugs that the patient may be taking. They may find that the diagnosis that the patient reports is not congruent with the medication that has been prescribed. Once assessments have been made it may be necessary to help the patient change the way they use their medications. Interventions such as educating patients on how to use a drug properly, how to improve compliance, or how to administer a drug must be targeted to the patient. Virtues Another dimension of professional expertis e is the virtue of caring. Experts value their clinical practice and their patients.

PAGE 49

35 Pharmacy personnel care about the job they are doing. They do not want to harm patients. Pharmacy personnel work to dispense a precise and accurate product. They care for their patients’ health and will contact other health care providers and payers to ensure that the patient gets optimal care. Research Questions The research questions of this project were intended to contribute towards a conceptual understanding of pharmacy technicians. They questions address the differences and similarities between the beliefs of pharmacists and pharmacy technicians on the tasks and functions that pharmacy technicians should perform in a community setting, and how those beliefs factor relevant to the adapted theoretical framework of profession expertise. The questions were designed to evaluate the beliefs of pharmacists and pharmacy technicians relative to proposed concepts, as well as to explore for concepts if needed to guide the understanding of pharmacy technician work. In examining the Model of Expert Practice as it applies to pharmacy, this study addressed the following research questions: 1. Do pharmacists’ and pharmacy technicians’ beliefs on tasks that pharmacy technicians should perform in community practice differ? 2. Does the Framework of Expert Practice for Pharmacy fit pharmacists’ and pharmacy technicians’ beliefs on the tasks that pharmacy technicians should perform in community practice? 3. Do pharmacists’ and pharmacy technicians’ beliefs differ on the categories of tasks that pharmacy technicians should perform in community practice?

PAGE 50

36 Conclusion The Jensen et al. (1999) Model of Expert Practice in Physical Therapy was developed using grounded theory. It is specifi c for physical therapy but can be adapted to represent professional expertise for all health professionals. The framework is made up of four dimensions: knowledge, clinical reas oning and judgment, movement, and virtues. The concept of movement can be viewed as the processes involved in assessing patient’s medication related problem and educating the patient to prevent or resolve medication related problems.

PAGE 51

37 CHAPTER 4 METHODOLOGY Introduction This study used a mail questionnaire to survey Florida community pharmacists and Florida community PTCB certified pharmacy technicians. The study developed and attempted to validate an instrument: The Community Pharmacy Technician Use Questionnaire. The validation study involved confirmatory factor analyses and compared the beliefs of two groups—pharmacist and pharmacy technicians—about what pharmacy technicians should do in community pharmacy practice sites. The methodology for this study is described in this section. First, the sampling procedure is outlined. Next, the instrument development as well as the means of determining reliability and validity of summated scales are described. Statistical analyses appropriate to the research questions are described. Subjects In order to investigate the research questions pharmacists and pharmacy technicians working in community pharmacy were identified for inclusion in this study. Address labels for community pharmacists and their home addresses was purchased from a seller of commercial lists. The seller claimed that the address labels were a random selection of all community pharmacists working in the state of Florida for which a mailable home address existed. The list was purchased in late March of 2004. A random sample of Pharmacy Technician Certification Board (PTCB) certified pharmacy

PAGE 52

38 technicians who reported to the board that they worked in a community pharmacy setting and who had a Florida home address was used. The PTCB supplied the list of 2000 PTCB certified community pharmacy technicians living in Florida in late June of 2004. Study Variables and Operationalization of Constructs Instrument Development The development of the instrument, The Community Pharmacy Technician Use Questionnaire, is described here. The instrument items were developed through an iterative process. They were developed based on the Jensen et al., Model of Professional Expertise. Jensen described the framework and its development in their book “Expertise in Physical Therapy Practice” (1999). Original Item Pool The items are limited to the scope of community pharmacy practice. First a list of the types of tasks that are performed in community pharmacy was created. The list was created by imagining all possible tasks within a community pharmacy, then revised through peer review. Items representing each task were then written. The items were then grouped under the four constructs of the framework according to the description of the framework given by Jensen et al. (1999). An expert committee reviewed the items and 57 items were selected for testing. Focus Group Four one-on-one interviews and a focus group of 10 pharmacists were conducted to explore how pharmacists think of the role of pharmacy technicians (Wilson et al., 2003). One of the goals of the interviews and focus group were to investigate if pharmacists thought about pharmacy technicians in terms that fit the Jensen et al., framework. Among other questions, the subjects were asked to describe the best and worst pharmacy

PAGE 53

39 technicians they had ever worked with, which tasks that they felt confident delegating to each of those types of pharmacy technicians, why they felt confident doing so, which tasks they did not feel confident delegating to each of those types of pharmacy technicians, and why they did not feel c onfident doing so. Content analysis of the transcripts from the five data collections resulted in the conclusion that pharmacists do think of pharmacy technicians in terms of the framework. Some of the comments from the focus group were used in writing the items. The content analysis of the five transcripts from the four one-on-one interviews and the focus group of 10 pharmacists found that the framework fit 179 (65%) of the 276 pharmacists’ comments that were about pharmacy technicians. The comments that the framework did not fit were discussions of tu rnover (n=20), where to find bi-lingual techs (n=1), a bad technician (n=1), models of practice such as military (n=10), pharmacy laws relevant to pharmacy technicians (n=56), and pharmacy technician pay (n=9). The text units that the framework fit sometimes contained more than one construct thus the numbers below cannot be summed. The content analysis identified four concepts that fit the construct Patient Assessment and Education. They were (1) Answer patient questions, (2) Gather information from patients, (3) Interact with or help patients, and (4) Provide information to patients. Examples of pharmacist statements are: Pharmacist: “We allow them to do some sort of talking with the customer about things…you know what is this medication for? This is for your blood pressure…What kind of drug is this? Oh this is a beta blocker. We have no problems saying just very categorical things.” Pharmacist: “If somebody had one insurance and something came up and it was wrong, they were able to go and tell this person, ‘Hey this is going on and it's not

PAGE 54

40 right.’ And then the person at the end is saving a lot of money. Because they had that input from this particular technician to let them know this is wrong.” The content analysis identified five concepts that fit the construct Knowledge and Skills. They were (1) Have an aptitude for learning, (2) Have certification, education, experience, and training, (3) Have knowledge of pharmacy practice, (4) Know the limits of their knowledge and services, and (5) Seek new knowledge. Other than Have an aptitude for learning the constructs of the Knowledge and Skills domain focused on knowledge in terms of pharmacy. Examples of pharmacist statements are: Pharmacist: “That is my definition of a good technician…well trained.” Pharmacist: “We encourage them to try and learn the drugs, know what they're for.” Pharmacist: “They need to think through it but ultimately they need to ask you or consult with you.” The content analysis identified five concepts that fit the construct Judgment and Reasoning. They were (1) Can work on more than one thing at a time, (2) Evaluate and recognize problems, (3) Have an effective and efficient approach to solving problems, (4) Make decisions, and (5) Work independently. Examples of pharmacist statements are: Pharmacist: “…a prescription that is issued correctly, written correctly, ready to go is not a big deal. It's the ones that, anytime a pharmacist has to get involved in prior to checking it, that's a big deal. And any technician should be able to manage everything right up until I sign off on it. And that is my definition of a good technician, who's well trained. Tr ouble shoot anything, and you don't have to step in.” Pharmacist: “What [pharmacist’s name] said is correct, they do have black and white decisions, but there is an avenue of judgment that goes with any job.” The content analysis identified five concepts that fit the construct Virtues. They were (1) Are team players, (2) Care about and are respectful of patients, (3) Have a good

PAGE 55

41 personality and disposition, and enjoy communicating with people, (4) Have integrity, and (5) Have a rapport with patient. Examples of pharmacist statements are: Community pharmacist: “The technician I count on the most is the one that I say, ‘Hey can you do X,Y,Z? X,Y,Z gets done. And I don't ever hear Oh, I didn't have time….They're not excuse makers. They do what needs to be done and say here's your work done. What else can I do?’” Community pharmacist: “It's good for the technicians to know that he cannot say certain things that may offend the customers.” Another goal of the focus group was to pilot test the 57 items developed for The Community Pharmacy Technician Use Questionnaire. The focus group participants completed an early version of the instrument and discussed it in terms of readability and understandability. The participants were asked to indicate whether a pharmacy technician should perform each of the 57 task s using a 6-point Likert-type scale that ranged from strongly disagree (1) to strongly agree (6). Items that had missing or unusable responses were deleted from the pool of items. Items that were discussed in the focus group as being unclear or meaningless were also deleted. Items that appeared to overlap constructs were deleted. Items that represented constructs that the participants repeatedly discussed were added. Care was taken to root each item in a pharmacy task and to isolate aspects of only one scale. One or two items for each scale were included that were thought to be beyond the capabilities of a pharmacy technician but within the capabilities of a pharmacist based on their education. Pretests The set of items developed from the focus group was evaluated through expert review and pretested on pharmacists at two continuing education programs attended primarily by community pharmacists. No factor analyses were performed on the pretested data. After the first data collection, charts showing the distributions of

PAGE 56

42 responses for each item were visually scanned for variability of response (Table 4-1). Items with low variability were rewritten for the second testing (Table 4-2). The reliability of the summated scales was tested in the two pretests. For each scale the item ratings were added for each subject. The internal consistency reliabilities of the summated scales for the four domains were determined using Cronbach’s coefficient alpha. Alpha coefficients below .6 were considered low. The contribution of an item to alpha was examined by estimating alpha for each scale Table 4-1. Item Means from First Testing Item Item Average Standard Deviation N Enter data into the computer accurately. 5.41 1.37 34 Apply insurance rules when processing a new claim 5.47 1.21 34 Obtain information from a patient needed to fill a prescription. 5.47 1.26 34 Deal with patients in a caring manner 5.56 1.21 34 Assess when a patient needs to speak to a pharmacist about their medication. 5.12 1.57 34 Understand the difference between an ace-inhibitor and a beta-blocker. 2.74 1.40 34 Evaluate the reason for a denied claim. 5.21 1.19 33 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) 3.88 1.65 34 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. 3.77 1.71 34 Identify the common side effects of a beta-blocker. 2.38 1.50 34 Determine when a prescription can be refilled. 5.00 1.41 34 Explain to a patient insurance claim that had a problem 5.47 .99 34 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 4.97 1.29 34 Include the appropriate information when labeling prescription vials. 5.21 1.49 34 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. 4.33 1.99 36 Assess a patient’s actual medication use. 2.89 1.43 36 Evaluate the reason for a denied claim. 5.21 1.19 33 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) 3.88 1.65 34

PAGE 57

43 Table 4-1. Continued Item Item Average Standard Deviation N Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. 3.77 1.71 34 Identify the common side effects of a beta-blocker. 2.38 1.50 34 Determine when a prescription can be refilled. 5.00 1.41 34 Explain to a patient insurance claim that had a problem 5.47 .99 34 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 4.97 1.29 34 Include the appropriate information when labeling prescription vials. 5.21 1.49 34 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. 4.33 1.99 36 Assess a patient’s actual medication use. 2.89 1.43 36 Be discrete with patients’ health information 5.70 1.67 36 Link the trade name with the generic name of a drug. 5.22 1.24 36 Evaluate a patient’s medication therapy. 2.63 1.66 35 Educate a patient on the appropriate use of their medication. 2.83 1.72 36 Recognize the therapeutic class of a prescribed medication. 3.25 1.78 36 Feel a personal responsibility to resolve a patient’s drug therapy problems. 3.11 1.91 36 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. 3.97 1.63 36 Table 4-2. Item Means from Second Testing Item Item Average Standard Deviation N Enter data into the computer accurately. 5.81 .68 21 Assess insurance rules when processing a new claim* 5.38 1.02 21 Obtain information from a patient needed to fill a prescription. 5.81 .68 21 Show caring for patients when assisting them* 5.86 .48 21 Assess when a patient needs to speak to a pharmacist about their medication. 5.38 1.12 21 Understand the difference between an ace-inhibitor and a beta-blocker. 2.62 1.20 21 Evaluate the reason for a denied claim. 5.29 .90 21 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) 4.05 1.80 21 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. 3.90 1.64 21

PAGE 58

44 Table 4-2. Continued Item Item Average Standard Deviation N Identify the common side effects of a beta-blocker. 2.19 .98 21 Determine when a prescription can be refilled. 5.50 1.00 20 Explain to a patient the reason a prescription cannot be filled under the patient’s insurance plan* 5.67 .73 21 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 4.86 1.35 21 Include the appropriate information when labeling prescription vials. 5.28 1.01 21 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. 3.71 2.05 21 Assess a patient’s actual medication use. 3.00 1.52 21 Protect confidential patient information from unauthorized disclosure* 6.0 0.00 20 Link the trade name with the generic name of a drug. 5.19 .98 21 Evaluate a patient’s medication therapy. 2.05 1.02 21 Educate a patient on the appropriate use of their medication. 2.43 1.29 21 Recognize the therapeutic class of a prescribed medication. 3.10 1.38 21 Feel a personal responsibility to resolve a patient’s drug therapy problems. 2.29 1.27 21 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. 3.90 1.70 21 *Item re-written after first testing after that item alone was deleted. Item-corrected total correlations were used to evaluate the correlation of an item with the sum of the other items in its scale. Item-corrected total correlations of below .3 were considered low. However, because of the low number of subjects in the two administrations, we loosened the criteria somewhat and looked at the pattern of performance for an item and scale across the two administrations. All statistics were calculated using SPSS. From the first testing, the reliability coefficient for the scale Patient Assessment and Education (n=34) was .64 while the standardized item alpha was .63 (Table 4-3). This is acceptable. For the second testing, the reliability coefficient for the scale Patient

PAGE 59

45 Assessment and Education (n=21) was .47 while the standardized item alpha was .59. In the first testing, the item “Obtain information from a patient needed to fill a prescription” had a low item-corrected total correlation but its deletion had little effect on alpha for the scale. The item performed better on the second testing with an acceptable item-corrected total correlation and did not suppress alpha. On the second testing but not the first testing, the items “Assess when a patient needs to speak to a pharmacist about their medication”, “Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.)”, and “Assess which medication a patient wants to have refilled when the patient does not know the name of the drug” had a low item-corrected total correlation, but little effect on alpha when deleted from the scale with the exception of the last item. However, this item performed well on the first administration. All of the items from this scale were included in the final questionnaire in the same form that they had during the second pre-testing. Table 4-3. Item Analysis for the Patient Assessment and Education Scale on the Pre-tests First Testing ( =.64) Second Testing ( =.63) Item Itemcorrected total correlation Alpha if item deleted Itemcorrected total correlation Alpha if item deleted Obtain information from a patient needed to fill a prescription. .16 .65 .49 .38 Assess when a patient needs to speak to a pharmacist about their medication. .32 .61 .11 .48 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .44 .57 .26 .42 Explain to a patient an insurance claim that had a problem. .35 .61

PAGE 60

46 Table 4-3. Continued First Testing ( =.64) Second Testing ( =.63) Item Itemcorrected total correlation Alpha if item deleted Itemcorrected total correlation Alpha if item deleted Explain to a patient the reason a prescription cannot be filled under the patient's insurance plan. .51 .37 Assess a patient’s actual medication use. .30 .61 .36 .36 Educate a patient on the appropriate use of their medication. .35 .60 .35 .37 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .53 .53 -.09 .61 This item was rewritten between first and second administration In the first testing the reliability coefficient for the scale Knowledge and Skills (n=32) was .60 while the standardized item alpha was .61 (Table 4-4). This is an acceptable level. It was slightly lower in the second testing. In the second testing the reliability coefficient for the scale Knowledge and Skills (n=21) was .57 while the standardized item alpha was .59. The items “Enter data into the computer accurately”, and “Identify the common side effects of a beta-blocker” had low item-corrected total correlations on the first testing but not on the second testing. In both pre-testings, the item “Include the appropriate information when labeling prescription vials” had low item-corrected total correlations but eliminating that item resulted in a reduction in alpha for the scale. The items “Link the trade name with the generic name of a drug”, and “Recognize the therapeutic class of a prescribed medication” had low item-corrected total correlations on the second testing but not the first testing. All of the items from this scale were included in the final questionnaire.

PAGE 61

47 Table 4-4. Item Analysis for the Knowledge and Skills Scale on the Pre-tests First Testing ( =.60) Second Testing ( =.57) Item Itemcorrected total correlation Alpha if item deleted Itemcorrected total correlation Alpha if item deleted Enter data into the computer accurately. .16 .63 .44 .50 Identify the common side effects of a beta-blocker. 16 .63 .49 .45 Include the appropriate information when labeling prescription vials. .25 .60 .22 .56 Link the trade name with the generic name of a drug. .49 .51 .00 .64 Recognize the therapeutic class of a prescribed medication. .51 .47 .28 .55 Understand the difference between an ace-inhibitor and a beta-blocker. .52 .48 .55 .40 In the first testing the reliability coefficient for the scale Reasoning and Judgment (n=32) was .41 while the standardized item alpha was .50 (Table 4-5). This is low. In contrast in the second testing the reliability coefficient for the scale Reasoning and Judgment (n=20) was .71 while the standardized item alpha was .76. The item “Apply insurance rules when processing a new claim” had a low item-corrected total correlation on the first testing, but a rewritten version of the item had an adequate item-corrected total correlation on the second testing. The items “Evaluate a patient’s medication therapy”, “Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist”, and “Evaluate whether a computer generated DUR needs to be shown to the pharmacist” had low item-corrected total correlations on the first testing but eliminating any of the items did not substantially increase alpha for the scale and the items item-corrected total correlations on the second testing were not low. All of the

PAGE 62

48 items from this scale were included in the final questionnaire in the same form that they had during the second pre-testing. Table 4-5. Item Analysis for the Reasoning and Judgment Scale on the First Pre-test First Testing ( =.41) Second Testing ( =.71) Item Itemcorrected total correlation Alpha if item deleted Itemcorrected total correlation Alpha if item deleted Apply insurance rules when processing a new claim. .21 .37 Assess insurance rules when processing a new claim. .57 .65 Determine when a prescription can be refilled. .33 .28 .49 .67 Evaluate a patient’s medication therapy. -.04 .54 .38 .69 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .30 .32 .47 .67 Evaluate the reason for a denied claim. .37 .30 .65 .64 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .21 .37 .38 .75 This item was rewritten between first and second administration. In the first testing, the reliability coefficient for the scale Virtues (n=34) was .42 while the standardized item alpha was .49 (Table 4-6). This is low. In the second testing the reliability coefficient for the scale Virtues (n=20) was .35 while the standardized item alpha was .44 (Table 4-11). This is also low. In the first and second testing, the item “Feel a personal responsibility to resolve a patient’s drug therapy problems” had a low item-corrected total correlation, but it affected alpha for the scale only on the first testing.

PAGE 63

49 Table 4-6. Item Analysis for the Virtues Scale on the First Pre-test First Testing ( =.42) Second Testing ( =.35) Item Itemcorrected total correlation Alpha if item deleted Itemcorrected total correlation Alpha if item deleted Feel a personal responsibility to resolve a patient’s drug therapy problems. .03 .60 .20 .28 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .36 .19 .26 .18 Be discreet with patient health information. .32 .29 Protect confidential patient information from unauthorized disclosure. ** ** Deal with patients in a caring manner. .32 .28 Show caring for patients when assisting them. .30 .30 This item was rewritten between first and second administration. ** This item had no variability on the second pre-test thus it was not included in the item analysis In first testing the item “Feel a personal responsibility to resolve a patient’s drug therapy problems” had a low item-corrected total correlation and suppressed alpha. On the second administration that item had a higher item-corrected total correlation and did not substantially suppress alpha. That item was reworded for the final questionnaire as “Assume personal responsibility to resolve a patients’ drug therapy problems.” In the second testing but not the first testing the item “Go out of their way to assist a patient in obtaining aid to pay for their prescriptions” had a low item-corrected total correlation. On the second administration that item did not substantially suppress alpha. In the second testing the item “Protect confidential patient information from unauthorized disclosure” had zero variance and thus was not included in the item analysis. The

PAGE 64

50 wording from the first testing was retained in the final instrument. The item “Deal with patients in a caring manner” from the first testing contributed more to alpha than did the rewritten version used in the second testing. The wording from the first testing was retained in the final instrument. Three items were added to the instrument’s Knowledge and Skills scale after the pre-testing based on the National Association of Boards of Pharmacy 2003-2004 Survey of Pharmacy Law and the importance that these tasks play in pharmacy. Those items are “Transfer a patient’s prescription.”, “Accept called in prescriptions from physicians’ offices.”, and “Call physicians for refill authorization.” The final number of items included in The Community Pharmacy Technician Use Questionnaire was 26. The final instrument was developed through expert review and the use of the data from the pretests. Data Collection Procedures All subjects were contacted by mail. A cover letter, a copy of The Community Pharmacy Technician Use Questionnaire and a business reply envelope were mailed to each subject in two separate mailings. The first mailing for the pharmacists went out on August 10, 2004; and the first mailing for the technicians went out on August 12, 2004. Subjects were asked to participate and return the instrument in the provided envelope (Appendix A and Appendix B). After two weeks, subjects were sent a letter that thanked those who had responded, and asked those who had not yet responded to complete the survey and return it (Appendix C). A second questionnaire and business reply envelope were included. The second mailing for both groups went out on August 25, 2004. The data collection for this analysis was closed on September 17, 2004.

PAGE 65

51 Questionnaire The questionnaire was designed to be straightforward, easy to understand, and professional in appearance. It was review ed by five individuals and approved by the University of Florida’s Institutional Review Board. The questionnaire was four pages. The first page was a cover bearing the title “Pharmacy Technician Responsibility Instrument” and the seal of the University of Florida’s College of Pharmacy (Appendix D and Appendix E). The second page included questions about the subjects’ practice experience. These questions were specific to the type of subject (pharmacists versus pharmacy technicians). Pharmacist subjects were asked to indicate the number of years they have practiced, their type of practice site, the number of technicians that they have supervised in their career, the number of competent technicians they have supervised in their career, if they have supervised a pharmacy technician with Pharmacy Technician Certification Board certification (CPhT), and if they have supervised a pharmacy technician with a two year associates degree in pharmaceutical sciences. Competence was not defined for the subjects. Superv ision was defined as direct, personal and immediate supervision. The pharmacy technician subjects were asked to indicate the number of years they have practiced, their type of practice site, and their pharmacy credentials and education. The third and fourth pages of the questionnaire were composed of The Community Pharmacy Technician Use Questionnaire. An area for comments was included for the subjects. The Community Pharmacy Technician Use Questionnaire The Community Pharmacy Technician Use Questionnaire presented subjects with pharmacy tasks relevant to the framework of professional expertise. The subjects

PAGE 66

52 indicated their beliefs on whether a capable pharmacy technician should perform tasks that were selected and pretested to represent the constructs of the framework. The subjects indicated their beliefs on whether a capable pharmacy technician should perform each task by selecting one through six on a six point Likert-type scale ranging from ‘strongly disagree’ to ‘strongly agree.’ Using a six point scale ensures that the respondents have enough choice to allow for some variation in responses while preventing them from choosing a neutral position. The questionnaire attempted to measure the subjects’ beliefs about whether or not they agreed that a pharmacy technician should or should not perform the tasks represented by the items. The leading statement for the items read, “A capable pharmacy technician should:” A brief statement preceding the stem encouraged the subjects to think of what a capable pharmacy technician should do assuming each task were allowed by law. That statement was: “Please assume that all tasks listed in this survey are not restricted under the law. Assume that all of the tasks listed below are permitted by law.” Instrument Validation The framework of professional expertise is useful in describing functions of pharmacists and pharmacy technicians. The instrument that measures the constructs relevant to pharmacy technicians was investigated in terms of its abilities to measure these constructs. Such an investigation is part of the validation of the instrument. This work attempted to measure the validity of interpretations made on the basis of data collected using an instrument designed to measure the beliefs of pharmacists and pharmacy technicians about what types of tasks a capable pharmacy technician should perform in community practice. It is important that the construct validity of the

PAGE 67

53 interpretations drawn based on the data collected with the instrument be measured. That is to say, it is important to evaluate how accurate the instrument’s operationalization of the construct is. The construct validity was evaluated using confirmatory factor analysis. The primary goal of this research requires the development and testing of an instrument using a framework of the professional expertise of pharmacy. To do this the Jensen et al., framework of professional expertise described in Chapter 3 was used. The items representing the framework constructs are described above in the instrument development section, but are included here in a visual form (Figure 4-1). In Figure 4-1 the i represent the error variances (small rectangles) on the observed variables (items in long rectangles), while the i (small rectangles) represent the error variances on the latent variables (constructs in big squares). Curved lines represent correlated latent variables. First, the two groups were compared to see if the variables loaded on the same factors in both samples. In doing this we check ed to see if the model for four factors fits for the two groups. In other words we wanted to know if we were measuring the same underlying factors for both groups. In this analysis, the factor loadings for each variable were constrained to be equal for both groups. Goodness of Fit indices were used to decide whether the constrained model adequately fit the data. These indices are described in detail later. It is a way to check to see if we have the same configural invariance. Since this step failed to find evidence that the groups have the same factors an exploratory factor analysis was performe d. Multiple group CFA is used to investigate measurement invariance. Measurement invariance is “whether a set of indicators assess the same latent variables in different groups” (Kline, 1998). Group membership may

PAGE 68

54 Figure 4-1. Model Targeted in the Confirmatory Factor Analysis Assessment and Education Obtain information from a patient needed to fill a prescription. Assess when a patient needs to speak to a pharmacist about their medication. Answer simple patient questions about th eir medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) Explain to a patient an insurance claim that had a problem. Assess a patient’s actual medication use. Educate a patient on the appropriate use of their medication. Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. Knowledge and Skills Reasoning and Judgment Virtues 2 1 3 4 5 7 6 Enter data into the computer accurately. Identify the common side e ffects of a beta-blocker. Include the appropriate information when labeling prescription vials. Link the trade name with the generic name of a drug. Recognize the therapeutic class of a prescribed medication. Understand the difference between an ace-inhibitor and a beta-blocker. Transfer a patient’s prescription. Accept called in prescriptions from physicians’ offices. Call physicians for refill authorization. 8 9 15 14 13 12 11 10 16 1 2 3 Determine when a prescr iption can be refilled. Apply insurance rules when processing a new claim. Evaluate whether a computer generated DUR needs to be shown to the p harmacist. Evaluate the reason for a denied claim. Evaluate a patient’s medication therapy. Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 21 17 18 19 20 22 4 Assume personal responsibility to resolve a patient’s drug therapy p roblems. Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. Deal with patients in a caring manner, Be discreet with patient health information. 23 24 25 26

PAGE 69

55 affect the relations between the latent variables and the items. Whenever the sample comprised identifiable subgroups and we are concerned about whether the observed variables measure the same factors in the subgroups, separate factor analyses should be conducted for the subgroups. We are concerned about whether the relationships of the observed variables and the factors are the same in the two groups. For this reason, the CFAs were performed separately for the two groups. Analyses Descriptive Analyses The first research question was evaluated using Chi-square difference tests. That question was: 1) “Do pharmacists and pharmacy technician beliefs on tasks that pharmacy technicians should perform in community practice differ?”. A cut point was set to determine which items the groups feel technicians should perform. The scale was 1 (strongly disagree) to 6 (strongly agree). For each response-number an anchor was provided: (1) strongly disagree, (2) disagree, (3) somewhat disagree, (4) somewhat agree, (5) agree, and (6) strongly agree. Responses of 1-3 were considered “disagree that a technician should perform”. Responses of 46 were considered “agree that a technician should perform”. The data from the two groups on each item were then compared using Chi-square difference tests. Since there were 26 tests the p-value for a significant result was set at .05/26
PAGE 70

56 Confirmatory Factor Analysis The second research question was addressed using confirmatory factor analysis (CFA). That research question is: “Does th e Framework of Expert Practice for Pharmacy fit pharmacists’ and pharmacy technicians’ beliefs on the tasks that pharmacy technicians should perform in community practice?”. The CFA was performed using LISREL. First only cases with complete data were included in this analysis. Contrary to what is almost always done in CFA, in this case, the comparison of groups on the same scale, the covariance matrix was analyzed, not the correlation matrix. If you start with variables that have been constructed in the same fashion, then separately standardize them, the variables are not comparable for the two groups. That is what would have happened if we had used the correlation matrix for the comparison. We used the same instruments for both groups, so the measure was the same so long as we did not standardize the two groups’ data separately. Thus this comparison used the covariance matrix in order to maintain the same units of measurement for the two groups. Since we used the covariance matrix we had to set the scale by setting the factors to one. We set the scale by setting one factor loading for each factor to one. We did not set the scale by setting the factor variances equal to one, since we were using the covariance matrix in the analysis. The way that the groups are combined in the combined group CFA is by analyzing the two groups separately and then combining the fit indexes. LISREL reports the Standardized Root Mean Square Residual (SRMR) separately for each group, but reports the Root Mean Square Error of Approxi mation (RMSEA), Non Normed Fit Index (NNFI), the Comparative Fit Index (CFI) and the Minimum Fit Function Chi-Square for the two groups combined. The SRMR was set a priori at SRMR
PAGE 71

57 since the number of subjects in each group was below the number of 1000 subjects needed to require a more stringent SRMR of /= 0. 95. The more stringent NNFI is usually >/=.96. The CFI was set a priori at CFI >/= 0.95. The standard procedure for testing for invariant factor loadings is the Minimum Fit Function ChiSquare in which the null hypothesis is that the model with loadings constrained to be equal fits the data and the alternative hypothesis is that the model with out between-group equality constraints fits the data. Rejecting the null hypothesis implies that the factor loadings vary across groups. If the null hypothesis is rejected then researchers often use more subjective comparisons of goodness of f it indices such as SRMR and CFI for the two models. If the indices for the two models are then judged to be sufficiently similar, the conclusion is usually that the factor loadings vary only a little across the two groups. The procedures used to measure fit in each step of the CFA are described here. The first step of the CFA checks if the variables load on the same factors in both samples. The goodness of fit statistics were calculated using LISREL. The second step is to see if the factor loadings are equal. This would have been tested by calculating the Wald Statistic in MS Excel using the factor loadings and variances for the two groups for each variable, which would have been calculated using LISREL. The second CFA was also performed using LISREL. Cases with incomplete data were included in this analysis. The data were entered for the two groups separately into LISREL and the target model was forced. Then a null model, in which each item loaded on its own factor was forced. LISREL provided the Root Mean Square Error of Approximation (RMSEA), the Minimum Fit Function Chi-Square, degrees of freedom

PAGE 72

58 and p-value for the Minimum Fit Function Chi-Square for each model. The NNFI and CFI for the fit of the two groups model simultaneously were calculated using Excel. Exploratory Factor Analysis After the first step of the confirmatory factor analysis found that the two groups’ factor configurations were not invariant then the CFA was stopped and an exploratory factor analysis was performed to see how many factors the two groups’ items fit onto. The data from the two groups were analyzed separately. The results of the confirmatory factor analysis will be described in greater detail in the results section. The exploratory factor analyses were performed using SPSS. Analysis of the correlation matrices were used to determine the number of eigenvalues greater than one and to generate scree plots. Based on the scree plot multiple models were possible. The number of factors was determined with logic based on the number of eigenvalues greater than one and the number of factors that appear to be distinct on the scree plot. The number of factors were then forced using principle axis method and promax oblique rotation of the correlation matrix to compare the loadings of the models. The factors were expected to be correlated based on previous work with the qualitative data and a logical understanding of what the factors represent. The factor pattern were examined to determine which items loaded on which factors by looking for high loadings and logical groupings. The pattern matrix presents the observed variables’ importance to the factors with the influence of the other observed variables partialled out. The second research question was answered by the failure of the CFA, but the third question still needed to be answered following the exploratory factor analysis. Again the third research question is: “Do pharmacists’ and pharmacy technicians’ beliefs differ on

PAGE 73

59 the categories of tasks that pharmacy technicians should perform in community practice?”. Obviously to do this models that were the same for the two groups needed to be determined. This was not possible. Internal Consistency Reliability Reliability measures how free from error a measure is and how consistently that measure can obtain the same results. It does not ensure that we are measuring what we intend to measure. Measurement error can occur when the items of a test do not measure the same concept. As a check on the reliability of the factors, the internal consistency of the instrument was measured using Cronbach’s alpha. The final factors’ reliabilities were estimated for the two groups separately. This was done using SPSS v10. An alpha of .6 and above was considered an adequate level of reliability. The alpha values of the factors after deleting each item singly from a factor for the two groups were also estimated. The item-corrected total correlations were also examined. The reliability of the factors were tested separately for the two groups. Item-corrected total correlations of below .3 were considered low, but if a factor had an alpha of .6 and above no change was made to the factor. Inter-Factor Correlations The correlations among the factors scores from the two groups’ four-factor models were examined separately. For each complete case a summated score was created by adding a subject’s responses to the items within a factor together. The models’ correlations were examined separately for the two groups. The correlations were examined for strength of correlation and significance to develop an understanding of the relationships among the factors within the two models. The correlations were made using SPSS v10.

PAGE 74

60 Within-Group Comparisons of Summated Scores by Type of Experience Types of work experience that were logically thought to predict pharmacists’ summated scores and pharmacy technicians’ summated scores were examined. The summated scores that were used to calculate the correlations within groups between factors in the analysis described above were used to make comparisons within groups by types of work experience. Pharmacist work experience variables were compared with the pharmacist summated scores. The pharmacists’ summated scores were compared based on four types of work experience: (1) the number of years they reported having worked as a licensed pharmacist, (2) the calculated percent of competent pharmacy technicians that reported having supervised, (3) whether or not they reported having supervised a PTCB certified pharmacy technician, and (4) whether or not they reported having supervised a pharmacy technician with an AA in pharmaceutical technology. Pharmacy technician work experience variables were compared with the pharmacy technician summated scores. The pharmacy technicians’ summated scores were compared based on four types of work experience: (1) the number of years they reported having worked as a pharmacy technician, (2) whether or not they re ported having education beyond a high school diploma, (3) whether or not they reported having completed a formal training program (either ASHP approved or employer designe d, but not on-the job training), and (4) whether or not they reported having an pharmacy technician certificates beyond PTCB certification. Correlations were made among continuous variables (e.g. number of years and summated scores), and independent samples t-tests between dichotomous and continuous

PAGE 75

61 variables (e.g. training yes/no and summated scores). For each comparison cases were eliminated list-wise. The correlations and t-tests were made using SPSS v10. Response Bias Response bias was investigated by comparing the results of the early and late responders to the questionnaire. Responses received by the second mailing August 26, 2004 were considered early responses and those received on the 27th or later but by the cut-off point were considered late responders. Late responders may be more similar in their beliefs to non-responders than early responders are to non-responders. Differences between early and late responders were tested within groups using Chi-square difference tests. In these tests we check for differences that may exist between the groups. Since we do not want to fail to detect any instances when such a difference exists we chose to set the p-value for the tests at .05 for each test. Sample Size Estimation In order to perform the confirmatory factor analysis at least 5 subjects were needed per item (Haire et al., 1998). This suggests that at least 130 subjects were needed per group for the confirmatory factor analysis. A more conservative number of 10 subjects per item were sought for this study. Since the instrument has 26 items at least 260 subjects per group (pharmacists and technicians) were sought. Two thousand subj ects in each group were contacted initially. This allowed for a minimally needed response rate of 13% for each group. The expected response rate was 30% for each group, based on previous work with pharmacists. Summary The study used a self-administered mail questionnaire. A random sample of pharmacists and PTCB certified pharmacy technicians working in a community

PAGE 76

62 pharmacy practice site in the state of Florida were surveyed. Non-identifiable follow-up was performed to ensure an adequate response rate. The validity and reliability of the instrument were evaluated. Analyses were conducted to explore on what tasks pharmacists and pharmacy technicians agree and disagree that pharmacy technicians should perform. Confirmatory factor analysis was used to investigate if the Framework of Professional Expertise for Pharmacy fits the way that pharmacists and pharmacy technicians think about the types of tasks that pharmacy technicians should perform. Exploratory factor analysis was used to estimate a model that fit the data for the two groups after the confirmatory factor analysis failed. It was not possible to construct one model that fit both groups. The internal consistency of the factors generated by the exploratory factor analyses were estimated. The correlations among the factors from the two groups data derived models were examined. The effects of types of work experience on the groups’ summated scores were examined. Possible response bias was also explored.

PAGE 77

63 CHAPTER 5 RESULTS This chapter presents the results of the analyses described in the previous chapter. First the descriptive statistics are presented then the analyses are presented. Questionnaire Response From the 4000 subjects targeted 1072 questionnaires were returned. Nine pharmacists’ and no technician questionnaires were returned as undeliverable. Of the 1072 returned questionnaires, 503 were from the pharmacist group and 569 were from the technician group. The response rate of the pharmacist group was 25%; and that of the technician group was 29%. The overall response rate was 27%. Not all of the returned questionnaires were used. Two hundred thirty-five questionnaires were excluded because respondents did not meet the inclusion criteria for the study for the following reasons: (1) the subjects reported that they did not work in community pharmacy (pharmacists n=147 and technician n=70); (2) the subjects reported that they were not pharmacists but students (n=2); (3) the subjects reported that they were retired or not working in pharmacy (pharmacists n=12 and technician=4). Thus, there were 837 usable cases. There were 344 usable cases in the pharmacist group, of which 314 had complete data. There were 495 usable cases in the technician group, of which 449 had complete data. Cases with complete data were usable cases that had a response for each item in the Community Pharmacy Technician Use Questionnaire. The revised response useable rate from the pharmacist group was 17%; and that of the technician group was 23%.

PAGE 78

64 Descriptive Data Work Experience Of the 314 included pharmacists, 295 (94%) responded to the question “How long have you been practicing pharmacy as a licensed pharmacist?”. For those pharmacists the average work-years reported was 21.2 (sd=13.2), with a low of less than one year and a high of 56 years. Of the 449 included pharmacy technicians, 401 (89%) responded to the question “How long have you been working as a pharmacy technician?”. For those pharmacy technicians the average work-years reported was 8.1 (sd=6.9), with a low of less than one year and a high of 50 years. The majority of the included pharmacists and pharmacy technicians reported that they worked in retail chain pharmacies, followed by independent pharmacies. For the pharmacists and the pharmacy technicians the next most common type of reported work place was supermarket pharmacies, followed by discount store pharmacies (Table 5-1). Table 5-1. Reported Community Work Experience of Subjects in Sample Type of pharmacy Pharmacist n (%) Technician n (%) Discount store 12 (4) 39 (8.7) Independent 61 (19) 44 (9.8) Retail chain 195 (62) 364 (81.1) Supermarket 55 (18) 40 (8.9) Total 323* 446** *Some pharmacist reported working in multiple settings **Not all technicians reported their work experience Pharmacist Reported Pharmacy Technician Supervisory Experience Of the 314 included pharmacists, 303 (96%) responded to the question: “How many technicians have you directly supervised in your career? Supervised here means

PAGE 79

65 direct, immediate and personal supervision.” For those pharmacists the average reported number of technicians supervised was 32.8 (sd=50.2), with a low of one technician and a high of 500 technicians. Pharmacist Reported Pharmacy Technician Competency. Three hundred pharmacists (96%) responded to the question: “How many of those technicians do you feel were competent ?”. The percent of competent technicians was calculated by taking the reported number of competent technicians supervised divided by the reported number of technicians supervised. Two hundred ninety-nine pharmacists responded to both questions. The average calculated pharmacist reported percentage of competent pharmacy technicians was 66% (sd=26), with a low of .04% and a high of 100%. Pharmacist Reported Type of Pharmacy Technician Supervised Of the 314 included pharmacists, 310 (98.7%) responded to the question: “Have you supervised a pharmacy technician who was certified by the Pharmacy Technician Certification Board? (CPhT)”. Of those pharmacists 267 (86.1%) reported that they had supervised a PTCB certified pharmacy technician; 31 (10%) reported that they had not; and 12 (3.9%) reported that they did not know. The same number of subjects who responded to the above question responded to the question: “Have you supervised a pharmacy technician who had an AA in Pharmacy Technician Sciences?”. Of those pharmacists 35 (11.3%) reported that they had supervised a pharmacy technician with such an AA; 218 (70.3%) reported that they had not; and 57 (18.4%) reported that they did not know. Pharmacy Technician Reported Credentials Pharmacy technician reported education. Recall that all pharmacy technicians in the targeted sample were PTCB certified. This means that all were required to have a

PAGE 80

66 high school diploma or General Equivalenc y Diploma (GED). The subjects reported having education in the following response cate gories: (1) some college n=182 (41%); (2) AA/AS general n=95 (21%); (3) AA in Pharmacy Technician Sciences n=14 (3%); (4) BA/BS n=35 (8%); (5) graduate degree/professional degree n=16 (4%); and (6) Pharmacy degree from another country n=2 (0.4%). In addition to the above response categories several pharmacy technicians wrote in different forms education in the “other” slot: (1) tech school diploma n=7 (2%); (2) in pharmacy school n=3 (1%); (3) category checked but not described n=2 (0.4%); (4) MD from another country n=1 (0.2%); (5) chemical engineer from another country n= 1 (0.2%); three year degree in Laboratory Medicine Technology n=1 (0.2%); and (7) working on BA n=1 (0.2%). Pharmacy technician reported training. Subjects were prompted to report the type of training they had. The subjects re ported having training in the following response categories: (1) on the job training n=395 (88 %); (2) employer developed training program n=197 (44%); and (3) ASHP approved program n=32 (7%). Pharmacy technician reported certificates. The pharmacy technicians were asked to write in any non-PTCB pharmacy technician certificates that they have. Thirty instances of certificates are not described here because they are not pharmacy related. The 47 pharmacy-related certificates were made up of three categories: (1) employer issued certificates; (2) government agency issu ed certificates; and (3) organization issued certificates. The employer issued certificates were: (1) technician certificate n=29; (2) level two technician or senior technician certificate n=5; (3) specialty technician certificates n=3; (4) technician continuing education certificates n=2; and (5) military certificates n=2. The government agency issued certificates were: (1)

PAGE 81

67 certificate/licensure from another state n=2; and (2) certificate/licensure from a protectorate n=1. The organizational issued certificates were: (1) the National Association of Chain Drug Stores (NACDS ) n=1; and (2) PCCA (presumably the Professional Compounding Centers of America) aseptic techniques n=1. Item Level Descriptive Data The means and standard deviations for the two groups’ responses on the items in The Community Pharmacy Technician Use Questionnaire were calculated (Table 5-2). The scale used was 1 (strongly disagree) to 6 (strongly agree), so larger item means represent more positive group belief that a capable pharmacy technician should perform the task represented by the item. Likewise smaller item means represent greater group belief that a capable pharmacy technician should not perform the task represented by the item. Ten of the items were ranked on average by the pharmacist and pharmacy technician groups as a five (agree) or above. Those items were: (1) “Enter data into the computer accurately.”, (2) “Apply insurance rules when processing a new claim.”, (3) “Obtain information from a patient needed to fill a prescription.”, (4) “Deal with patients in a caring manner.”, (5) “Assess when a patient needs to speak to a pharmacist about their medication.”, (6) “Evaluate the reason for a denied claim.”, (7) “Explain to a patient an insurance claim that had a problem.”, (8) “Include the appropriate information when labeling prescription vials.”, (9) “Be discrete with patients’ health information.” and (10) “Call physicians for refill authorization.” The pharmacy technician group ranked on average two additional items as a five (agree) or above. Those items were: (1) “Determine when a prescription can be refilled.”, and (2) “Link the trade name with the

PAGE 82

68 generic name of a drug.” The pharmacist and pharmacy technician groups ranked on average one item as a two (disagree) or lower. That item was: “Assume personal Table 5-2. Item Means from the Pharmacist Group (n=314) and the Pharmacy Technician Group (n=449) on The Community Pharmacy Technician Use Questionnaire Pharmacist Group Pharmacy Technician Group Item Item Average Standard Deviation Item Average Standard Deviation Enter data into the computer accurately. 5.58 0.78 5.87 0.50 Apply insurance rules when processing a new claim 5.65 0.68 5.69 0.73 Obtain information from a patient needed to fill a prescription. 5.67 0.69 5.83 0.60 Deal with patients in a caring manner 5.64 0.74 5.78 0.68 Assess when a patient needs to speak to a pharmacist about their medication. 5.11 1.23 5.43 1.11 Understand the difference between an aceinhibitor and a beta-blocker. 2.94 1.44 4.43 1.31 Evaluate the reason for a denied claim. 5.40 0.94 5.57 0.86 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) 3.66 1.56 4.70 1.48 Transfer a patient’s prescription. 3.15 1.79 3.99 1.71 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. 4.57 1.32 4.05 1.58 Identify the common side effects of a betablocker. 2.42 1.32 3.64 1.48 Determine when a prescription can be refilled. 4.77 1.25 5.46 0.94 Explain to a patient insurance claim that had a problem 5.57 0.65 5.61 0.83 Accept called in prescriptions from physician’s offices. 2.34 1.52 3.39 1.80 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 4.82 1.24 4.66 1.41 Include the appropriate information when labeling prescription vials. 5.03 1.07 5.59 0.78 Be discrete with patients’ health information 5.70 0.76 5.83 0.60 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. 3.90 1.76 4.86 1.49 Assess a patient’s actual medication use. 3.21 1.48 3.80 1.65

PAGE 83

69 Table 5-2. Continued Pharmacist Group Pharmacy Technician Group Item Item Average Standard Deviation Item Average Link the trade name with the generic name of a drug. 4.97 1.21 5.52 0.85 Evaluate a patient’s medication therapy. 2.20 1.30 3.11 1.56 Educate a patient on the appropriate use of their medication. 2.60 1.48 3.42 1.61 Recognize the therapeutic class of a prescribed medication. 3.63 1.40 4.38 1.42 Assume personal responsibility to resolve a patient’s drug therapy problems. 1.88 1.15 2.48 1.43 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. 3.78 1.43 4.60 1.51 Call physicians for refill authorization. 5.29 1.05 5.48 1.07 responsibility to resolve a patient’s drug therapy problems.” The pharmacist group ranked on average four additional items as a two (disagree) or lower. Those items were: (1) “Identify the common side effects of a beta-blocker.”, (2) “Accept called in prescriptions from physician’s offices.”, (3) “Evaluate a patient’s medication therapy.”, and (4) “Educate a patient on the appropriate use of their medication.” Analyses Chi-Square Tests The first research question was evaluated using the Chi-square tests. That question is: 1) “Do pharmacists and pharmacy technician beliefs on tasks that pharmacy technicians should perform in community practice differ?”. Recall that the scale used in the questionnaire was 1 (strongly disagree) to 6 (strongly agree); and, that for each response-number an anchor was provided: (1) strongly disagree, (2) disagree, (3) somewhat disagree, (4) somewhat agree, (5) agree, and (6) strongly agree. For this analysis both groups’ scores on the items were dichotomized using a cut point to

PAGE 84

70 determine which items the groups believe technicians should or should not perform. Items scored one through three by subjects were considered “disagree” and items scored four through six by subjects were considered “agree”. Chi-square tests were then applied to the dichotomized results. Since there were 26 tests performed a p-value of 0.05/26=.002 was necessary to show evidence that the null hypothesis (belief is not dependent on group membership) should be rejected (Table 5-3). The results of the ChiSquared test on the dichotomized results from the two groups found that 16 (62%) of the beliefs on the tasks that pharmacy technicians should perform in community practice depend on whether or not the belief comes from pharmacists or from pharmacy technicians. For eight of those, while the difference in the groups’ beliefs were statistically significant, most of the pharmacists and most of the pharmacy technicians felt that the tasks should be performed by a pharmacy technician. Those tasks were: (1) “Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.)”; (2) “Go out of their way to assist a patient in obtaining aid to pay for their prescriptions.”; (3) “Determine when a prescription can be refilled.”; (4) “Include the appropriate information when labeling prescription vials.” ;(5) “Evaluate whether a computer generated DUR needs to be shown to the pharmacist.”; (6) “Link the trade name with the generic name of a drug.”; (7) “Recognize the therapeutic class of a prescribed medication.”; and (8) “Assess which medication a patient wants to have refilled when the patient does not know the name of the drug.” Of the other eight significantly different items most of the pharmacists felt that pharmacy technicians should not perform the task, while for six of them most pharmacy

PAGE 85

71 technicians felt that pharmacy technicians should perform the task. Those six tasks were: (1) “Understand the difference between an ace-inhibitor and a beta-blocker.”; (2) Table 5-3. Dichotomized Means from th e Pharmacist Group (n=315) and Pharmacy Technician Group (n=448) on the Items of The Community Pharmacy Technician Use Questionnaire Item Group No Yes Chi-Square difference test Pharmacist 7 307 Enter data into the computer accurately. Technician 3 446 x2 = 3.5 p = .06 Pharmacist 3 311 Apply insurance rules when processing a new claim Technician 9 440 x2 = 1.3 p = .25 Pharmacist 3 311 Obtain information from a patient needed to fill a prescription. Technician 6 443 x2 = .23 p = .63 Pharmacist 4 310 Deal with patients in a caring manner Technician 8 441 x2 = .31 p = .58 Pharmacist 31 283 Assess when a patient needs to speak to a pharmacist about their medication. Technician 26 423 x2 = 4.5 p = .04 Pharmacist 190 124 Understand the difference between an ace-inhibitor and a beta-blocker. Technician 81 368 x2 = 145.5 p < .001 Pharmacist 12 302 Evaluate the reason for a denied claim. Technician 13 436 x2 = .50 p = .48 Pharmacist 124 190 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) Technician 78 371 x2 = 46.4 p < .001 Pharmacist 179 135 Transfer a patient’s prescription. Technician 149 300 x2 = 42.8 p < .001 Pharmacist 57 257 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. Technician 155 294 x2 = 24.7 p < .001 Pharmacist 247 67 Identify the common side effects of a beta-blocker. Technician 186 263 x2 = 104.4 p < .001 Pharmacist 40 274 Determine when a prescription can be refilled. Technician 18 431 x2 = 20.1 p < .001 Pharmacist 2 312 Explain to a patient insurance claim that had a problem Technician 12 437 x2 = 4.3 p = .04 Pharmacist 243 71 Accept called in prescriptions from physician’s offices. Technician 210 239 x2 = 71.8 p < .001 Pharmacist 37 277 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. Technician 77 372 x2 = 4.2 p = .04 Pharmacist 29 285 Include the appropriate information when labeling prescription vials. Technician 8 441 x2 = 22.3 p < .001 Technician 8 306 Be discrete with patients’ health information Technician 5 444 x2 = 2.3 p = .13

PAGE 86

72 Table 5-3. Continued Item Group No Yes Chi-Square difference test Pharmacist 125 189 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. Technician 72 377 x2 = 54.5 p < .001 Pharmacist 166 148 Assess a patient’s actual medication use. Technician 175 274 x2 = 14.4 p < .001 Pharmacist 32 282 Link the trade name with the generic name of a drug. Technician 13 436 x2 = 17.7 p < .001 Pharmacist 260 54 Evaluate a patient’s medication therapy. Technician 257 192 x2 = 55.3 p < .001 Pharmacist 223 91 Educate a patient on the appropriate use of their medication. Technician 219 230 x2 = 37.5 p < .001 Pharmacist 114 200 Recognize the therapeutic class of a prescribed medication. Technician 101 348 x2 = 17.4 p < .001 Pharmacist 279 35 Assume personal responsibility to resolve a patient’s drug therapy problems. Technician 330 119 x2 = 27.1 p < .001 Pharmacist 117 197 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. Technician 84 365 x2 = 32.8 p < .001 Pharmacist 17 297 Call physicians for refill authorization. Technician 30 419 x2 = 0.51 p = .47 “Transfer a patient’s prescription.”; (3) “Identify the common side effects of a betablocker.”; (4) “Accept called in prescriptions from physician’s offices.”; (5) “Assess a patient’s actual medication use.”; and (6) “Educate a patient on the appropriate use of their medication.” The two items for which there was a statistically significant difference of beliefs between the groups and on average both groups felt that pharmacy technicians should not perform the task were (1) “Evaluate a patient’s medication therapy.”; and (2) “Assume personal responsibility to resolve a patient’s drug therapy problems.” Confirmatory Factor Analysis The second research question was evaluated using confirmatory factor analysis. That question was: “Does the Framework of Expert Practice for Pharmacy fit pharmacists’ and pharmacy technicians’ beliefs on the tasks that pharmacy technicians should perform in community practice?”.

PAGE 87

73 The variables were tested to see if they loaded on the same four factors in both samples. The pharmacist’s data inadequately fit the model (SRMR=0.19), as did the technician’s data (SRMR=0.14). The goodness of fit statistics for both groups measured simultaneously were generally consistent with the SRMR statistics of the individual groups. The other fit indexes suggested inadequate fit. The P-value for the test of close fit (RMSEA <0.01) was significant, indicating that the data significantly differ from the target model. This suggests that we should reject the hypothesis that the variables loaded on the same targeted factors in both samples. The Non-Normed Fit Index (NNFI or TLI =0.59) and the Comparative Fit Index (CFI =0.61) indicated that simultaneously modeling the two groups does not have adequate fit. This suggests that the data do not fit the targeted four factors for both groups. The goodness of fit Minimum Fit Function ChiSquare test for this model was 2 = 6690.68 (df =622) p<0.01. This test measures the goodness of fit statistics for both groups simultaneously. The Chi-Square test was significant. This suggests that the model does not fit. The contribution to the Chi-Square for the pharmacist group was 1550.30 (23.17%), and for the technician group was 5140.38 (76.83%). Confirmatory factor analyses were also performed using all of the data available for the two groups. The P-value for the test of close fit (RMSEA <0.01) was significant for pharmacist target model (n=344). The Non-Normed Fit Index (NNFI or TLI =0.55) and the Comparative Fit Index (CFI =0.55) indicated that fit was about halfway between the pharmacist target model and the null or saturated model. The goodness of fit Minimum Fit Function Chi-Square test for the pharmacist target model was 2 = 1740.13 (df =293) p<0.01. The P-value for the test of close fit (RMSEA <0.01) was significant

PAGE 88

74 for pharmacy technician target model (n=495). The Non-Normed Fit Index (NNFI or TLI =0.59) and the Comparative Fit Index (CFI =0.63) indicated that fit was about halfway between the pharmacy technician target model and the null or saturated model. The goodness of fit Minimum Fit Function Chi-Square test for the pharmacy technician target model was 2 = 1479.54 (df =269) p<0.01. Exploratory Factor Analysis Since the first step of the confirmatory factor analysis found that the two groups’ factor configurations vary from the proposed four factor model, exploratory factor analysis was performed to see how many factors the model that fits the data has. Pharmacist data The correlation matrix was used to run the exploratory factor analysis on the pharmacist data. The analysis found that the number of eigenvalues over one was six, explaining 60% of the variability in the data (Table 5-4). The scree plot representation of the eigenvalues was less clear. It suggested three to six factors might be extracted from the data, with four or five factors appeari ng to be most probable. The approximate Chisquare was significant (X2=3218.23, df=325, p<.001). Table 5-4. Eigenvalues for Factors Extracted from the Pharmacist Data Initial Eigenvalues Rotation Sums of Squared Loadings Factor Total % of Variance Cumulative % Total 1 7.038 27.07 27.07 5.115 2 3.722 14.32 41.39 4.634 3 1.434 5.52 46.90 4.213 4 1.330 5.12 52.02 2.890 5 1.062 4.09 56.10 3.647 6 1.005 3.87 59.97 1.009 7 .880 3.38 63.35 8 .815 3.14 66.49 9 .791 3.04 69.53 10 .743 2.86 72.39

PAGE 89

75 Table 5-4. Continued Initial Eigenvalues Rotation Sums of Squared Loadings Factor Total % of Variance Cumulative % Total 11 .694 2.67 75.06 12 .666 2.56 77.62 13 .597 2.30 79.91 14 .589 2.27 82.18 15 .563 2.17 84.35 16 .530 2.04 86.38 17 .493 2.00 88.28 18 .457 1.76 90.04 19 .418 1.61 91.65 20 .401 1.54 93.19 21 .364 1.40 94.59 22 .338 1.30 95.89 23 .306 1.18 97.07 24 .295 1.13 98.20 25 .256 .99 99.19 26 .212 .81 100.00 Extraction Method: Principal Axis Factoring When factors are correlated, sums of squared loadings cannot be added to obtain a total variance. Scree PlotFactor Number25 23 21 19 17 15 13 11 9 7 5 3 1Eigenvalue8 6 4 2 0 Figure 5-1. Scree Plot of the Eigenvalues for the Factors Extracted from Pharmacist Data

PAGE 90

76 Pharmacist Model Development Six-factor pharmacist model The six-factor model was extracted in 22 iterations. The rotated solution converged in eight rotations. The six-factor model had one factor that had only one item load on it in the pattern matrix (Table 5-5). That item was :“Go out of their way to assist a patient in obtaining aid to pay for their prescription.” The Pattern matrix suggested that the item “Assess when a patient needs to speak to a pharmacist about their medication.” might also load on that sixth factor. Some items’ did not clearly load on only one factor. The factors seemed to represent: (1) clinical pha rmacy knowledge tasks, (2) tasks, functions and virtues typical of pharmacy technicians in current practice, (3) taking transfers, new prescriptions, and refill authorizations over the phone, (4) patient or therapy assessment, (5) unclear meaning, and (6) one item or unclear meaning. Table 5-5. Pattern Matrix for 6-Factor Model from the Pharmacist Data Factor Clinical pharmacy knowledge tasks Tasks, functions and virtues typical of pharmacy technicians in current practice Unclear meaning Taking transfers, new prescriptions, and refill authorizations over the phone Patient or therapy assessment One item Enter data into the computer accurately. .775 Apply insurance rules when processing a new claim. .850 Obtain information from a patient needed to fill a prescription. .741 Deal with patients in a caring manner. .565 Assess when a patient needs to speak to a pharmacist about their medication. -.392Understand the difference between an ace-inhibitor and a betablocker. .641 Evaluate the reason for a denied claim. .660 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .332 .301

PAGE 91

77 Table 5-5. Continued Factor Clinical pharmacy knowledge tasks Tasks, functions and virtues typical of pharmacy technicians in current practice Unclear meaning Taking transfers, new prescriptions, and refill authorizations over the phone Patient or therapy assessment One item Transfer a patient’s prescription. .851 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .342Identify the common side effects of a beta-blocker. .716 Determine when a prescription can be refilled. .250.241 Explain to a patient an insurance claim that had a problem. .718 Accept called in prescriptions from physicians’ offices. .594 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .574 Include the appropriate information when labeling prescription vials. .606 Be discreet with patient health information. .509 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .582Assess a patient’s actual medication use. .403 Link the trade name with the generic name of a drug. .615 Evaluate a patient’s medication therapy. .811 Educate a patient on the appropriate use of their medication. .612 Recognize the therapeutic class of a prescribed medication. .465 Assume personal responsibility to resolve a patient’s drug therapy problems. .866 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .544Call physicians for refill authorization. .329.318

PAGE 92

78 Five-factor pharmacist model The five-factor model was extracted in 25 iterations. The rotated solution converged in seven. The five-factor model had one factor on which two seemingly unrelated items loaded in the pattern matrix (Table 5-6). Those items were: “Go out of their way to assist a patient in obtaining aid to pay for their prescription.”; and “Assess when a patient needs to speak to a pharmacist about their medication.” Some items’ did not clearly load on only one factor. The factors seemed to represent: (1) clinical pharmacy knowledge tasks, (2) tasks and functions typical of pharmacy technicians in current practice, (3) taking transfers, new prescriptions, and refill authorizations over the phone, (4) pharmacy practice judgment, and (5) unclear meaning. Table 5-6. Pattern Matrix for 5-Factor Model from the Pharmacist Data Factor Clinical pharmacy knowledge tasks Tasks and functions typical of pharmacy technicians in current practice Pharmacy practice judgment Taking transfers, new prescriptions, and refill authorizations over the phone Unclear meaning Enter data into the computer accurately. .700 Apply insurance rules when processing a new claim. .876 Obtain information from a patient needed to fill a prescription. .704 Deal with patients in a caring manner. .523 Assess when a patient needs to speak to a pharmacist about their medication. -.400Understand the difference between an ace-inhibitor and a beta-blocker. .662 Evaluate the reason for a denied claim. .724 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .515 Transfer a patient’s prescription. .861Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .322Identify the common side effects of a beta-blocker. .790 Determine when a prescription can be refilled. .272.256

PAGE 93

79 Table 5-6. Continued Factor Clinical pharmacy knowledge tasks Tasks and functions typical of pharmacy technicians in current practice Pharmacy practice judgment Taking transfers, new prescriptions, and refill authorizations over the phone Unclear meaning Explain to a patient an insurance claim that had a problem. .808 Accept called in prescriptions from physicians’ offices. .553Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .597 Include the appropriate information when labeling prescription vials. .630 Be discreet with patient health information. .513 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .538 Assess a patient’s actual medication use. .577 Link the trade name with the generic name of a drug. .639 Evaluate a patient’s medication therapy. .829 Educate a patient on the appropriate use of their medication. .741 Recognize the therapeutic class of a prescribed medication. .401.399 Assume personal responsibility to resolve a patient’s drug therapy problems. .759 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .422 Call physicians for refill authorization. .394 .322 Four-factor pharmacist model The four-factor model was extracted in 11 iterations. The rotated solution converged in 13. The four-factor model seemed to have logical loadings in the pattern matrix (Table 5-7). The factors seemed to represent: (1) clinical pharmacy knowledge tasks, (2) tasks and functions typical of pharmacy technicians in current practice, (3) pharmacy information evaluation and management skills, and (4) pharmacist only task as specified by law.

PAGE 94

80 Table 5-7. Pattern Matrix for 4-Factor Model from the Pharmacist Data Factor Clinical pharmacy knowledge tasks Tasks and functions typical of pharmacy technicians in current practice Pharmacy information evaluation and management skills Pharmacist only tasks as specified by law Enter data into the computer accurately. .740 Apply insurance rules when processing a new claim. .816 Obtain information from a patient needed to fill a prescription. .704 Deal with patients in a caring manner. .606 Assess when a patient needs to speak to a pharmacist about their medication. .473 Understand the difference between an ace-inhibitor and a beta-blocker. .425 Evaluate the reason for a denied claim. .655 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .547 Transfer a patient’s prescription. .637Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .316 Identify the common side effects of a beta-blocker. .560 Determine when a prescription can be refilled. .379 Explain to a patient an insurance claim that had a problem. .740 Accept called in prescriptions from physicians’ offices. .491Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .396 Include the appropriate information when labeling prescription vials. .388 Be discreet with patient health information. .403 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .642 Assess a patient’s actual medication use. .548 Link the trade name with the generic name of a drug. .457 Evaluate a patient’s medication therapy. .801 Educate a patient on the appropriate use of their medication. .736 Recognize the therapeutic class of a prescribed medication. .664

PAGE 95

81 Table 5-7. Continued Factor Clinical pharmacy knowledge tasks Tasks and functions typical of pharmacy technicians in current practice Pharmacy information evaluation and management skills Pharmacist only tasks as specified by law Assume personal responsibility to resolve a patient’s drug therapy problems. .642 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .542 Call physicians for refill authorization. .440 Pharmacist Model Selection The four-factor technician model was selected as the best model of the data based on interpretation. Since the six-factor pharmacist model had a factor on which only one item loaded it was eliminated from the choices. The five-factor model had one factor on which two seemingly unrelated items loaded making interpretation of the factor unclear. The four-factor model had no such problems. In conclusion, the four-factor model was selected as the most logical structuring of the items based on the loadings from the exploratory factor analysis, the scree plot of eignevalues and theoretical interpretation of the data. Pharmacy Technician Data The correlation matrix was used to run the exploratory factor analysis on the technician data. The number of eigenvalues over one was five, explaining 59% of the variability in the data (Table 5-8). The scree plot representation of the eigenvalues was less clear. It suggested three or four factors might be extracted from the data. Figure 5-2. The approximate Chi-square was significant (X2=5529.98, df=325, p<.001).

PAGE 96

82 Table 5-8. Eigenvalues for Factors Extracted from the Technician Data Initial Eigenvalues Rotation Sums of Squared Loadings Factor Total % of Variance Cumulative % Total 1 8.069 31.04 31.04 5.981 2 3.734 14.36 45.40 5.196 3 1.381 5.31 50.71 3.978 4 1.166 4.49 55.20 5.242 5 1.062 4.09 59.28 2.839 6 .992 3.81 63.09 7 .890 3.42 66.52 8 .808 3.11 69.63 9 .795 3.06 72.68 10 .655 2.52 75.20 11 .645 2.48 77.68 12 .629 2.42 80.10 13 .553 2.13 82.23 14 .539 2.08 84.30 15 .506 1.95 86.25 16 .467 1.80 88.05 17 .427 1.64 89.69 18 .418 1.61 91.30 19 .368 1.42 92.71 20 .345 1.33 94.04 21 .322 1.24 95.28 22 .307 1.18 96.46 23 .270 1.04 97.49 24 .239 .92 98.41 25 .225 .87 99.28 26 .188 .72 100.00 Extraction Method: Principal Axis Factoring When factors are correlated, sums of squared loadings cannot be added to obtain a total variance.

PAGE 97

83 Scree PlotFactor Number25 23 21 19 17 15 13 11 9 7 5 3 1Eigenvalue10 8 6 4 2 0 Figure 5-2. Scree Plot of the Eigenvalues for the Factors Extracted from Technician Data Pharmac y Technician Model Development Five-factor technician model The five-factor model was extracted in 16 iterations. The rotated solution converged in eight rotations. The five-factor model had one factor on which two seemingly unrelated items loaded in the pattern matrix (Table 5-9). Those items were: “Go out of their way to assist a patient in obtaining aid to pay for their prescription.”; and “Assess when a patient needs to speak to a pharmacist about their medication.” Some items’ did not clearly load on only one factor. The five-factor model also had a factor that was difficult to lable. That factor seem ed to deal with prescription data management, but it included items that are different such as “Deal with patients in a caring manner.” The factors seemed to represent: (1) prescription data management or unclear meaning, (2) clinical pharmacy knowledge tasks, (3) general drug knowledge, (4) prescription processing, and (5) pharmacist only tasks as specified by law.

PAGE 98

84 Table 5-9. Pattern Matrix for 5-Factor Model from the Technician Data Factor Prescription data management Clinical pharmacy knowledge tasks General drug knowledge Prescription processing Pharmacist only tasks as specified by law Enter data into the computer accurately. .953 Apply insurance rules when processing a new claim. .534 Obtain information from a patient needed to fill a prescription. .733 Deal with patients in a caring manner. .734 Assess when a patient needs to speak to a pharmacist about their medication. .321 Understand the difference between an ace-inhibitor and a beta-blocker. .789 Evaluate the reason for a denied claim. .647Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .229 Transfer a patient’s prescription. .796Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .234 .242Identify the common side effects of a beta-blocker. .833 Determine when a prescription can be refilled. .624Explain to a patient an insurance claim that had a problem. .680Accept called in prescriptions from physicians’ offices. .736Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .413 Include the appropriate information when labeling prescription vials. .595 Be discreet with patient health information. .843 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .512 Assess a patient’s actual medication use. .732 Link the trade name with the generic name of a drug. .420 Evaluate a patient’s medication therapy. .799 Educate a patient on the appropriate use of their medication. .696 Recognize the therapeutic class of a prescribed medication. .444

PAGE 99

85 Table 5-9. Continued Factor Prescription data management Clinical pharmacy knowledge tasks General drug knowledge Prescription processing Pharmacist only tasks as specified by law Assume personal responsibility to resolve a patient’s drug therapy problems. .720 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .418Call physicians for refill authorization. .390 Four-factor technician model The four-factor model was extracted in 28 iterations. The rotated solution converged in eight. The four-factor model seemed to have logical loadings in the pattern matrix (Table 5-10). Some items’ did not clearly load on only one factor. Two items had low (below .3) loadings. The factors seemed to represent: (1) tasks and functions typical of pharmacy technicians in current practice, (2) clinical pharmacy knowledge tasks, (3) general drug knowledge, and (4) pharmacist only tasks as specified by law. Table 5-10. Pattern Matrix for 4-Factor Model from the Technician Data Factor Tasks and functions typical of pharmacy technicians in current practice Clinical pharmacy knowledge tasks General drug knowledge Pharmacist only tasks as specified by law Enter data into the computer accurately. .880 Apply insurance rules when processing a new claim. .712 Obtain information from a patient needed to fill a prescription. .837 Understand the difference between an ace-inhibitor and a betablocker. .766 Evaluate the reason for a denied claim. .694 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .264 Transfer a patient’s prescription. .854Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .256

PAGE 100

86 Table 5-10. Continued Factor Tasks and functions typical of pharmacy technicians in current practice Clinical pharmacy knowledge tasks General drug knowledge Pharmacist only tasks as specified by law Deal with patients in a caring manner. .711 Assess when a patient needs to speak to a pharmacist about their medication. .341 Identify the common side effects of a beta-blocker. .780 Determine when a prescription can be refilled. .571 Explain to a patient an insurance claim that had a problem. .750 Accept called in prescriptions from physicians’ offices. .660Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .368 Include the appropriate information when labeling prescription vials. .591 Be discreet with patient health information. .738 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .511 Assess a patient’s actual medication use. .731 Link the trade name with the generic name of a drug. .485 Evaluate a patient’s medication therapy. .828 Educate a patient on the appropriate use of their medication. .696 Recognize the therapeutic class of a prescribed medication. .433 Assume personal responsibility to resolve a patient’s drug therapy problems. .744 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .428 Call physicians for refill authorization. .538

PAGE 101

87 Pharmacy Technician Model Selection The four-factor technician model was selected as the best model of the data based on interpretation. The five-factor technician model had one factor on which two seemingly unrelated items loaded making interpretation of the factor unclear. The fourfactor model had no such problems. In conclusion, the four-factor model was selected as the most logical structuring of the items base d on the loadings from the exploratory factor analysis, the scree plot of eignevalues and theoretical interpretation of the data. Comparison of Models Generated for the Two Groups The exploratory factor analyses suggested that the models generated by the data for the two groups were different. In order to answer the last research question a common model for the two groups was needed. Since the models were not comparable, it was not possible to address this question on a factor level. Internal Consistency Reliability An item analysis was performed to check the reliability of the sets of items in the factors from the two groups’ models. The analyses included tests of the consistency of the items within a factor, the alpha if an item was deleted, and reliability coefficients for the factors overall. Using the Chronbach’s alpha test results allowed an exploration of whether or not the items within a factor were consistent. Pharmacist Data Clinical pharmacy knowledge tasks From the pharmacist data the reliability coefficient for the clinical pharmacy knowledge tasks factor (n=314) and the standardized item alpha were .86 (Table 5-11). This is acceptable. The range of possible means for the factor was 10 to 60. The mean

PAGE 102

88 for the factor on the pharmacist data was 31.7 (9.4) and the mean inter-item correlation was .38. Table 5-11. Item Analysis for the Clinical Pharmacy Knowledge Tasks Factor Item Item-corrected total correlation Alpha if item deleted Assess when a patient needs to speak to a pharmacist about their medication. .32 .86 Understand the difference between an aceinhibitor and a beta-blocker. .56 .84 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .59 .84 Identify the common side effects of a beta-blocker. .68 .83 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .50 .85 Assess a patient’s actual medication use. .56 .84 Evaluate a patient’s medication therapy. .71 .83 Educate a patient on the appropriate use of their medication. .62 .83 Assume personal responsibility to resolve a patient’s drug therapy problems. .59 .84 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .49 .85 Tasks and functions typical of pharmacy technicians in current practice factor From the pharmacist data the reliability coefficient for the tasks and functions typical of pharmacy technicians in current practice factor (n=314) was .82 while the standardized item alpha was .85 (Table 5-12). This is acceptable. The range of possible means for the factor was eight to 48. The mean for the factor on the pharmacist data was 43.6 (4.6) and the mean inter-item correlation was .42.

PAGE 103

89 Table 5-12. Item Analysis for the Tasks and Functions Typical of Pharmacy Technicians in Current Practice Factor Item Item-corrected total correlation Alpha if item deleted Enter data into the computer accurately. .62 .79 Apply insurance rules when processing a new claim. .70 .78 Obtain information from a patient needed to fill a prescription. .63 .79 Deal with patients in a caring manner. .54 .80 Evaluate the reason for a denied claim. .62 .79 Determine when a prescription can be refilled. .43 .83 Explain to a patient an insurance claim that had a problem. .72 .78 Call physicians for refill authorization. .36 .83 Pharmacy information evaluation and management skills factor From the pharmacist data the reliability coefficient for the pharmacy information evaluation and management skills factor (n=314) was .67 while the standardized item alpha was .70 (Table 5-13). This is acceptable. The range of possible means for the factor was six to 36. The mean for the factor on the pharmacist data was 28.7 (4.4) and the mean inter-item correlation was .28. The item “Go out of their way to assist a patient in obtaining aid to pay for their prescriptions” had a low item-corrected total correlation. Deletion of this item resulted in an increase in alpha. Table 5-13. Item Analysis for the Pharmacy Information Evaluation and Management Skills Factor Item Item-corrected total correlation Alpha if item deleted Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .14 .73 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .47 .61 Include the appropriate information when labeling prescription vials. .47 .61

PAGE 104

90 Table 5-13. Continued Item Item-corrected total correlation Alpha if item deleted Be discreet with patient health information. .50 .62 Link the trade name with the generic name of a drug. .52 .59 Recognize the therapeutic class of a prescribed medication. .45 .62 Pharmacist only tasks as specified by law factor The Pharmacist only tasks as specified by law factor was the same for both groups. From the pharmacist data the reliability coefficient for the pharmacist only tasks as specified by law factor (n=314) was .73 while the standardized item alpha was .74 (Table 5-14). This is acceptable. The range of possible means for the factor was two to 12. The mean for the factor on the pharmacist data was 5.5 (2.9) and the mean inter-item correlation was .59. Table 5-14. Item Analysis for the Pharmaci st Only Tasks as Specified by Law Factor Item Item-corrected total correlation Alpha if item deleted Transfer a patient’s prescription. .59 NA Accept called in prescriptions from physicians’ offices. .59 NA Technician Data Tasks and functions typical of pharmacy technicians in current practice factor For the technician data the reliability coefficient for the tasks and functions typical of pharmacy technicians in current practice factor (n=449) was .88 while the standardized item alpha was .90 (Table 5-15). The range of possible means for the factor was 11 to 66. The mean for the factor on the technician data was 62.2 (5.9) and the mean inter-item correlation was .45.

PAGE 105

91 Table 5-15. Item Analysis for the Tasks and Functions Typical of Pharmacy Technicians in Current Practice Factor Item Item-corrected total correlation Alpha if item deleted Enter data into the computer accurately. .78 .87 Apply insurance rules when processing a new claim. .64 .87 Obtain information from a patient needed to fill a prescription. .78 .86 Deal with patients in a caring manner. .65 .87 Assess when a patient needs to speak to a pharmacist about their medication. .36 .90 Evaluate the reason for a denied claim. .68 .87 Determine when a prescription can be refilled. .59 .87 Explain to a patient an insurance claim that had a problem. .71 .86 Include the appropriate information when labeling prescription vials. .58 .87 Be discreet with patient health information. .64 .87 Link the trade name with the generic name of a drug. 51 .88 Clinical pharmacy knowledge tasks factor From the technician data the reliability coefficient for the clinical pharmacy knowledge tasks factor (n=449) was .83 while the standardized item alpha was .82 (Table 5-16). The range of possible means for the factor was 10 to 60. The mean for the factor on the technician data was 41.1 (9.3) and the mean inter-item correlation was .32. The item “Call physicians for refill authorization.” had a low item-corrected total correlation. Deletion of this item did not result in an increase in alpha. Table 5-16. Item Analysis for the Clinical Pharmacy Knowledge Tasks Factor Item Item-corrected total correlation Alpha if item deleted Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) .43 .82 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. .39 .82

PAGE 106

92 Table 5-16. Continued Item Item-corrected total correlation Alpha if item deleted Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. .48 .81 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. .46 .82 Assess a patient’s actual medication use. .68 .79 Evaluate a patient’s medication therapy. .69 .79 Educate a patient on the appropriate use of their medication. .65 .80 Assume personal responsibility to resolve a patient’s drug therapy problems. .62 .80 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. .43 .82 Call physicians for refill authorization. .27 .83 General drug knowledge factor From the technician data the reliability coefficient for the general drug knowledge factor (n=449) was .79 while the standardized item alpha was .79 (Table 5-17). The range of possible means for the factor was three to 18. The mean for the factor on the technician data was 12.5 (3.5) and the mean inter-item correlation was .55. Table 5-17. Item Analysis for the General Drug Knowledge Factor Item Item-corrected total correlation Alpha if item deleted Understand the difference between an ace-inhibitor and a beta-blocker. .66 .68 Identify the common side effects of a beta-blocker. .69 .64 Recognize the therapeutic class of a prescribed medication. .54 .80 Pharmacist only tasks as specified by law factor The Pharmacist only tasks as specified by law factor was the same for both groups. From the technician data the reliability coefficient for the pharmacist only tasks as specified by law factor (n=449) was .78 while the standardized item alpha was .78 (Table

PAGE 107

93 5-18). This is acceptable. The range of possible means for the factor was two to 12. The mean for the factor on the technician data was 7.3 (3.2) and the mean inter-item correlation was .64. Table 5-18. Item Analysis for the Pharmaci st Only Tasks as Specified by Law Factor Item Item-corrected total correlation Alpha if item deleted Transfer a patient’s prescription. .64 NA Accept called in prescriptions from physicians’ offices. .64 NA Inter-Factor Correlations The correlations among the factors scores from the two groups’ four-factor models were examined. For each complete case a summated score was created by adding a subject’s responses to items within a factor together. The models correlations were examined separately for the two groups. Factor Correlations within the Pharmacist Model The correlations among the factors in the pharmacist model were all significant (Table 5-19). The lowest correlation was between the Pharmacy information evaluation and management skills factor and the Pharmacist only tasks as specified by law factor. The highest correlation was between the Tasks and functions typical of pharmacy technicians in current practice factor and the Pharmacy information evaluation and management skills factor.

PAGE 108

94 Table 5-19. Factor Correlations from the Pharmacist Model (n=314) Clinical pharmacy knowledge tasks factor Tasks and functions typical of pharmacy technicians in current practice factor Pharmacy information evaluation and management skills factor Pharmacist only tasks as specified by law factor Pearson Correlation 1.0 Clinical pharmacy knowledge tasks factor Sig. (2tailed) NA Pearson Correlation .330 1.0 Tasks and functions typical of pharmacy technicians in current practice factor Sig. (2tailed) <.001 NA Pearson Correlation .452 .500 1.0 Pharmacy information evaluation and management skills factor Sig. (2tailed) <.001 <.001 NA Pearson Correlation .409 .420 .257 1.0 Pharmacist only tasks as specified by law factor Sig. (2tailed) <.001 <.001 <.001 NA Factor Correlations within the Pharmacy Technician Model The correlations among the factors in the technician model were all significant (Table 5-20). The lowest correlation was between the Pharmacist only tasks as specified by law factor and the General drug knowledge factor. The highest correlation was between the General drug knowledge factor and the Clinical pharmacy knowledge tasks factor.

PAGE 109

95 Table 5-20. Factor Correlations from the Pharmacy Technician Model (n=449) Clinical pharmacy knowledge tasks factor Tasks and functions typical of pharmacy technicians in current practice factor General drug knowledge factor Pharmacist only tasks as specified by law factor Pearson Correlation 1.0 Clinical pharmacy knowledge tasks factor Sig. (2tailed) NA Pearson Correlation .490 1.0 Tasks and functions typical of pharmacy technicians in current practice factor Sig. (2tailed) <.001 NA Pearson Correlation .679 .360 1.0 General drug knowledge factor Sig. (2tailed) <.001 <.001 NA Pearson Correlation .514 .421 .330 1.0 Pharmacist only tasks as specified by law factor Sig. (2tailed) <.001 <.001 <.001 NA Within-Group Comparisons of Summated Scores by Type of Experience The summated scores that were used to calculate the correlations within groups between factors were used to make comparisons within groups by types of work experience. Pharmacist work experience variables were compared with the pharmacist summated scores. Pharmacy technician work experience variables were compared with the pharmacy technician summated scores. Correlations were made among continuous variables (e.g. number of years and summated scores), and independent samples t-tests

PAGE 110

96 between dichotomous and continuous variables (e.g. training yes/no and summated scores). Pharmacist Group Comparisons Types of work experience that were logically thought to predict pharmacists’ summated scores were used in the following analyses. The pharmacists’ summated scores were compared based on four types of work experience: (1) the number of years they reported having worked as a licensed pharmacist, (2) the calculated percent of competent pharmacy technicians that reported having supervised, (3) whether or not they reported having supervised a PTCB certified pharmacy technician, and (4) whether or not they reported having supervised a pharmacy technician with an AA in pharmaceutical technology. For each comparison cases were eliminated list-wise. Work experience To explore the relationship of the work experience with the pharmacists’ summated scores, correlations were used. The p-value for comparison of the correlations between pharmacist reported years of work experience and the summated scores was set at .05/4=0.0125. Data for years of work experience was available for 295 pharmacists (Table 5-21). The correlations were low, and none were significant. Table 5-21. Correlations between the Factors and the Number of Years Practicing as a Licensed Pharmacists (n=295) Number of years practicing as a licensed pharmacists Factor Mean sd Correlation Sig. (2tailed) Clinical pharmacy knowledge tasks factor 31.4 9.3 -.005 .936 Tasks and functions typical of pharmacy technicians in current practice factor 43.5 4.6 -.082 .162 Pharmacy information evaluation and management skills factor 28.6 4.4 .015 .793

PAGE 111

97 Table 5-21. Continued Number of years practicing as a licensed pharmacists Factor Mean sd Correlation Sig. (2tailed) Pharmacist only tasks as specified by law factor 8.4 2.3 .003 .955 Pharmacist reported pharmacy technician competency To explore the relationship of the pharmacist reported pharmacy technician competency with the pharmacists’ summated scores, correlations were used. The p-value for comparison of the correlations among percent of pharmacist reported competent pharmacy technicians supervised and the summated scores was set at .05/4=0.0125. Data for the percentage of competent pharmacy technicians supervised was available for 299 pharmacists (Table 5-22). The correlations were low. The correlation between Pharmacist reported pharmacy technician competency and Pharmacy information evaluation and management skills factor was significant. Table 5-22. Correlations between the Factors and Pharmacist Reported Pharmacy Technician Competency (n=299) Pharmacist reported pharmacy technician competency Factor Mean sd Correlation Sig. (2tailed) Clinical pharmacy knowledge tasks factor 31.7 9.5 .101 .082 Tasks and functions typical of pharmacy technicians in current practice factor 43.6 4.6 .016 .787 Pharmacy information evaluation and management skills factor 28.8 4.3 .164 .004 Pharmacist only tasks as specified by law factor 8.5 2.3 .045 .441 Supervision of PTCB certified pharmacy technicians To explore effects of the pharmacists’ experience supervising a PTCB certified pharmacy technician on the pharmacists’ summated scores t-tests were used. The p-value

PAGE 112

98 for comparison of the pharmacists who have and have not supervised a PTCB certified pharmacy technician was set at .05/4=0.0125. Only 31 pharmacists reported not having experience supervising a PTCB certified pharmacy technician (Table 5-23). This difference in means was significant for one factor: Tasks and functions typical of pharmacy technicians in current practice factor (Table 5-24). The summated scores for those pharmacists with no experience supervising a PTCB certified pharmacy technician were lower on that factor relative to the pharmacists who reported experience supervising a PTCB certified pharmacy technician. Table 5-23. Factors Means for Pharmacist Who Have and Have Not Supervised a PTCB Certified Pharmacy Technician Factor Pharmacists who have supervised a PTCB certified pharmacy technician N Mean Standard Deviation No 31 32.7 8.7 Clinical pharmacy knowledge tasks factor Yes 267 31.5 9.6 No 31 41.1 4.9 Tasks and functions typical of pharmacy technicians in current practice factor Yes 267 44.0 4.5 No 31 27.7 5.2 Pharmacy information evaluation and management skills factor Yes 267 28.8 4.3 No 31 7.9 2.5 Pharmacist only tasks as specified by law factor Yes 267 8.5 2.3 Table 5-24. Comparison of Means on Factors Dependent on Whether or Not the Pharmacist Has Supervised a PTCB Certified Pharmacy Technician t-test for Equality of Means Factor t df Sig. (2tailed) Mean difference Clinical pharmacy knowledge tasks factor .689 296 .492 1.24 Tasks and functions typical of pharmacy technicians in current practice factor -3.4 296 .001 -2.91

PAGE 113

99 Table 5-24. Continued t-test for Equality of Means Factor t df Sig. (2tailed) Mean difference Pharmacy information evaluation and management skills factor -1.384 296 .167 -1.15 Pharmacist only tasks as specified by law factor -1.407 296 .161 -.62 Supervision of pharmacy technicians with AA in pharmaceutical sciences To explore effects of the pharmacists’ experience supervising a pharmacy technician with an AA in pharmaceutical sciences on the pharmacists’ summated scores t-tests were used. The p-value for comparison of the pharmacists who have and have not supervised a pharmacy technician with an AA in pharmaceutical sciences was set at .05/4=0.0125. Only 35 pharmacists reported having experience supervising a pharmacy technician with such an AA (Table 5-25). No significant differences among the means were found (Table 5-26). Table 5-25. Factors Means for Pharmacist Who Have and Have Not Supervised a Pharmacy Technician with an AA in Pharmaceutical Sciences Factor Pharmacists who have supervised a pharmacy technician with an AA in pharmaceutical sciences N Mean Standard Deviation No 218 31.4 9.2 Clinical pharmacy knowledge tasks factor Yes 35 35.4 11.3 No 218 43.5 4.7 Tasks and functions typical of pharmacy technicians in current practice factor Yes 35 45.1 3.6 No 218 28.6 4.4 Pharmacy information evaluation and management skills factor Yes 35 29.3 5.1 No 218 8.4 2.3 Pharmacist only tasks as specified by law factor Yes 35 9.0 2.6

PAGE 114

100 Table 5-26. Comparison of Means on Factors Dependent on Whether or Not the Pharmacist Has Supervised a Pharmacy Technician with an AA in Pharmaceutical Sciences t-test for Equality of Means Factor t df Sig. (2tailed) Mean difference Clinical pharmacy knowledge tasks factor -2.339 251 .020 -4.0422 Tasks and functions typical of pharmacy technicians in current practice factor -1.960 251 .051 -1.6291 Pharmacy information evaluation and management skills factor -.838 251 .403 -.6813 Pharmacist only tasks as specified by law factor -1.322 251 .187 -.5586 Pharmacy Technician Group Comparisons Types of work experience that were logically thought to predict pharmacy technicians’ summated scores were used in the following analyses. The pharmacy technicians’ summated scores were compared based on four types of work experience: (1) the number of years they reported having worked as a pharmacy technician, (2) whether or not they reported having educa tion beyond a high school diploma, (3) whether or not they reported having completed a form al training program (either ASHP approved or employer designed, but not on-the job traini ng), and (4) whether or not they reported having an pharmacy technician certificates beyond PTCB certification. For each comparison cases were eliminated list-wise. Work experience To explore effects of the work experience on the pharmacy technicians’ summated scores, correlations were used. The p-value for comparison of the correlations among the pharmacy technicians’ reported years of work experience and the summated scores was set at .05/4=0.0125. Data for years of work experience was available for 401

PAGE 115

101 pharmacy technicians (Table 5-27). The correlations were low. All were significant, except the correlation between years experience and the general drug knowledge factor. Table 5-27. Correlations between the Factors and the Number of Years Working as a Pharmacy Technician (n=400) Number of years practicing as a licensed pharmacists Factor Mean sd Correlation Sig. (2tailed) Clinical pharmacy knowledge tasks factor 41.4 9.3 .148 .003 Tasks and functions typical of pharmacy technicians in current practice factor 62.4 4.9 .135 .007 General drug knowledge factor 12.4 3.5 .107 .033 Pharmacist only tasks as specified by law factor 9.5 2.1 .162 .001 Education To explore effects of the pharmacy technicians’ education attainment on the pharmacy technicians’ summated scores t-tests were used. The p-value for comparison of the pharmacy technicians who have and who do not have some education beyond a GED or high school diploma was .05/4=0.0125. N early three-fourths of the technicians reported having some education beyond a GED or high school diploma (Table 5-28). The differences were very small one or two tenths of a point difference for three of the factors. No significant differences among the means were found (Table 5-29). Table 5-28. Factors Means for Pharmacy Technicians Who Reported Having and Reported Not Having Some Education Beyond a GED or High School Diploma Factor Pharmacy technicians who have education beyond a GED or high school diploma N Mean Standard Deviation No 127 41.8 9.4 Clinical pharmacy knowledge tasks factor Yes 322 40.9 9.3

PAGE 116

102 Table 5-28. Continued Factor Pharmacy technicians who have education beyond a GED or high school diploma N Mean Standard Deviation No 127 62.3 7.4 Tasks and functions typical of pharmacy technicians in current practice factor Yes 322 62.1 5.2 No 127 12.3 4.6 General drug knowledge factor Yes 322 12.5 4.3 No 127 9.5 2.0 Pharmacist only tasks as specified by law factor Yes 322 9.4 2.3 Table 5-29. Comparison of Means on Factors Dependent on Whether or Not the Pharmacy Technician Reported Ha ving Education Beyond a GED or High School Diploma t-test for Equality of Means Factor t df Sig. (2tailed) Mean difference Clinical pharmacy knowledge tasks factor .943 447 .346 .9183 Tasks and functions typical of pharmacy technicians in current practice factor .335 447 .738 .2065 General drug knowledge factor -.674 447 .501 -.2493 Pharmacist only tasks as specified by law factor .738 447 .461 .1696 Training To explore effects of the pharmacy technicians’ training experience on the pharmacy technicians’ summated scores, t-tests were used. Technicians who reported having completed an employer developed training program, or an ASHP approved pharmacy technician training program were included in the “have training experience” group. Technicians who reported having on-thejob training or no training were included in the “no training experience” group The p-value for comparison of pharmacy technician training experience was .05/4=0.0125. About half of the pharmacy technicians reported

PAGE 117

103 some training beyond on-the-job training (Table 5-30). For one factor the means were the same. No significant differences among the means were found (Table 5-31). Table 5-30. Factors Means for Pharmacy Technicians Who Reported Having and Reported Not Having Some Training Beyond On-The-Job Training Factor Pharmacy technicians who have education beyond on-the-job training N Mean Standard Deviation No 226 41.4 9.6 Clinical pharmacy knowledge tasks factor Yes 212 40.8 9.0 No 226 62.3 5.5 Tasks and functions typical of pharmacy technicians in current practice factor Yes 212 62.0 6.4 No 226 12.2 4.5 General drug knowledge factor Yes 212 12.7 4.3 No 226 9.5 2.2 Pharmacist only tasks as specified by law factor Yes 212 9.5 2.2 Table 5-31. Comparison of Means on Factors Dependent on Whether or Not the Pharmacy Technician Reported Having Training Beyond On-The-Job Training t-test for Equality of Means Factor t df Sig. (2tailed) Mean difference Clinical pharmacy knowledge tasks factor .673 .436 .502 .5999 Tasks and functions typical of pharmacy technicians in current practice factor .378 436 .705 .2145 General drug knowledge factor -1.373 436 .170 -.4624 Pharmacist only tasks as specified by law factor .133 436 .894 .0280 Additional certifications To explore effects of the pharmacy tec hnicians’ certification other than PTCB certification on the pharmacy technicians’ summated scores t-tests were used. Technicians who reported having a pharmacy related certificate certification other than their PTCB certificate were included in the have additional certification group.

PAGE 118

104 Technicians who did not report any such certificates were included in the no additional certification group The p-value for comparison of pharmacy technician certification was .05/4=0.0125. A significant difference among the means was found for one factor: Tasks and functions typical of pharmacy technicians in current practice factor (Table 5-33). The mean summated scores for pharmacy technicians in the have additional certification group were higher on that factor (Table 5-32). Table 5-32. Factors Means for Pharmacy Technicians Who Reported Having and Reported Not Having Pharmacy Certificates in Addition to PTCB Certification Factor Pharmacy technicians who have pharmacy certificates in addition to PTCB certification N Mean Standard Deviation No 406 41.0 9.3 Clinical pharmacy knowledge tasks factor Yes 43 43.1 9.3 No 406 52.0 6.1 Tasks and functions typical of pharmacy technicians in current practice factor Yes 43 64.0 2.5 No 406 12.4 3.6 General drug knowledge factor Yes 43 12.9 3.0 No 406 9.4 2.2 Pharmacist only tasks as specified by law factor Yes 43 10.0 1.8 Table 5-33. Comparison of Means on Factors Dependent on Whether or Not the Pharmacy Technician Reported Having Pharmacy Certificates in Addition to PTCB Certification t-test for Equality of Means Factor t df Sig. (2tailed) Mean difference Clinical pharmacy knowledge tasks factor -1.453 447 .147 -2.1631 Tasks and functions typical of pharmacy technicians in current practice factor* -4.143** 104.706** >.001 -2.0356 General drug knowledge factor -.793 447 .428 -.4491 Pharmacist only tasks as specified by law factor -1.551 447 .122 -.5446 Levene’s Test for Equality of variances was significant **Test for equality of means with equal variances not assumed

PAGE 119

105 Comparison of Early and Late Responders Differences between early and late responders were checked by dichotomizing the responses on The Community Pharmacy Technician Use Questionnaire of the two groups. The pharmacist early and late responders were considered two groups and the technician early and late responders were considered two other groups. Thus the pharmacist groups and the technician groups were analyzed separately. Since this was the case, the dichotomized responses for each group were then compared by item using chi-square tests. In order for an item to be significantly different between groups, its pvalue must be less than or equal to .05. The tests found that there were no significant differences between early and late responders among the pharmacists and two among the pharmacy technicians (Table 5-34 and Table 5-35). The two items that were significantly different between early and late responding pharmacy technicians were: (1) “Apply insurance rules when processing a new claim.”, (2) “Determine when a prescription can be refilled.”, and (3) “Accept called in prescriptions from physician’s offices.” Table 5-34. Dichotomized Means from th e Early Responding Pharmacist Group (n=206) and Late Responding Pharmacist Group (n=108) on the Items of The Community Pharmacy Technician Use Questionnaire Item Group No Yes Chi-Square difference test Early 2 204 Enter data into the computer accurately. Late 2 106 x2 = .11 p = .74 Early 2 204 Apply insurance rules when processing a new claim Late 1 107 x2 = .002 p = .97 Early 3 203 Obtain information from a patient needed to fill a prescription. Late 0 108 x2 = 1.59 p = .21 Early 3 203 Deal with patients in a caring manner Late 1 107 x2 = .16 p = .69 Early 20 186 Assess when a patient needs to speak to a pharmacist about their medication. Late 11 97 x2 = .02 p = .89 Early 127 79 Understand the difference between an ace-inhibitor and a beta-blocker. Late 63 45 x2 = .33 p = .57

PAGE 120

106 Table 5-34. Continued Item Group No Yes Chi-Square difference test Early 8 198 Evaluate the reason for a denied claim. Late 4 104 x2 = .01 p = .94 Early 84 122 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) Late 40 68 x2 = .42 p = .52 Early 126 80 Transfer a patient’s prescription. Late 53 55 x2 = 4.23 p = .04 Early 34 172 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. Late 23 85 x2 = 1.10 p = .30 Early 168 38 Identify the common side effects of a betablocker. Late 79 29 x2 = 2.0 p = .08 Early 26 180 Determine when a prescription can be refilled. Late 14 94 x2 = .01 p = .93 Early 2 204 Explain to a patient insurance claim that had a problem Late 0 108 x2 = 1.06 p = .30 Early 156 50 Accept called in prescriptions from physician’s offices. Late 87 21 x2 = .94 p = .33 Early 26 180 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. Late 11 97 x2 = .41 p = .53 Early 18 188 Include the appropriate information when labeling prescription vials. Late 11 97 x2 = .18 p = .67 Early 5 201 Be discrete with patients’ health information Late 3 105 x2 = .04 p = .85 Early 82 124 Evaluate whether a computer generated DUR needs to be shown to the Early. Late 43 65 x2 = .00 p = .99 Early 109 97 Assess a patient’s actual medication use. Late 57 51 x2 = .00 p = .98 Early 21 185 Link the trade name with the generic name of a drug. Late 11 97 x2 = .00 p = .99 Early 173 33 Evaluate a patient’s medication therapy. Late 87 21 x2 = .58 p = .45 Early 150 56 Educate a patient on the appropriate use of their medication. Late 73 35 x2 = .94 p = .33 Early 75 131 Recognize the therapeutic class of a prescribed medication. Late 39 69 x2 = .00 p = .96 Early 184 22 Assume personal responsibility to resolve a patient’s drug therapy problems. Late 95 13 x2 = .13 p = .72 Early 78 128 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug Late 39 69 x2 = .09 p = .76

PAGE 121

107 Table 5-34. Continued Item Group No Yes Chi-Square difference test Early 12 194 Call physicians for refill authorization. Late 5 103 x2 = .20 p = .66 Table 5-35. Dichotomized Means from th e Early Responding Technician Group (n=249) and Late Responding Technician Group (n=200) on the Items of The Community Pharmacy Technician Use Questionnaire Item Group No Yes Chi-Square difference test Early 2 247 Enter data into the computer accurately. Late 1 199 x2 = .15 p = .70 Early 8 241 Apply insurance rules when processing a new claim. Late 1 199 x2 = 4.16 p = .04 Early 2 247 Obtain information from a patient needed to fill a prescription. Late 4 169 x2 = 1.21 p = .27 Early 3 246 Deal with patients in a caring manner. Late 5 195 x2 = 1.06 p = .30 Early 13 239 Assess when a patient needs to speak to a pharmacist about their medication. Late 13 187 x2 = .33 p = .56 Early 52 197 Understand the difference between an ace-inhibitor and a beta-blocker. Late 29 171 x2 = 3.06 p = .08 Early 6 243 Evaluate the reason for a denied claim. Late 7 193 x2 = .47 p = .49 Early 50 199 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) Late 28 172 x2 = 2.86 p = .09 Early 81 168 Transfer a patient’s prescription. Late 68 132 x2 = .11 p = .74 Early 82 167 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. Late 73 127 x2 = .63 p = .43 Early 108 141 Identify the common side effects of a beta-blocker. Late 78 122 x2 = .87 p = .35 Early 6 243 Determine when a prescription can be refilled. Late 12 188 x2 = 3.72 p = .05 Early 7 242 Explain to a patient insurance claim that had a problem Late 5 195 x2 = .04 p = .84 Early 104 145 Accept called in prescriptions from physician’s offices. Late 106 94 x2 = 5.62 p = .02 Early 37 212 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. Late 40 160 x2 = 2.06 p = .15

PAGE 122

108 Table 5-35. Continued Item Group No Yes Chi-Square difference test Early 4 245 Include the appropriate information when labeling prescription vials. Late 4 196 x2 = .10 p = .75 Early 3 246 Be discrete with patients’ health information Late 2 198 x2 = .04 p = .84 Early 43 206 Evaluate whether a computer generated DUR needs to be shown to the Early. Late 29 171 x2 = .63 p = .43 Early 96 153 Assess a patient’s actual medication use. Late 79 121 x2 = .04 p = .84 Early 7 242 Link the trade name with the generic name of a drug. Late 6 194 x2 = .01 p = .91 Early 149 100 Evaluate a patient’s medication therapy. Late 108 92 x2 = 1.55 p = .21 Early 129 120 Educate a patient on the appropriate use of their medication. Late 90 110 x2 = 2.06 p = .15 Early 61 188 Recognize the therapeutic class of a prescribed medication. Late 40 160 x2 = 1.29 p = .26 Early 191 58 Assume personal responsibility to resolve a patient’s drug therapy problems. Late 139 61 x2 = 1.96 p = .09 Early 46 203 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. Late 38 162 x2 = .02 p = .89 Early 15 234 Call physicians for refill authorization. Late 15 185 x2 = .39 p = .53

PAGE 123

109 CHAPTER 6 DISCUSSION Introduction This chapter presents the discussion of the results from this project. The discussion is presented following the format introduced in the methods section. Sections discussing the limitations and suggestions for future research are also included in this chapter. Response Rate The subject’s responded in numbers sufficient to meet the minimum needed response rate. Still the number of responses was somewhat less than expected. The response rate may have been affected by numerous hurricanes during the time of the data collection. The weekend after the first mailing Hurricane Charley made landfall in Florida south of the Tampa area. One subject sent in her questionnaire two weeks later—but before receiving the second mailing—stating that the hurricane had prevented her from responding earlier. The follow-up mailing was potentially affected as well. The weekend after the follow-up mailing Hurricane Frances made landfall in Florida on the Atlantic coast. The next two weeks were followed by Hurricanes Ivan which made landfall in the panhandle, and Jeanne which ran north along the western coast of the peninsula. These four hurricanes caused widespread devastation in the state and undoubtedly affected the response rate. The response from the pharmacist group may also have been affected by the list used to target the subjects. The pharmacist list was purchased from a commercial seller of lists. The company representative insisted that the list was of only community

PAGE 124

110 pharmacists. She claimed that each person had been telephoned and his or her type of employment verified. Still, some of the respondents were not community pharmacy. It is likely that many more who did not respond were also not in community pharmacy. This may have affected the response rate, and did affect the useable response rate. Descriptive Data While all the pharmacy technicians in the study were PTCB certified, many had only those educational requirements mandate d for certification—a high school diploma or Graduate Equivalency Diploma (GED )—and few had any formal training. Nevertheless, the education level of the pharmacy technician sample may be greater than it is for Florida pharmacy technicians on average for two reasons. First, the education levels of the sample may have been affected by the store managers and assistant store managers from the retail chain Walgreens. Walgreens requires all such personnel to be PTCB certified. Several of the subjects indicated that they were store managers. Those subjects reported having either a bachelor’s degree or a master’s degree. A large portion of the pharmacy technician sample reported working for retail chains. Second, the pharmacy technician subjects were selected because they had a national pharmacy technician credential—PTCB certification. Holders of such a certificate may value credentials more than those who have not taken the time to sit for the certification exam. While associate’s degrees and diploma programs exist for pharmacy technician studies in the state, PTCB certification is the only standardized credential that one can obtain in Florida. Still, Florida does not mandate this certification for pharmacy technicians. This means that the sample perhaps represents a group of more dedicated, motivated, and qualified pharmacy technicians than may be found in actual practice. Despite that this group did not possess many educational credentials. Unlike Florida

PAGE 125

111 pharmacists, Florida pharmacy technicians have no state mandated education. Those who responded to the education questions were not consistently educated and many reported having only a high school diploma or GED. Since pharmacy technicians are not formally educated it is possible that they c ould be unknowingly used to perform tasks that they should not perform. Formal training does not appear to be the norm for pharmacy technicians in this sample. Most of the pharmacy technicians reported that they had been trained on the job. Less than half reported having participated in an employer developed training program. This suggests that most technicians learn their trade informally through work experience. Unlike Florida pharmacists, Florida pharmacy technicians have no state mandated experiential work or training. The pharmacy technicians in the sample reported few pharmacy-related certificates other than PTCB certification. N early all of the other certificates reported were part of an employer’s program. All of the technicians included in the sample were working. This suggests that not all employers promote or have certification programs. This is not surprising since the technicians did not report a large number of employer training programs, the end result of which might be a certificate. Similarly, the pharmacist data suggests that they are supervising pharmacy technicians with less than ideal credentialing. While most of the pharmacists in the sample reported that they had supervised a PTCB certified pharmacy technician some indicated that they did not know if they had. Few pharmacists reported having supervised a pharmacy technician with an a ssociate’s degree in pharmaceutical technician sciences. More, in fact, reported not knowing if they had than reported that they had.

PAGE 126

112 This lack of familiarity with support staff’s credentials suggests that pharmacy technicians are not being selected for their credentials and skills. This is further supported by the pharmacist perceived competency of pharmacy technicians that they had supervised that were calculated from the pharmacists’ reports of the number of technicians that they had supervised and the number of those which were competent. The pharmacists reported that only two-thirds of the technicians that they had supervised were competent. This number is simply a report of opinion and not an actual measure of competence that can be generalized to all pharmacy technicians in the state of Florida. In other words, it is not a reliable or valid measure of community pharmacy technician competency in Florida. Still pharmacists should be experts at recognizing what a pharmacy technician is capable of or not capable of doing. Group Differences by Items The first research question was “Do pharmacists and pharmacy technician beliefs on tasks that pharmacy technicians should perform in community practice differ? ”. The pharmacy technicians in the sample believe that a capable pharmacy technician should perform more tasks than the pharmacists in the sample believe they should perform. The pharmacists agreed that a capable pharmacy technician should perform all but eight of the tasks in the questionnaire. The pharmacy technicians agreed that a capable pharmacy technician should perform all but two of the tasks in the questionnaire. Those two items were among the eight items that most of the pharmacists disagreed with. For each of these eight items there was a significant difference between the two groups’ beliefs. The items that pharmacist thought that a capable pharmacy technician should not perform are for the most part not surprising. Most of the items were written to represent

PAGE 127

113 aspects of pharmacy practice that were believed to be outside of the skill set of pharmacy technicians. In instrument development these items were thought to require the specialized knowledge of pharmacotherapy or a professional-patient relationship that only a pharmacist could possess. In fact every one of the six items that were written during the development stage to represent aspects of pharmacy practice that are outside of the skill set of a capable pharmacy technician are in this set of eight items. The differences between pharmacists and pharmacy technicians on these six items seem to be more than statistically significant, they seem to be practically significant. They seem practically significant since the majority of the pharmacists feel that a pharmacy technician should not perform the tasks, while the majority of the technicians feel that a pharmacy technician should perform the task. Not only is there a significant difference in the means there is a logical difference as well. The six items that represent services that pharmacy technicians are not qualified to provide should be things that a capable pharmacy technician would recognize as being beyond his or her ability. Those items are: (1) “Understand the difference between an ace-inhibitor and a beta-blocker.”; (2) “Identify the common side effects of a beta-blocker.”; (3) “Assess a patient’s actual medication use.”; (4) “Evaluate a patient’s medication therapy.”; (5) “Educate a patient on the appropriate use of their medication.”; and (6) “Assume personal responsibility to resolve a patient’s drug therapy problems.” Proper skills mix use would avoid the dilution of pharmacists’ skills by best use of pharmacists and pharmacy technicians. Indeed it is important that pharmacy technicians be able to judge what situations are beyond their skill set.

PAGE 128

114 Two items that most pharmacists felt pharmacy technicians should not perform and for which there were significant differences between the groups were not written to be outside of a capable pharmacy technicians practice. Those two tasks are (1) transferring a prescription, and (2) accepting called in prescriptions from physicians’ offices. The two tasks were included in the questionnaire because they represent tasks that pharmacy technicians are permitted to perform in some states but not in Florida (NABP, 2003). These are tasks that are performed in states with greater regulation of pharmacy technicians than Florida has (NABP, 2003). There is probably a practical difference as well as a significant difference in the beliefs of the two groups on these two items. S lightly more than half of the pharmacists felt that a capable pharmacy technician should not transfer a prescription, while only onethird of the pharmacy technicians felt that a capable pharmacy technician should not transfer a prescription. In contrast most pharmacists felt that capable pharmacy technician should not accept called in prescriptions from physicians offices, while slightly less than half of the pharmacy technicians felt that a capable pharmacy technician should not accept called in prescriptions from physicians offices. The pharmacy technicians in the sample seem to feel that these two tasks which pharmacy technicians are not permitted to perform in the state should be performed by pharmacy technicians. The pharmacists seem to disagree more strongly that pharmacy technicians should accept called in prescriptions from physicians’ offices than transfer a prescription. Finally, there were eight additional items on which the two groups’ beliefs significantly differed. Despite the statistical difference, the means for these items for both groups suggest that they agree that a capable pharmacy technician should be able to

PAGE 129

115 perform those tasks. For some of these eight items subjects commented that the task could be performed by the computer software. Those items were: (1) “Determine when a prescription can be refilled.”, (2) “Include the appropriate information when labeling prescription vials.”, and (3) “Link the trade name with the generic name of a drug.” For the item “Evaluate whether a computer generated DUR needs to be shown to the pharmacist.” subjects commented that all DUR or drug use review reports were printed and viewed by the pharmacists or that that the pharmacist could not release a prescription to a patient until he or she had signed off in the computer database for each DUR. For that company the software is tied into the register and thus prevents the prescription from being rung up for sale. Not all pharmacy organizations use the same software. Some of the items are thus apparently outdated for some practice sites in the state. The remaining items seem to represent a practical difference between pharmacists and pharmacy technicians. Those items are: (1) “Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.)”, (2) “Recognize the therapeutic class of a prescribed medication.”, and (3) “Assess which medication a patient wants to have refilled when the patient does not know the name of the drug.” These three items all seem to require knowledge of the purpose or use of medications. The pharmacy technicians seem to believe that this knowledge would be held by capable pharmacy technician more than the pharmacists believe it would be. The pharmacy technicians seem to believe that a capable pharmacy technician should be capable of providing a greater level of service than the pharmacists seem to believe such a technician should be capable of. Of the items that most of the pharmacists and pharmacy technicians in the sample disagree that a capable pharmacy technician

PAGE 130

116 should perform, most are outside of the sc ope of a pharmacy technician’s training and abilities. Two of the tasks about which pharmacists disagree whether a pharmacy technician should perform are tasks that may be legally performed by pharmacy technicians in some states. Confirmatory Factor Analysis The second research question was: “Does the Framework of Expert Practice for Pharmacy fit pharmacists’ and pharmacy technicians’ beliefs on the tasks that pharmacy technicians should perform in community practice?”. The goodness of fit statistics from the complete data suggest that The Community Pharmacy Technician Use Questionnaire did not model the professional expertise of pharmacy technicians as described by the conceptual framework used to develop the instrument. Analyzing all of the data did not create a better fit of the model. Several things may have contributed to problems with the measure. Using tasks to represent virtues or education and assessment may create doublebarreled questions. Consider the items “Assume personal responsibility to resolve a patient’s drug therapy problems.” and “Go out of their way to assist a patient in obtaining aid to pay for their prescriptions.” These items were probably interpreted for their knowledge component rather than for their virtue component. Recall that the virtues scale was problematic in the pretests. It is possible that the items were double-barreled and thus bad items. Secondly, it may be that some of the constructs in the model are applications of other constructs. For instance to use judgment one must have knowledge and virtues. Or to assess and educate a patient one must have knowledge, virtues and judgment.

PAGE 131

117 Some revisions might overcome this problem. Eliminating or revising items that appear to be double barreled might do this. At the same time items that were outdated could be eliminated, such as those items that represented tasks that could be performed by some of the newer pharmacy software programs. Still simple revisions may not overcome the lack of construct validity for the questionnaire. It is possible that pharmacy technicians and pharmacists do not think of a capable pharmacy technician in terms that fit the model of professional expertise. This does not agree with the results of the focus group and one-on-one interviews with pharmacists. Those data suggest that pharmacists do think of pharmacy technicians in terms that fit the model of professional expertise of pharmacy technicians. It may be that in discussing a good technician the pharmacists were able to capture the constructs of professional expertise, but in completing a questionnaire the subjects were not. This may be because in a conversation about what a good technician is or can do, the pharmacists thought about the qualities needed by a good technician, but when pharmacy personnel complete the questionnaire they may not be able to think as abstractly about the qualities of a good (or capable) technician, and instead they focus on the tasks within their understanding of current practice. Perhaps the subjects’ responses were confounded by the subjects’ familiarity with past and modern pharmacy practice. One pharmacist indicated on his/her questionnaire that the responses were based on pharmacy tec hnicians that he/she had worked with. One pharmacy technician called me and asked if he should answer the questions based on what is legal and currently done or what a capable pharmacy technician should do.

PAGE 132

118 Despite the instructions it clearly was hard for the pharmacists and the pharmacy technicians to think beyond current pharmacy practice and their own experiences. The items may have been too conceptually different from the targeted framework. Some things in the Jensen et al. (1999) model were not captured by the items in the questionnaire: (1) the targeted clinical reasoning domain included collaborative problem solving, evaluative approaches, learning from mistakes and confidence in decisions; (2) the targeted knowledge domain included things like seeking new knowledge and teaching new practitioners; (3) the targeted movement domain included things like touch, examination, intervention, the underlying reason of the interaction, and communication; and (4) the targeted virtues domain included things like religious affiliation and love of people. It was not possible to capture these types of ideas in terms of a task. Using items that do not focus on tasks might create a questionnaire whose data would better fit the targeted model. The data from the two groups did not fit the proposed model of professional expertise for pharmacy technicians. The fit of the model may be improved through revisions to the questionnaire or to the analysis. It may also be that pharmacists and pharmacy technicians have difficulty in thinking about what a capable pharmacy technician should do because of their familiarity with what the average pharmacy technician is currently capable of doing. Exploratory Factor Analyses The third research question was: “Do pharmacists’ and pharmacy technicians’ beliefs differ on the categories of tasks that pharmacy technicians should perform in community practice?” The research question was evaluated by separately modeling the data for the two groups using exploratory factor analysis. The exploratory factor analysis

PAGE 133

119 suggested that the data from the two groups fit similar models, but not the same model. This does not suggest that the two groups’ beliefs differ by category or type of tasks. The data suggested different models for the two gr oups during the exploratory factor analyses. It also suggested that the items in The Community Pharmacy Technician Use Questionnaire have some underlying concepts that are common to the ways that pharmacists and pharmacy technicians think about the tasks that a capable pharmacy technician should or should not perform. Data Driven Models While the two models generated form the data were different, the models had some similarities. For this reason the models are not discussed separately. Instead, the common and distinct features are discussed he re. The exploratory factor analysis found two conceptually similar factors, one comm on factor, and two factors that were not conceptually similar for the two groups. The similar concepts from the two groups’ models were made up of tasks that pharmacy technicians typically do, and tasks that are professional in nature. The common factor was made up of tasks that pharmacy technicians may not do by law in Florida. Th e factors are grounded in current practice. Two seem to be exclusively based on what a pharmacy technician is capable of doing. Pharmacy technicians are capable of performi ng (and may perform) technical tasks, while they are not capable of providing (and may not provide) clinical services. Tasks and functions typical of pharmacy technicians. The tasks and functions typical of pharmacy technicians in current practice may represent a set of tasks that are part of a core set of tasks and functions that pharmacy technicians would ideally perform. The skills needed to perform these tasks and functions may likewise be part of a core set of pharmacy technician skills. Such a skills set might be necessary for a pharmacy

PAGE 134

120 technician to be a capable pharmacy technician. Pharmacy technician educators and trainers should consider these tasks and their underlying skills set when developing educational materials and training programs. Clinical pharmacy knowledge tasks. The clinical pharmacy knowledge tasks seem to represent tasks and services that are beyond the scope of a capable pharmacy technician. It is important for pharmacy t echnicians to know what they should not do and what they do not know. That may seem obvious, or it may seem ambiguous. Clearly the skills needed to provide pharmaceutical care are not within the domain of the pharmacy technician. Pharmacy technician educators and trainers should prepare pharmacy technicians to recognize when they are dealing with situations that are outside of their knowledge. It would be important in future research to determine whether tasks involving therapeutic knowledge that pharmacy technicians think a capable pharmacy technician should perform are being performed by pharmacy technicians today. Those tasks are: (1) Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.), (2) Evaluate whether a computer generated DUR needs to be shown to the pharmacist., and (3) Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. Pharmacist only tasks as specified by law. It may be that pharmacy technicians are not capable of performing the pharmacist only tasks as specified by law. The factor did surface as a distinct factor for both gr oups suggesting that it is somehow different from the other factors. If the subjects were thinking about a capable pharmacy technician, as prompted, then the factor may represent tasks that pharmacy technicians should perform but legally may not. Even if the subjects were thinking about a typical

PAGE 135

121 pharmacy technician, one has to wonder how this factor is distinct from the pharmacy information evaluation and management skills factor. Most likely, the pharmacist only tasks as specified by law factor represents tasks that a capable pharmacy technician should perform but legally may not. The tasks themselves do not require professional training or a professional patient relationship and are allowed legally in some states. Data from a state where pharmacy technicians may perform the tasks of transferring prescriptions and accepting called in prescriptions from physicians’ offices may have these two tasks load on the typical pharmacy technician tasks factor. While who may accept called in prescriptions from physicians’ offices is regulated in Florida, who may telephone in prescriptions from physicians’ offices is not. Patients may not phone in their own prescriptions, but any staff member authorized by a physician may. As electronic prescribing becomes the norm and phoned in prescriptions obsolete or even illegal this issue may become unimportant. Pharmacy information evaluation and management skills. The pharmacist group only factor pharmacy information evaluation and management skills seems to represent prescription information management and evaluation skills. To some degree they may be related to modern software or the electronic part of the prescription filling process, as well as being able to evaluate information. Three of the items in the factor may represent tasks that are supported by software: (1) “Include the appropriate information when labeling prescription vials.”; (2) Link the trade name with the generic name of a drug.”; and (3) “Recognize the therapeutic class of a prescribed medication.” The item “Be discreet with patient health information.” seems to clearly involve recognizing and protecting information. One of the items may depend on the

PAGE 136

122 interpretation of third party payer claims’ rejects (information) that are transmitted electronically from the pharmaceutical benefits managers during the electronic portion of the filling process. That item is: “Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist.” It is possible that pharmacy information evaluation and management skills or pharmacy protocols underlies these tasks. The last item in the factor did not contribute to the overall consistency of the factor. That item was: “Go out of their way to assist a patient in obtaining aid to pay for their prescriptions.” Still it can be thought of in terms of dealing with third party payers when a claim is rejected. General drug knowledge. The pharmacy technician group only factor general drug knowledge seems to represent items that require basic drug knowledge. This is easily apparent for three of the items: (1) “Understand the difference between an aceinhibitor and a beta-blocker.”, (2) “Identify the common side effects of a beta-blocker.”, and (3) “Recognize the therapeutic class of a prescribed medication.” Pharmacy technicians may value this type of knowledge. It may make them feel more confident about the quality of the work they do when they have some ideas about the purpose and functions of the products they are processing and packaging for patients. The factors that were unique to the two groups suggest a difference in the way that the pharmacists and pharmacy technicians thought about what a capable pharmacy technician should do. The factor that was uni que to the pharmacists’ model suggests that the pharmacists think of a capable pharmacy technician in terms of being able to manage and evaluate prescription information. The factor that was unique to the pharmacy technicians suggests that the pharmacy technicians think of a capable pharmacy

PAGE 137

123 technician in terms of general drug knowledge. This type of knowledge is not a prerequisite for being a pharmacy technician in Florida. The pharmacy technicians endorsed the items in this factor quite highly suggesting that they agree that a capable pharmacy technician should have the type of drug knowledge that these tasks require. Factor Correlations Within Models Factor correlations within the pharmacist model. The correlations among the factors in the pharmacist model were moderate to low. The high correlation between the Tasks and functions typical of pharmacy technicians in current practice factor and the Pharmacy information evaluation and management skills factor suggest that the later represents some specialized form of pharmacy technician tasks. The low correlation between the Pharmacy information evaluation and management skills factor and the Pharmacist only tasks as specified by law fact or suggest that these two factors are about two different things within a vaguely common concept. The correlations suggest that the content for most of the factors is somewhat related yet for distinct for each. Factor correlations within the pharmacy technician model. The correlations among the factors in the pharmacist model were moderate to high. The low correlation was between the General drug knowledge factor and the Pharmacist only tasks as specified by law factor suggests that technicians do not associate the tasks in the Pharmacist only tasks as specified by law factor with drug knowledge. The high correlation was between the Clinical pharmacy knowledge tasks factor and the General drug knowledge factor tasks suggests that the General drug knowledge factor involves some clinical drug knowledge. The correlations suggest that the law factor is somewhat more correlated with the Clinical pharmacy knowledge tasks factor than the Tasks and functions typical of pharmacy technicians in current practice factor. It seems that

PAGE 138

124 pharmacy technicians think of the law factor as related to functions that pharmacist should perform, as well as related to pharmacy technician functions. The line in the sand is probably where the law says the line is for this factor. Model Differences Between Groups The pharmacy technicians’ beliefs were consistently more positive about the appropriateness of pharmacy technicians doing all tasks than the pharmacists’ beliefs were. This may be because technicians think that a capable technician should perform more tasks than pharmacists think they should perform. Alternatively it may be that technicians think of pharmacy technician as being more capable and thus as performing more tasks, than pharmacists think of them. The item “Go out of their way to assist a patient in obtaining aid to pay for their prescriptions.” seems to have been interpreted by the subjects in a way that was not intended. This item was intended to target a virtue. Instead it seems to have been interpreted in terms of knowledge. Pharmacists seemed to interpret it in terms of pharmacy information evaluation and management skills. Pharmacy technicians seemed to interpret it in terms of clinical knowledge. Within-Group Comparisons of Summated scores by Type of Experience The comparisons between the factors and type of work experience among the pharmacists and pharmacy technicians had only one significant finding per group. While the pharmacists and pharmacy technicians generally endorsed the items differently dependent on their work experiences the differences were often not significantly different. Also, while some significant corre lations were found those correlations were low. Some of the variables may have been problematic due to the amount of variability that they contained. For instance, the pharmacy technician education variable may not be

PAGE 139

125 meaningful since the educational attainment of the pharmacy technician in the sample was so varied. The mean summated scores for pharmacists who reported experience supervising a PTCB certified pharmacy technician and for pharmacists who reported no such experience were significantly different for one factor: Tasks and functions typical of pharmacy technicians in current practice factor. The pharmacists who reported experience supervising a PTCB certified pharmacy technician had higher summated scores than pharmacists who reported no such experience. This suggests that the pharmacists who had experience working with a PTCB certified pharmacy technician more strongly agree that a capable pharmacy technician should perform these typical pharmacy technician tasks. The mean summated scores for pharmacy technician reported having some certification other than PTCB certification and pharmacy technicians who reported no such certifications were significantly different for one factor: Tasks and functions typical of pharmacy technicians in current practice factor. This suggests that the pharmacy technicians who had some certification other than PTCB certification more strongly agree that a capable pharmacy technician should perform these typical pharmacy technician tasks. Model Comparisons with Proposed Model The items intended to represent discreet constructs of the proposed model were reorganized into the different factors of th e models generated by the exploratory factor analysis. The originally proposed model and the data derived models all had four factors. For the most part these factors are not similar. Three of the data driven factors seem to draw on multiple factors from the proposed model.

PAGE 140

126 The data derived factor clinical pharmacy knowledge tasks factor was similar to the underlying concept of the proposed assessment and education factor. Still that factor seemed to also involve the knowledge and skills factor, and the judgment and reasoning factor. The clinical pharmacy knowledge tasks factor seems to capture a great deal of patient-practitioner relationship information. Two other factors seem to draw on multiple parts of the originally proposed model: (1) Tasks and functions typical of pharmacy technicians in current practice; and (2) Pharmacy information evaluation and management skills. Unlike the clinical pharmacy knowledge tasks factor, which seems to emphasize one particular part of the originally proposed model these two factors do not seem to emphasize any one factor from the originally proposed model. Instead the Tasks and functions typical of pharmacy technicians in current practice seems to draw from all four of the originally proposed factors, while the Pharmacy information evaluation and management skills factor seems to draw on three of the originally proposed factors. The Pharmacy information evaluation and management skills factor does not seem related to the originally proposed patient assessment and education factor. For both groups the pharmacist only tasks as specified by law factor did not seem related to the proposed model. It seems that the underlying concept of the law that is acting in this factor is not obviously related to professional expertise or judgment. The pharmacy technician group factor general drug knowledge factor seems to include only the knowledge aspect from the proposed model. Still this factor seems to focus on general drug knowledge and not on knowledge as it is intended in the proposed model.

PAGE 141

127 Exploratory factor analysis summary. The exploratory factor analyses suggest that three concepts are similar in the beliefs of pharmacists and pharmacy technicians in the study; while two are dissimilar. The similar factors were: (1) Tasks and functions typical of pharmacy technicians in current practice, (2) Clinical pharmacy knowledge tasks, and (3) Pharmacist only tasks as specified by law. The dissimilar factors were: (1) Pharmacy information evaluation and management skills factor (from the pharmacist data), and (2) general drug knowledge factor (from the technician data). Pharmacy technician educators and trainers should consider these concepts when developing educational materials and training programs. Limitations This work did not have a generalizable sample of pharmacists or pharmacy technicians. The pharmacist list appears not to represent what it was supposed to represent: a randomly selected sample of all community pharmacists residing and working in the state of Florida. The pharmacy technicians in this sample were not a randomly selected sample of pharmacy technicians but PTCB certified pharmacy technicians who had identified themselves to the PTCB as working in community pharmacy. Also only a small portion of the targeted sample is represented in the study. The beliefs of the non-responders are lost to the analysis. It is possible that although the response-bias analysis suggests that early and late responders did not differ on most items, it could still be the case that non-responders may differ in their beliefs from those who did respond. The instrument did not include all tasks that are performed in community pharmacy. There was not room for all of the tasks. Of particular concern was the omission of a question assessing pharmacist and pharmacy technician beliefs about

PAGE 142

128 whether or not a capable pharmacy technician should perform the final check of a prescription before dispensing. This study did not measure the stability of the instrument. No test-retest of the measure was done. Nor did the analysis compare half of the data’s exploratory model to another half of the data within groups. The only reliability estimates used was the internal consistency of the generated factors. Suggestions for Future Research Future researchers may want to focus on which pharmacy technician tasks or functions technicians are currently performing as opposed to what pharmacists and pharmacy technicians think they should be performing. More ground work needs to be done in the area of describing practice as it exists. Clearly more groundwork is needed. More qualitative work before item development might also prevent the use of outdated and problematic items in the questionnaire. Conclusion The pharmacist and pharmacy technicians in the study did not agree on whether a capable pharmacy technician should perform all of the tasks in The Community Pharmacy Technician Use Questionnaire. Pharmacists in the study did not believe that pharmacy technicians should perform many of the tasks requiring specialized knowledge and/or a professional patient relationship. Meanwhile, pharmacy technicians believed that pharmacy technicians should perform most of the tasks even those requiring specialized knowledge of drug therapy. The data from the two groups did not fit the proposed model of professional expertise for pharmacy technicians. The exploratory factor analyses suggest that three factors are similar to the pharmacists’ and pharmacy

PAGE 143

129 technicians’ data and two were not. The factors that were similar for the two groups were: (1) Tasks and functions typical of pharmacy technicians in current practice, (2) Clinical pharmacy knowledge tasks, and (3) Pharmacist only tasks as specified by law. The clinical pharmacy knowledge tasks factors from the two groups seem to represent tasks that are outside of the pharmacy technician domain. The other factors from the two groups seem to represent aspects of practice that are performed by pharmacy technicians (Tasks and functions typical of pharmacy technicians in current practice), and that are illegal for pharmacy technicians to perform in this state but possibly not outside of their domain (Pharmacist only tasks as specified by law). The factors that were dissimilar for the two groups were: (1) Pharmacy information evaluation and management skills factor (from the pharmacist data), and (2) general drug knowledge factor (from the technician data). They seem to represent knowledge based decision tasks that are supported by software (pharmacy information evaluation and management skills), and drug knowledge that pharmacy technicians feel a capable pharmacy technician should possess (general drug knowledge).

PAGE 144

130 APPENDIX A INITIAL COVER LETTER SENT TO PHARMACIST SUBJECTS This appendix contains the cover letter that was sent to the pharmacist subjects to recruit them into the study. This cover letter was sent out to the 2000 targeted pharmacist subjects with the first mailing.

PAGE 145

131 Date Dear Pharmacist, The role of the pharmacy technician is in flux. Pharmacy technicians are becoming more important in the dispensing process. You have been chosen to represent the opinions of working pharmacist on the role of the pharmacy technician. I would like to know your opinion on the types of tasks that pharmacy technicians should optimally perform. I have undertaken this study because of the belief that pharmacists’ opinions regarding the role of pharmacy technicians should be understood in order to help inform policy making. Your opinion on this matter is important. Please take a few minutes at your earliest convenience to complete the questionnaire and return it to me in the provided business reply envelope. Your responses on the questionnaire will be confidential. Since every participant’s opinion is important in our understanding the tasks that pharmacy technicians should perform, it is essential that you return your questionnaire. Cordially, Debbie L. Wilson, MA, CPhT Doctoral Student dwilson@cop3.health.ufl.edu

PAGE 146

132 APPENDIX B INITIAL COVER LETTER SENT TO TECHNICIAN SUBJECTS This appendix contains the cover letter that was sent to the technician subjects to recruit them into the study. This cover letter was sent out to the 2000 targeted technician subjects with the first mailing.

PAGE 147

133 Date Dear Pharmacy Technician, The role of the pharmacy technician is in flux. Pharmacy technicians are becoming more important in the dispensing process. You have been chosen to represent the opinions of working pharmacy technicians on the role of the pharmacy technician. I would like to know your opinion on the types of tasks that pharmacy technicians should optimally perform. I have undertaken this study because of the belief that pharmacy technicians’ opinions regarding the role of pharmacy technicians should be understood in order to help inform policy making. Your opinion on this matter is important. Please take a few minutes at your earliest convenience to complete the questionnaire and return it to me in the provided business reply envelope. Your responses on the questionnaire will be confidential. Since every participant’s opinion is important in our understanding the tasks that pharmacy technicians believe they should perform, it is essential that you return your questionnaire. Cordially, Debbie L. Wilson, MA, CPhT Doctoral Student dwilson@cop3.health.ufl.edu

PAGE 148

134 APPENDIX C FOLLOW-UP COVER LETTER SENT TO ALL SUBJECTS This appendix contains the cover letter that was sent the pharmacist and technician subjects with the second mailing of the questionnaire. This cover letter was sent out to the 4000 targeted pharmacist and technician subjects with the second mailing to encourage them to participate in the study if they had not already done so.

PAGE 149

135 Date Two weeks ago I wrote to you seeking your opinion on the types of tasks that pharmacy technicians should perform. If you have completed and returned your questionnaire, I thank you. If you have not completed and returned your questionnaire please take the time now to do so. I am writing you again to emphasize how important your opinions on this issue are. In the event that our questionnaire has been misplaced, a replacement has been included. Your cooperation is greatly appreciated. Cordially, Debbie L. Wilson, MA, CPhT Doctoral Student dwilson@cop3.health.ufl.edu

PAGE 150

136 APPENDIX D PHARMACIST QUESTIONNAIRE This appendix contains the questionnaire that was sent to the pharmacist subjects during both mailings.

PAGE 151

137 Pharmacy Technician Responsibility Survey Completion of this brief survey should take no longer than 10 minutes. Responses will be confidential. Your participation in this survey is voluntary. Please ask me any questions that you have. I would be happy to answer them. You can contact me at 352273-6248 or dwilson@cop3.health.ufl.edu Your participation is greatly appreciated.

PAGE 152

138 Pharmacy Technician Responsibility Survey First, please fill out the following questions to the best of your ability. Explain your answers, and any concerns or comments that you have in the "Comments" area if needed. 1. How long have you been practicing pharmacy as a licensed pharmacist? (NUMBER OF YEARS) 2 What type of pharmacy do you work in? ____Retail chain ____Discount store ____Other (Please explain) ____Privately owned retail store ____Supermarket 3. How many technicians have you directly supervised in your career? Supervised here means direct, immediate and personal supervision. (WRITE A NUMBER) 4. How many of those technicians do you feel were competent ? (WRITE A NUMBER) 5. Have you supervised a pharmacy technician who was certified by the Pharmacy Technician Certification Board? (CPhT) YES NO DON’T KNOW 6. Have you supervised a pharmacy technician who had an AA in Pharmacy Technician Sciences? YES NO DON’T KNOW Comments:

PAGE 153

139 Pharmacy Technician Responsibility Survey Please rate the statements that follow based on your opinion. For each circle only one. Imagine that the law permits pharmacy technicians to do each of the following tasks. Which of the following is acceptable task given the role of a pharmacy technician? Strongly 1 Disagree 2 Disagree 3 Somewhat Disagree 4 Somewhat Agree 5 Agree 6 Strongly Agree 1 Enter data into the computer accurately. 1 2 3 4 5 6 2 Apply insurance rules when processing a new claim. 1 2 3 4 5 6 3 Obtain information from a patient needed to fill a prescription. 1 2 3 4 5 6 4 Deal with patients in a caring manner. 1 2 3 4 5 6 5 Assess when a patient needs to speak to a pharmacist about their medication. 1 2 3 4 5 6 6 Understand the difference between an ace-inhibitor and a beta-blocker. 1 2 3 4 5 6 7 Evaluate the reason for a denied claim. 1 2 3 4 5 6 8 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) 1 2 3 4 5 6 9 Transfer a patient’s prescription. 1 2 3 4 5 6 10 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. 1 2 3 4 5 6 11 Identify the common side effects of a beta-blocker. 1 2 3 4 5 6 13 Determine when a prescription can be refilled. 1 2 3 4 5 6 13 Explain to a patient an insurance claim that had a problem. 1 2 3 4 5 6 14 Accept called in prescriptions from physicians’ offices. 1 2 3 4 5 6

PAGE 154

140 Imagine that the law permits pharmacy technicians to do each of the following tasks. Which of the following is acceptable task given the role of a pharmacy technician? Strongly 1 Disagree 2 Disagree 3 Somewhat Disagree 4 Somewhat Agree 5 Agree 6 Strongly Agree 15 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 1 2 3 4 5 6 16 Include the appropriate information when labeling prescription vials. 1 2 3 4 5 6 17 Be discreet with patient health information. 1 2 3 4 5 6 18 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. 1 2 3 4 5 6 19 Assess a patient’s actual medication use. 1 2 3 4 5 6 20 Link the trade name with the generic name of a drug. 1 2 3 4 5 6 21 Evaluate a patient’s medication therapy. 1 2 3 4 5 6 22 Educate a patient on the appropriate use of their medication. 1 2 3 4 5 6 23 Recognize the therapeutic class of a prescribed medication. 1 2 3 4 5 6 24 Assume personal responsibility to resolve a patient’s drug therapy problems. 1 2 3 4 5 6 25 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. 1 2 3 4 5 6 26 Call physicians for refill authorization. 1 2 3 4 5 6 Comments: Please return your survey to Debbie Wilson. Thank you very much for your help!

PAGE 155

141 APPENDIX E PHARMACIST QUESTIONNAIRE This appendix contains the questionnaire that was sent to the pharmacist subjects during both mailings.

PAGE 156

142 Pharmacy Technician Responsibility Survey Completion of this brief survey should take no longer than 10 minutes. Responses will be confidential. Your participation in this survey is voluntary. Please ask me any questions that you have. I would be happy to answer them. You can contact me at 352273-6248 or dwilson@cop3.health.ufl.edu Your participation is greatly appreciated.

PAGE 157

143 Pharmacy Technician Responsibility Survey First, please fill out the following questions to the best of your ability. Explain your answers, and any concerns or comments that you have in the "Comments" area if needed. 1. How long have you been working pharmacy as pharmacy technician? (NUMBER OF YEARS) 2. What type of pharmacy do you work in? ____Retail chain ____Discount store ____Other (Please explain) ____Privately owned retail store ____Supermarket 4. Please check the education that you have: ____ High School Diploma ____ Some college ____ AA/AS general ____ AA in Pharmacy Technician Sciences ____ BA/BS ____ Graduate degree/Professional degree ____ Pharmacy degree from another country ____ Other (Please explain) 5. Please check the training that you have: ____ On the job training ____ Employer developed training program ____ ASHP Approved Program 6. Please describe any non-PTCB pharmacy technician certificates that you have: Comments:

PAGE 158

144 Pharmacy Technician Responsibility Survey Please rate the statements that follow based on your opinion. For each circle only one. Imagine that the law permits pharmacy technicians to do each of the following tasks. Which of the following is acceptable task given the role of a pharmacy technician? Strongly 1 Disagree 2 Disagree 3 Somewhat Disagree 4 Somewhat Agree 5 Agree 6 Strongly Agree 1 Enter data into the computer accurately. 1 2 3 4 5 6 2 Apply insurance rules when processing a new claim. 1 2 3 4 5 6 3 Obtain information from a patient needed to fill a prescription. 1 2 3 4 5 6 4 Deal with patients in a caring manner. 1 2 3 4 5 6 5 Assess when a patient needs to speak to a pharmacist about their medication. 1 2 3 4 5 6 6 Understand the difference between an ace-inhibitor and a beta-blocker. 1 2 3 4 5 6 7 Evaluate the reason for a denied claim. 1 2 3 4 5 6 8 Answer simple patient questions about their medication (ex. Q: What is this medicine for? A: This is for your blood pressure.) 1 2 3 4 5 6 9 Transfer a patient’s prescription. 1 2 3 4 5 6 10 Go out of their way to assist a patient in obtaining aid to pay for their prescriptions. 1 2 3 4 5 6 11 Identify the common side effects of a beta-blocker. 1 2 3 4 5 6 13 Determine when a prescription can be refilled. 1 2 3 4 5 6 13 Explain to a patient an insurance claim that had a problem. 1 2 3 4 5 6 14 Accept called in prescriptions from physicians’ offices. 1 2 3 4 5 6

PAGE 159

145 Imagine that the law permits pharmacy technicians to do each of the following tasks. Which of the following is acceptable task given the role of a pharmacy technician? Strongly 1 Disagree 2 Disagree 3 Somewhat Disagree 4 Somewhat Agree 5 Agree 6 Strongly Agree 15 Evaluate circumstances that suggest the possibility of drug diversion and alerting the pharmacist. 1 2 3 4 5 6 16 Include the appropriate information when labeling prescription vials. 1 2 3 4 5 6 17 Be discreet with patient health information. 1 2 3 4 5 6 18 Evaluate whether a computer generated DUR needs to be shown to the pharmacist. 1 2 3 4 5 6 19 Assess a patient’s actual medication use. 1 2 3 4 5 6 20 Link the trade name with the generic name of a drug. 1 2 3 4 5 6 21 Evaluate a patient’s medication therapy. 1 2 3 4 5 6 22 Educate a patient on the appropriate use of their medication. 1 2 3 4 5 6 23 Recognize the therapeutic class of a prescribed medication. 1 2 3 4 5 6 24 Assume personal responsibility to resolve a patient’s drug therapy problems. 1 2 3 4 5 6 25 Assess which medication a patient wants to have refilled when the patient does not know the name of the drug. 1 2 3 4 5 6 26 Call physicians for refill authorization. 1 2 3 4 5 6 Comments: Please return your survey to Debbie Wilson. Thank you very much for your help!

PAGE 160

146 APPENDIX F CONFIRMATORY FACTOR ANLAYSIS WITH COMPLETE DATA PROGRAM This appendix contains the LISREL code that was used to perform the confirmatory factor analysis with complete data. Complete data means that for each case every item had a response. Such cases were selected for through list-wise deletion.

PAGE 161

147 Group 1: pharmacist observed variables it01 it02 it03 it04 it05 it06 it07 it08 it09 it10 it11 it12 it13 it14 it15 it16 it17 it18 it19 it20 it21 it22 it23 it24 it25 it26 correlation matrix from file h:\rph_cov.txt standard deviations from file h:\rsd.txt sample size 315 latent variables assessment knowledge reasoning virtues equations it03=1*assessment it05 it08 it13 it19 it22 it25=assessment it01=1*knowledge it06 it09 it11 it14 it16 it20 it23 it26=knowledge it02=1*reasoning it07 it12 it15 it18 it21=reasoning it04=1*virtues it10 it17 it24=virtues Group 2: technician correlation matrix from file h:\tech_cov.txt standard deviations from file h:\tsd.txt sample size 448 equations it03=1*assessment it05 it08 it13 it19 it22 it25=assessment it01=1*knowledge it06 it09 it11 it14 it16 it20 it23 it26=knowledge it02=1*reasoning it07 it12 it15 it18 it21=reasoning it04=1*virtues it10 it17 it24=virtues let the error variances of inf-mazes be free let the covariances of vc-ps be free let the variances of vc-ps be free LISREL output sc ad=off

PAGE 162

148 APPENDIX G CONFIRMATORY FACTOR ANLAYSIS WITH MISSING DATA PROGRAM This appendix contains the LISREL code that was used to perform the confirmatory factor analysis with incomplete or missing data. Incomplete data means data from all cases regardless of whether or not there was a response for each item.

PAGE 163

149 Pharmacist models Target pharmacist model CFA prof expertise using pharmacist data observed variables know_01 reas_02 assed_03 virt_04 assed_05 know_06 reas_07 assed_08 know_09 virt_10 know_11 reas_12 assed_13 know_14 reas_15 know_16 virt_17 reas_18 assed_19 know_20 reas_21 assed_22 know_23 virt_24 assed_25 know_26 raw data from file :\rph.dat sample size= 344 missing value code -9 latent variables know reas assed virt equations know_01 know_06 know_09 know_11 know_14 know_16 know_20 know_23 know_26 =know reas_02 reas_07 reas_12 reas_15 reas_18 reas_21 =reas assed_03 assed_05 assed_08 assed_13 assed_19 assed_22 assed_25 =assed virt_04 virt_10 virt_17 virt_24 =virt LISREL output rs mi Null pharmacist model CFA prof expertise using pharmacist data: Estimate the NULL MODEL p. 480 observed variables know_01 reas_02 assed_03 virt_04 assed_05 know_06 reas_07 assed_08 know_09 virt_10 know_11 reas_12 assed_13 know_14 reas_15 know_16 virt_17 reas_18 assed_19 know_20 reas_21 assed_22 know_23 virt_24 assed_25 know_26 raw data from file a:\rph.dat sample size= 344 missing value code -9 latent variables f1 – f26 equations know_01 =f1 reas_02 =f2 assed_03 =f3 virt_04 =f4 assed_05 = f5 know_06 =f6 reas_07 =f7 assed_08 =f8 know_09 =f9 virt_10 =f10 know_11 =f11

PAGE 164

150 reas_12 =f12 assed_13 =f13 know_14 =f14 reas_15 =f15 know_16 =f16 virt_17 =f17 reas_18 =f18 assed_19 =f19 know_20 =f20 reas_21 =f21 assed_22 =f22 know_23 =f23 virt_24 =f24 assed_25 =f25 know_26 =f26 set the corrleation of f1 f41 to zero let the error variances of know_01 reas_02 assed_03 virt_04 assed_05 know_06 reas_07 assed_08 know_09 virt_10 know_11 reas_12 assed_13 know_14 reas_15 know_16 virt_17 reas_18 assed_19 know_20 reas_21 assed_22 know_23 virt_24 assed_25 know_26 be zero LISREL output me=ml rs Technician models Target tech model CFA prof expertise using technician data observed variables know_01 reas_02 assed_03 virt_04 assed_05 know_06 reas_07 assed_08 know_09 virt_10 know_11 reas_12 assed_13 know_14 reas_15 know_16 virt_17 reas_18 assed_19 know_20 reas_21 assed_22 know_23 virt_24 assed_25 know_26 raw data from file :\cpht.dat sample size= 494 missing value code -9 latent variables know reas assed virt equations know_01 know_06 know_09 know_11 know_14 know_16 know_20 know_23 know_26 =know reas_02 reas_07 reas_12 reas_15 reas_18 reas_21 =reas assed_03 assed_05 assed_08 assed_13 assed_19 assed_22 assed_25 =assed virt_04 virt_10 virt_17 virt_24 =virt LISREL output rs mi Null tech model CFA prof expertise using technician data: Estimate the NULL MODEL p. 480 observed variables

PAGE 165

151 know_01 reas_02 assed_03 virt_04 assed_05 know_06 reas_07 assed_08 know_09 virt_10 know_11 reas_12 assed_13 know_14 reas_15 know_16 virt_17 reas_18 assed_19 know_20 reas_21 assed_22 know_23 virt_24 assed_25 know_26 raw data from file a:\cpht.dat sample size= 494 missing value code -9 latent variables f1 – f26 equations know_01 =f1 reas_02 =f2 assed_03 =f3 virt_04 =f4 assed_05 = f5 know_06 =f6 reas_07 =f7 assed_08 =f8 know_09 =f9 virt_10 =f10 know_11 =f11 reas_12 =f12 assed_13 =f13 know_14 =f14 reas_15 =f15 know_16 =f16 virt_17 =f17 reas_18 =f18 assed_19 =f19 know_20 =f20 reas_21 =f21 assed_22 =f22 know_23 =f23 virt_24 =f24 assed_25 =f25 know_26 =f26 set the corrleation of f1 f41 to zero let the error variances of know_01 reas_02 assed_03 virt_04 assed_05 know_06 reas_07 assed_08 know_09 virt_10 know_11 reas_12 assed_13 know_14 reas_15 know_16 virt_17 reas_18 assed_19 know_20 reas_21 assed_22 know_23 virt_24 assed_25 know_26 be zero LISREL output me=ml rs

PAGE 166

152 LIST OF REFERENCES American Pharmaceutical Association and the American Society of HealthSystem Pharmacists. (1996). White paper on pharmacy technicians: Recommendations of pharmacy practitioner organizations on the functions, training, and regulation of technicians. Journal of the American Pharmaceutical Association, 8 (NS36), 515-518. American Society of Health-System Pharmacists. (1998). Manual for pharmacy technicians (2nd ed.). Bethesda MD: American Society of Health-System Pharmacists. American Society of Health-System Pharmacists. (2000). NABP proposes national competence assessment for technicians. American Journal of Health-System Pharmacists, 57 (Jul. 1), 1204. American Society of Health-System Phar macists. (2000). Pharmacy technician’s role in an ambulatory care infusion clinic. American Journal of Health-System Pharmacists, 57 (Sep. 15), 1664-5. American Society of Health-System Pharmacists. (2002). ASHP-accredited pharmacy technician training program di rectory. [On line] [accessed 2002 May 16]. Available from URL: http://www.ashp.com/directories/technician/index.cfm American Society of Health-Systems Pharmacists. (2003). White paper on pharmacy technicians. 2002: Needed changes can no longer wait. American Journal of Health-System Pharmacists, 60, 37-51. American Society of Hospital Pharmacists. (1981). ASHP survey of use of pharmacy technicians. American Journal of Hospital Pharmacists, 38, 1780-1. American Society of Hospital Pharmacists. (1985). ASHP survey of use of pharmacy technicians--1985. American Journal of Hospital Pharmacists, 42, 2720-1. American Society of Hospital Pharm acists. (1987). Toward a well-defined category of technical personnel in pharmacy. American Journal of Hospital Pharmacists, 44 (Nov.), 2560-2565. American Society of Hospital Pharmacists. (1989). Final report of the ASHP task force on technical personnel in pharmacy. American Journal of Hospital Pharmacists, 46 (Jul.). 1420-1428.

PAGE 167

153 American Society of Hospital Pharmacists. (1989). Technical personnel in pharmacy: directions for the profession in society. Proceedings of an invitational conference conducted by the University of Maryland Center on Drugs and Public Policy and sponsored by the ASHP Research and Education Foundation. American Journal of Hospital Pharmacists, 46 (Mar.), 491-557. American Society of Hospital Pharmacists. (1994). Summary of the final report of the Scope of Pharmacy Practice Project. American Journal of Hospital Pharmacists, 51 (Sep. 1), 2179-2181. Araque, E., & Latiolais, C.J. (1985). Job responsibilities and competency standards: study of hospital pharmacy technicians in Ohio. Journal of Pharmaceutical Technology, 1 (Mar-Apr), 74-80. Arizona State Board of Pharmacy. (2001) Arizona administrative code R4-23403-J. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.pharmacy.state.az.us/link15.htm Ballington, D.A., Spires, R.L., Tapley, D.J., & Bateman, C.V. (1990). Survey of technician use in hospital and community pharmacies in South Carolina. American Journal of Hospital Pharmacists, 47 (Sep), 2066-2068. California State Board of Pharmacy. ( 2001). Pharmacy technician. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.pharmacy.ca.gov/applicant_pharmacy_technician.htm Connecticut State Board of Pharmacy. (2001). Sec. 20576-37. Training. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.ctdrugcontrol.com/dlaws801.htm Cooksey, J.A., Knapp, K.K., Walton, S.M. & Cultice, J.M. (2002). Challenges to the pharmacist profession from escalating pharmaceutical demand. Health Affairs, 21 (5), 182-188. The Council on Credentialing in Pharmacy. (2000). White paper on credentialing in pharmacy. [On line] [accessed 2002 May 16]. Available from URL: http://www.ptcb.org/presentations/CCP-FINAL-0900.pdf Drug Topics. (1999). Tech’s time. Drug Topics, Nov. 15, 52-60. Ervin, K.C., Skledar, S., Hess, M.M. & Ryan, M. (2001). Data analyst technician: An innovative role for the pharmacy technician. American Journal of Hospital Pharmacists, 58 (Oct. 1), 1815-1818. Fitzgerald, W.L., Smalley, M.D., & Cash, H. (1991). Pharmacy technicians: Current status in the states. American Pharmacy, 6 (NS31), 35-37.

PAGE 168

154 Gebhart, F. (1997). Washout: California Board rejects tech-check-tech. Hospital Pharmacist Report, 11 (Jun.), 9-10. Greenberg, R.B. (1981). ASHP survey of use of pharmacy technicians. American Journal of Hospital Pharmacists, 38 (Nov.), 1780-1781. Hair, F.H., Anderson, R.E., Tatham, R.L., & Black, W.C. (1998). Multivariate data analysis. New Jersey: Prentice-Hall, Inc. Hogan, G.F. (1985). AAAHP Survey of use of pharmacy technicians—1985. American Journal of Hospital Pharmacists, 42 (Dec.), 2720-2721. Health Resources and Services Administration (2000). The pharmacist workforce: A study of the supply and demand for pharmacists. Health and Human Services Health Resources and Services Administration. [On line] [accessed 2002 May 16] Available from URL: http://bhpr.hrsa.gov:80/healthworkforce/pharmacist.html Idaho State Board of Pharmacy. (2001). Administrative rules. [On line] [accessed 2001 Dec 21]. Available from URL: http://www2.state.id.us/adm/adminrules/rules/idapa27/0101.pdf Indiana State Board of Pharmacy. (2001). Qualifications of a pharmacy technician. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.in.gov/hpb/boards/isbp/reqapp/qualifications.html International Currency Converter. (2004). Historical rates. [On line] [accessed 2004 Nov 29]. Available from URL: www.iccfx.com/history.php3?type=available Iowa State Board of Pharmacy. (2001). 657-22.16(155A) [On line] [accessed 2001 Dec 21]. Available from URL: http://www.legis.state.ia.us/Rules/ 2001/iac/657iac/65722/65722.pdf#xml=http://staffweb. legis.state.ia.us/search97cgi/s97is.dll?action=View&VdkVgwKey=http%3A%2F%2Fww w%2Elegis%2Estate%2Eia%2Eus%2F Rules%2F2001%2Fiac%2F657iac%2F65722%2F 65722%2Epdf&doctype=xml&Collection=Administrative+CodeV6&QueryZip=pharmac y+technician& Jensen, G.M., Gwyer, J., Hack, L.M., & Shepard, K.F. (1999). Expertise in physical therapy practice Newton, Mass: Butterworth-Heinemann. Jensen, G.M., Gwyer, J., Shepard, K.F., & Hack, L.M. (2000). Expert practice in physical therapy. Physical Therapy, 80 (1), 28-43. Kalman, M.K., Witkowski, D.E. & Ogawa, G.S. (1992). Increasing pharmacy productivity by expanding the role of pharmacy technicians. American Journal of Hospital Pharmacists, 49 (Jan.), 84-89.

PAGE 169

155 Klammer, G.A., & Ensom, RJ (1994). Pharmacy technician refill checking: safe and practical. Canadian Journal of Hospital Pharmacy, 47 (3), 117-119,122-123. Kline, R.B. (1998). Principles and practice of structural equation modeling New York: Guilford Press. Koch, K.E., (1996, Dec.). Incorporating the clinical pharmacy technician in the pharmaceutical care practice model. Paper presented at the ASHP-Midyear-ClinicalMeeting 1996. Lipowski, E.E., Campbell, D.E., Brushwood, D.B., Wilson, D. (2002). Time savings associated with dispensing unit-of-use packages. Journal of the American Pharmaceutical Association, 42 (4), 577-581. Maine State Board of Pharmacy. (2001). Pharmacists. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.state.me.us/pfr/olr/categories/cat30.htm Massachusetts State Board of Pharmac y. (2001). 8.02: Pharmacy technicians. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.state.ma.us/reg/boards/ph/cmr/24708.htm#8.02 McGhan W.F., Smith W.E., Adams D.W. (1983). A randomized trial comparing pharmacists and technicians as dispensers of prescriptions for ambulatory patients. Medical Care, 21 (4), 445-453. Meade, V. (1994). Scope of practice study: Results now in. American Pharmacist, 9 (NS34), 23-25. Meyer, G.E., Brandell, R., Smith, J.E., Milewski, F.J., Coniglio, M. (1991). Use of bar codes in inpatient drug distribution. Am erican Society of Hospital Pharmacists, 48 (May), 953-966. Muenzen, P.M., Greenberg, S., Murer, M.M. (1999). PTCB task analysis identifies role of certified pharmacy technici ans in pharmaceutical care. Journal of the American Pharmaceutical Association, 39 (6), 857-863. National Association of Boards of Pharmacy. (2002). 2001-2002 committee and task force reports [accessed 2002 June 18]. Available from URL: www.nabp.net National Association of Boards of Pharmacy. (2003). Survey of pharmacy law— 2003-2004 Park Ridge, IL.,: 36-48. National Pharmacy Technician Association. (2002). Membership. [On line] [accessed 2002 May 16]. Available from URL: https://secure.pharmacytechnician.org/membership.html

PAGE 170

156 National Pharmacy Technician Association. (2002). Technician specialization. [On line] [accessed 2002 May 16]. Available from URL: http://www.pharmacytechnician.org/technician_special/ts_generalinfo.html Nevada State Board of Pharmacy. (2001). Chapter 639 – Pharmacists and pharmacy. [On line] [accessed 2001 Dec 21]. Available from URL: https://payment.glsuitehost.com/NVBoPWeb/Regs/default.asp New Mexico State Board of Pharmacy. (2001). 16.19.22.9 NMAC. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.state.nm.us/pharmacy/part22.html Nunnally, J.C., & Bernstein, I.H. (1994). Psychometric theory (3rd ed.). (pp.112113, 264-265). New York: McGraw-Hill. Oklahoma State Board of Pharmacy. ( 2001). Pharmacy technician training guidelines—Phase I and II. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.pharmacy.state.ok.us/techguid.pdf Pharmacy Practice News. (2003). Pharmacy strives for more direct patient care. Pharmacy Practice News, Oct., 1, 16, 18. Pharmacy Technician Certification Board. (2003). Statistics. [On line] [accessed 2003 January 11, 2003]. Available from URL: http://www.ptcb.org/about.stats.asp Phillips, C.S., Ryan, M.R., & Roberts, K.B. (1988). Current and future delegation of pharmacy activities to technicians in Tennessee. American Journal of Hospital Pharmacists, 45 (Mar), 577-583. Planas, L.G, Kimberlin, C., Brushwood, D. Schlenker B.R. (2001). The development of a pharmacist model of perceived responsibility for drug therapy outcomes using the triangle model of responsibility University of Florida. Raehl, C.L., Pitterle, M.E., Bond, C.A. (1992). Legal status and functions of hospital-based pharmacy technicians and their relationship to clinical pharmacy services. American Journal of Hospital Pharmacists, 49 (9), 2179-87. Sammartano, E., Tozzi, W. & Greenstein, M. (1988). Use of pharmacy technicians in hospitals and extended care facilities in the metropolitan New York City area. New York State Journal of Pharmacy, 8 (1), 7-11. Stolar, M.H. (1981). National survey of hospital pharmacy technician use. American Journal of Hospital Pharmacists, 38 (Aug), 1133-1137.

PAGE 171

157 Texas State Board of Pharmacy. (2001). Pharmacy technicians. [On line] [accessed 2001 Dec 21]. Available from URL: http://www.tsbp.state.tx.us/Pharmacytechs.htm Ukens, C. (1996). Pharmacy boards tackling tough technician issues. Drug Topics, Feb. 5, 36. United States Department of Labor Bureau of Labor Statistics. (2004). Pharmacy technicians. [On line] [accessed 2004 April 30]. Available from URL: http://www.bls.gov/oco/ocos252.htm Whitney, H.A. (1986). The rush to judgment. Journal of Pharmaceutical Technology, 2, 193-194. Wilson, D. (2001). New directions in research for CPhTs. CPhT Connection, Summer, 1. Wilson, D.L (2003). Review of tech-check-tech. Journal of Pharmaceutical Technology, 19 (3), 159-169. Wilson D.L. (2003). Correlates of pharmacy technician’s competency. Florida Pharmacy Today, 67 (6/7), 14-16, 25. Wilson, D.L., Kimberlin, CA., & Brushwood, DB. (2003, December). Professional expertise and pharmacy technicians. Paper presented at the 38th Annual ASHP Midyear Clinical Meeting, New Orleans, Louisiana. Wilson, D.L. (2004). Defining “pharmacy technician”. Journal of Pharmaceutical Technology. 20 96-105. Young, D. (2002). Pharmacists, technician found liable for millions in medication error. American Journal of Health-System Pharmacists, 59 (Jun. 15), 1143-4.

PAGE 172

158 BIOGRAPHICAL SKETCH Debbie Wilson initially entered the field of pharmacy with the intent of pursuing a PharmD. She left her background in French (BA 1992 University of Tennessee) and linguistics (MA 1999 University of Florida) to pursue pre-pharmacy at Santa Fe Community College and began working as a pharmacy technician. She gained two and a half years work experience in nuclear and community pharmacy. After finding both settings lacking in what she had imagined pharmacy to be, she left the work setting not to pursue the PharmD, but a PhD in pharmacy health care administration where she is able to study pharmacy, the changes it is undergoing and develop theory to guide those changes. Debbie’s dissertation is titled: “Professional Expertise and Pharmacy Technicians.” She recently (2003) won a competitive $5000 grant to conduct her project from the P.A. Foote Grant in Health Outcomes. The Department of Pharmacy Health Care Administration and the Pharmacy Tec hnician Certification Board have also provided assistance for her project. Her project combined qualitative and quantitative research methodologies to develop an understanding of pharmacist and pharmacy technician attitudes on the professional expertise of pharmacy technicians. Debbie has worked as a research assistant on the Institute for the Advancement of Community Pharmacy funded project titled Unit-of-Use Packing to Improve Quality in Pharmacy. She also worked as a research assistant on the National Institutes of Cancer funded project titled Conquering Pain. Debbie was (2003) a finalist for the Levitt Award

PAGE 173

159 in Pharmaceutical Outcomes for the project Conquering Pain. She has worked as a teaching assistant for several courses taught by the Department of Pharmacy Health Care Administration including Professional Phar macy Communications, State and Federal Pharmacy Law, and Medications Use Process. Debbie's research interests have focused on projects using qualitative methodology in pharmacy health care administration, and various topics within the study of pharmacy technicians. Her work on pharmacy technicians has drawn national attention. One of Debbie's recent articles "Review of Tech-Check-Tech" was editorialized in the Journal of Pharmacy Technology (vol. 19, no. 3). The article was recently released in a free collection by the journal as one of five back issues to provide “a collection of articles with historic signi ficance to the technician profession”, and advertised in the American Association of Pharmacy Technicians Newsletter (vol. 26, issue. 3). For three consecutive years (2000-2003) she served on the National Pharmacy Technician's Association's Leadership Team as a Florida State Coordinator. Additionally, as the 2000-2001 and 2001-2002 President of the College of Pharmacy's Graduate Student Council, Debbie took an active role in encouraging university sponsored health insurance benefits for graduate assistants at UF by working with the University of Florida's Graduate Student Council and the UF Faculty Senate.


Permanent Link: http://ufdc.ufl.edu/UFE0008401/00001

Material Information

Title: Professional Expertise and Pharmacy Technicians
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0008401:00001

Permanent Link: http://ufdc.ufl.edu/UFE0008401/00001

Material Information

Title: Professional Expertise and Pharmacy Technicians
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0008401:00001


This item has the following downloads:


Full Text












PROFESSIONAL EXPERTISE AND PHARMACY TECHNICIANS


By

DEBBIE LOUISE WILSON


















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2004

































Copyright 2004

by

DEBBIE LOUISE WILSON


























This work is dedicated to my life partner R. Scott Smith. Thank you for encouraging me.















ACKNOWLEDGMENTS

I would like to acknowledge the P.A. Foote Grant in Health Outcomes for making

this work possible through the provision of the $5000 grant. I would like to thank the

Pharmacy Technician Certification Board for providing the list of CPhTs free of charge.

I would like to thank David Brushwood for the funds and support to execute the focus

group of pharmacists and pilot studies that were crucial to the development of the

questionnaire. I would like to thank the Department of Pharmacy Health Care

Administration for its support.
















TABLE OF CONTENTS



A C K N O W L E D G M E N T S ................................................................................................. iv

LIST OF TABLES ..................................................... ix

LIST OF FIGURES ............................. ............ .................................... xii

CHAPTER

1 IN TR O D U C T IO N ........ .. ......................................... ..........................................1.

O b j e ctiv e s .............................................................................................................. .. 2
B background ................................................................................ ..........................2
Significance .............. .....................................................................5...........

2 L IT E R A TU R E R E V IE W .................................................................. ..................... 8

Practice and Regulation of Pharmacy Technicians in the United States of America... 8
H history of Pharm acy Technicians .................................................... ...............8...
Credentialing of Pharm acy Technicians......................................... ............... 10
Current Practice of Pharm acy Technicians .................................... ................ 13
Empirical Studies of the Optimal Function of Pharmacy Technicians.................... 18
Studies at the N national Level.................. .................................................... 18
Studies at the State L evel ............................................................. .................... 20
Evaluations of Performance of Pharmacy Technicians .........................................22
Com m unity D ispensing Study.................. .................................................. 22
Institutional Tech-Check-Tech Studies ............... .................................... 23
C ourt Judgm ent .............. .. .............. ........................ .......................... 24
Technology and Pharm acy Technicians......................................... ................ 24
S u m m a ry .................................................................................................................. .. 2 5

3 THEORETICAL FRAMEWORK OF PROFESSIONAL EXPERTISE................26

O v erview ............................................................. ........ ......... .. ..... ............. 2 6
Description of the Theoretical Framework of Professional Expertise.....................27
K now ledge ...................................................................................... ............ 2 8
Clinical R easoning and Judgm ent .................................................. ................ 29
M o v e m en t ............................................................................................................ 3 0
V irtu e s .............. .................................................................................... . 3 1


v









Adapted Framework of Expert Practice for Pharmacy.........................................31
Knowledge and Skills .................................................................................... 32
R easoning and Judgm ent....................................... ...................... .................. 33
Patient Assessment and Education ................................................................. 34
V irtu e s ............................................................................................................. . 3 4
Research Questions ........................ .. ........... ............................... 35
C o n c lu sio n ............................................................................................................... .. 3 6

4 M E T H O D O L O G Y ................................................... ............................................ 37

In tro d u ctio n ................................................................................................................ 3 7
S u objects ................. ... ......... .... ...................................... ........................... ........ 3 7
Study Variables and Operationalization of Constructs.......................................... 38
Instrum ent D evelopm ent ...................................... ....................... .................. 38
O original Item Pool .............. .................. ..................... .......................... 38
F o cu s G ro u p ........................................................................................................ 3 8
P re te sts ............................................................................................................. .. 4 1
D ata C collection P procedures ........................................ ........................ ................ 50
Q u estion n aire .................................................................... ......................... 5 1
The Community Pharmacy Technician Use Questionnaire...................... 51
Instrument Validation .............................. ............................................ 52
A n aly se s ..................................................................................................... ........ .. 5 5
Descriptive Analyses ........................................................................ 55
C onfirm atory Factor A analysis ........................................................ ................ 56
E xploratory F actor A nalysis........................................................... ................ 58
Internal Consistency Reliability .................................................................59
Inter-F actor C orrelations ............................................................ .. .................. 59
Within-Group Comparisons of Summated Scores by Type of Experience......... 60
R e sp o n se B ia s...................................................................................................... 6 1
Sam ple Size E stim ation .............. .... ............. ................................. ...............6 1
S u m m a ry .................................................................................................................. .. 6 1

5 R E S U L T S ................................................................................................................. .. 6 3

Q questionnaire R response ...................................................................... ................ 63
D escrip tiv e D ata ......................................................................................................... 6 4
W ork E experience ..................................................................... ..... ............... 64
Pharmacist Reported Pharmacy Technician Supervisory Experience..............64
Pharmacist Reported Type of Pharmacy Technician Supervised.....................65
Pharmacy Technician Reported Credentials .................................................. 65
Item L evel D escriptive D ata........................................................... ................ 67
A n aly se s ..................................................................................................... ........ .. 6 9
C hi-Square T ests .............................. ............................................ 69
C onfirm atory Factor A analysis ...................................... ...................... ................ 72
E xploratory F actor A analysis ........................................ ....................... ................ 74
P harm acist data........................................................................................... 74
Pharmacist Model Development .................................................................... 76









Six-factor pharm acist m odel ................................................... ................ 76
Five-factor pharm acist m odel.................................................. ................ 78
Four-factor pharm acist m odel ................................................. ................ 79
P harm acist M odel Selection ........................................................... .................. 81
Pharm acy T echnician D ata................ .............................................. ................ 81
Pharmacy Technician Model Development ..................................................83
Five-factor technician m odel ................................................... ................ 83
Four-factor technician m odel .................................................. ................ 85
Pharmacy Technician M odel Selection ................ ................................... 87
Comparison of Models Generated for the Two Groups .................. ..................... 87
Internal Consistency R liability ......................................................... 87
P harm acist D ata ...................................................... ..................... .... ......... ... 87
Clinical pharmacy knowledge tasks...... ......................................... 87
Tasks and functions typical of pharmacy technicians in current practice
factor ..................................................................... ................... ............. 8 8
Pharmacy information evaluation and management skills factor .............89
Pharmacist only tasks as specified by law factor ....................................90
Technician D ata .............................................. ..... .... .. ..... .... ... .. ................ .. 90
Tasks and functions typical of pharmacy technicians in current practice
factor ......... ................................. .. ............... 90
Clinical pharmacy knowledge tasks factor.............................. ................ 91
G general drug know ledge factor............................................... ................ 92
Pharmacist only tasks as specified by law factor ....................................92
Inter-Factor C orrelations ............................................................ .................... 93
Factor Correlations within the Pharmacist Model..........................................93
Factor Correlations within the Pharmacy Technician Model...........................94
Within-Group Comparisons of Summated Scores by Type of Experience............. 95
Pharm acist G roup Com parisons..................................................... ................ 96
W ork experience ....................................................... ........ ...... .. ............ 96
Pharmacist reported pharmacy technician competency ..............................97
Supervision of PTCB certified pharmacy technicians ...............................97
Supervision of pharmacy technicians with AA in pharmaceutical sciences 99
Pharmacy Technician Group Comparisons .............................................100
W ork experience ... .. ... ................ .............................................. 100
E d u c atio n .................................................................................................... 10 1
T raining ............................................................................................. 102
A additional certifications...... ............ .......... ..................... 103
Comparison of Early and Late Responders ....... ... ...................................... 105

6 D IS C U S SIO N .............................................................................. ... .... ............... 109

In tro d u ctio n .............................................................................................................. 10 9
R e sp o n se R ate ........................................................................................................... 10 9
D escriptiv e D ata ....................................................................................................... 1 10
G group D differences by Item s.................................... ....................... ............... 112
Confirm atory Factor A analysis .........................................................1...... 16
Exploratory Factor A analyses ........................................................1...... 18









D ata D riv en M o d els ..................................................................... ............... 1 19
Factor Correlations Within Models........................................ 123
M odel D differences Betw een Groups ............................................ ................ 124
Within-Group Comparisons of Summated scores by Type of Experience .......124
M odel Comparisons with Proposed M odel ....... ... ................................... 125
L im itatio n s ............... ... ...................................................................................... 12 7
Suggestions for Future Research ....... .......... .......... ...................... 128
C o n c lu sio n ............................................................................................................... 12 8

APPENDIX

A INITIAL COVER LETTER SENT TO PHARMACIST SUBJECTS ...................130

B INITIAL COVER LETTER SENT TO TECHNICIAN SUBJECTS ................... 132

C FOLLOW-UP COVER LETTER SENT TO ALL SUBJECTS.............................134

D PHARM ACIST QUESTIONN AIRE .......................................................................136

E PHARM ACIST QUESTIONN AIRE .......................................................................141

F CONFIRMATORY FACTOR ANLAYSIS WITH COMPLETE DATA PROGRAM146

G CONFIRMATORY FACTOR ANLAYSIS WITH MISSING DATA PROGRAM148

L IST O F R E F E R E N C E S ................................................................................................. 152

BIOGRAPH ICAL SKETCH .................. .............................................................. 158















LIST OF TABLES


Table page

2-1 Pharm acy Technician D esignations U sed........................................... ............... 14

2-2 Pharmacy Technician Credentials Mandated by States (includes the District of
Colum bia, Guam and Puerto R ico) ..................................................... ................ 14

2-3 Pharmacy Technician Functions in the Hospital Setting ...................................16

2-4 Pharmacy Technician Functions in the Ambulatory Setting................................17

4-1 Item M eans from First Testing ............................................................ ................ 42

4-2 Item M eans from Second Testing ....................................................... ................ 43

4-3 Item Analysis for the Patient Assessment and Education Scale on the Pre-tests.....45

4-4 Item Analysis for the Knowledge and Skills Scale on the Pre-tests .....................47

4-5 Item Analysis for the Reasoning and Judgment Scale on the First Pre-test ..........48

4-6 Item Analysis for the Virtues Scale on the First Pre-test....................................49

5-1 Reported Community Work Experience of Subjects in Sample..............................64

5-2 Item Means from the Pharmacist Group (n=314) and the Pharmacy Technician
Group (n=449) on The Community Pharmacy Technician Use Questionnaire.......68

5-3 Dichotomized Means from the Pharmacist Group (n=315) and Pharmacy
Technician Group (n=448) on the Items of The Community Pharmacy Technician
U se Q u e stio n n aire .................................................................................................... 7 1

5-4 Eigenvalues for Factors Extracted from the Pharmacist Data...............................74

5-5 Pattern Matrix for 6-Factor Model from the Pharmacist Data...............................76

5-6 Pattern Matrix for 5-Factor Model from the Pharmacist Data...............................78

5-7 Pattern Matrix for 4-Factor Model from the Pharmacist Data .................................80

5-8 Eigenvalues for Factors Extracted from the Technician Data ..................................82









5-9 Pattern Matrix for 5-Factor Model from the Technician Data .................................84

5-10 Pattern Matrix for 4-Factor Model from the Technician Data .................................85

5-11 Item Analysis for the Clinical Pharmacy Knowledge Tasks Factor .....................88

5-12 Item Analysis for the Tasks and Functions Typical of Pharmacy Technicians in
C current P practice F actor ..................................................................... ................ 89

5-13 Item Analysis for the Pharmacy Information Evaluation and Management Skills
F acto r..................................................................................................... ........ .. 8 9

5-14 Item Analysis for the Pharmacist Only Tasks as Specified by Law Factor.............90

5-15 Item Analysis for the Tasks and Functions Typical of Pharmacy Technicians in
C current Practice Factor .................................................................. .............. 91

5-16 Item Analysis for the Clinical Pharmacy Knowledge Tasks Factor .....................91

5-17 Item Analysis for the General Drug Knowledge Factor ....................................92

5-18 Item Analysis for the Pharmacist Only Tasks as Specified by Law Factor.............93

5-19 Factor Correlations from the Pharmacist Model (n=314)..................................94

5-20 Factor Correlations from the Pharmacy Technician Model (n=449) ....................95

5-21 Correlations between the Factors and the Number of Years Practicing as a Licensed
Pharm acists (n=295)... .................................................................... ............... 96

5-22 Correlations between the Factors and Pharmacist Reported Pharmacy Technician
C om petency (n=299) ... ................................................................... ............... 97

5-23 Factors Means for Pharmacist Who Have and Have Not Supervised a PTCB
C certified Pharm acy Technician ........................................................... ................ 98

5-24 Comparison of Means on Factors Dependent on Whether or Not the Pharmacist
Has Supervised a PTCB Certified Pharmacy Technician ..................................98

5-25 Factors Means for Pharmacist Who Have and Have Not Supervised a Pharmacy
Technician with an AA in Pharmaceutical Sciences........................... ................ 99

5-26 Comparison of Means on Factors Dependent on Whether or Not the Pharmacist
Has Supervised a Pharmacy Technician with an AA in Pharmaceutical Sciences 100

5-27 Correlations between the Factors and the Number of Years Working as a Pharmacy
T echnician (n=400) .............. ................. ................................................. 101









5-28 Factors Means for Pharmacy Technicians Who Reported Having and Reported Not
Having Some Education Beyond a GED or High School Diploma ....................... 101

5-29 Comparison of Means on Factors Dependent on Whether or Not the Pharmacy
Technician Reported Having Education Beyond a GED or High School Diplomal02

5-30 Factors Means for Pharmacy Technicians Who Reported Having and Reported Not
Having Some Training Beyond On-The-Job Training................ ................... 103

5-31 Comparison of Means on Factors Dependent on Whether or Not the Pharmacy
Technician Reported Having Training Beyond On-The-Job Training ................103

5-32 Factors Means for Pharmacy Technicians Who Reported Having and Reported Not
Having Pharmacy Certificates in Addition to PTCB Certification..................... 104

5-33 Comparison of Means on Factors Dependent on Whether or Not the Pharmacy
Technician Reported Having Pharmacy Certificates in Addition to PTCB
C ertificatio n ............................................................................................................ 10 4

5-34 Dichotomized Means from the Early Responding Pharmacist Group (n=206) and
Late Responding Pharmacist Group (n=108) on the Items of The Community
Pharmacy Technician Use Questionnaire ....... ... ....................................... 105

5-35 Dichotomized Means from the Early Responding Technician Group (n=249) and
Late Responding Technician Group (n=200) on the Items of The Community
Pharmacy Technician Use Questionnaire ....... ... ....................................... 107















LIST OF FIGURES


Figure page

3-1 Model of Expert Practice for Physical Therapy (Adapted from Jensen et al., 1999)27

4-1 Model Targeted in the Confirmatory Factor Analysis ........................................54

5-1 Scree Plot of the Eigenvalues for the Factors Extracted from Pharmacist Data......75

5-2 Scree Plot of the Eigenvalues for the Factors Extracted from Technician Data ......83















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PROFESSIONAL EXPERTISE AND PHARMACY TECHNICIANS

By

Debbie Louise Wilson

December 2004

Chair: Carole Kimberlin
Cochair: David Brushwood
Major Department: Pharmacy Health Care Administration

Pharmacy technicians are often defined as performing tasks not requiring

professional judgment. The framework of professional expertise as described in the

Model of Expert Practice in Physical Therapy is similar to the construct of professional

judgment as used in pharmacy. The model constructs used in this investigation were: (1)

Patient Assessment and Education, (2) Knowledge and Skills, (3) Reasoning and

Judgment, and (4) Virtues.

Pharmacists and Pharmacy Technician Certification Board certified technicians

working in community pharmacy in Florida were included. Data on pharmacist and

technician' beliefs were collected with a self-administered mail questionnaire. Chi-

square tests on dichotomized items were used to check for differences in the beliefs of the

two groups on each item. Pharmacist and pharmacy technicians' beliefs on the tasks that

a capable community pharmacy technician should perform relevant to a framework of









professional expertise were examined using confirmatory factor analysis (CFA) with

LISREL.

A total of 503 pharmacists and 569 technicians responded (response rate 27%).

The chi-square tests found that the pharmacist and technician beliefs differed on 16 of 26

items. For eight items, pharmacists believed that technicians should not perform the

tasks. Technicians, however, believed that technicians should perform six of the eight

tasks, including "assess a patient's actual medication use" and "educate patients on the

appropriate use of their medications". The CFA found that pharmacist and technician

beliefs on the tasks did not fit the proposed framework. Following CFA, exploratory

factor analysis found that both groups had two factors that were conceptually the same

with only one or two items loading differently on each factor: (1) clinical pharmacy

knowledge tasks, and (2) tasks and functions typical of pharmacy technicians in current

practice. A third factor ("pharmacist-only tasks as specified by law") had identical item

loadings on the factors.

The beliefs of the pharmacists and pharmacy technicians on the items did not fit the

proposed framework. Technicians were more likely than pharmacists to agree that

technicians should perform a broader range of tasks and to believe that technicians should

perform tasks requiring specialized drug knowledge or a professional relationship with

patients.














CHAPTER 1
INTRODUCTION

This study examined the beliefs of pharmacists and pharmacy technicians about the

tasks pharmacy technicians should perform in the community pharmacy workforce.

Pharmacy technicians are already an important part of the pharmacy workforce. Today

pharmacy technicians are performing tasks that were previously only performed by

licensed pharmacists. Pharmacy technicians are not licensed and credentialed as

pharmacists are. Technician functions are not clearly defined in state regulations.

Minimal educational requirements are often not specified by states. Pharmacy

technicians serve under the supervision of pharmacists. As a result, the tasks that a

pharmacy technician is allowed to perform are, for the most part, determined by the

individual supervising pharmacist and vary not only from site to site, but from pharmacist

to pharmacist within a site. Indeed pharmacy technicians may be performing tasks that

they should not perform. Because each individual pharmacist who supervises a

pharmacy technician has a primary role in determining what functions that technician can

perform, it is important to study pharmacists' beliefs about what functions a pharmacy

technician should be able to perform. Since pharmacy technicians are the group of

interest it is important to study their beliefs about this as well.









Objectives

The objectives of this research are to

1. develop and validate an instrument to measure beliefs of pharmacists and

pharmacy technicians about the functions pharmacy technicians should

perform in community practice,

2. describe the beliefs of pharmacists and pharmacy technicians about the

functions pharmacy technicians should perform in community practice,

3. examine the differences that exist between pharmacists' and pharmacy

technicians' beliefs about the functions that pharmacy technicians should

perform in community practice, and arrive at a clearer understanding of what

role a pharmacy technician should play in pharmacy practice as judged by a

consensus of the beliefs of both pharmacists and technicians.

Background


The regulation of the pharmacy technician role in the dispensing process varies by

state. The practice of pharmacy technicians also varies from site to site with tasks being

delegated to pharmacy technicians by pharmacists (The Council on Credentialing in

Pharmacy [CCP], 2000).

The CCP (2000) defines a pharmacy technician as "an individual who, under the

supervision of a licensed pharmacist, assists in pharmacy activities not requiring the

professional judgment of the pharmacist." The American Society of Health-Systems

Pharmacists (ASHP) Manual for Pharmacy Technicians (1998) also uses the concept of

professional judgment to differentiate the types of tasks that pharmacists and technicians

can perform. ASHP has defined a pharmacy technician as "someone who, under the









supervision of a licensed pharmacist, assists in various activities of the pharmacy

department not requiring the professional judgment of the pharmacist." The American

Society of Hospital Pharmacists (ASHP) Task Force on Technical Personnel in Pharmacy

defined the term as "someone who, under the supervision of a licensed pharmacist, assists

in various technical activities of the pharmacy department that do not require the

immediate judgment of a pharmacist" (ASHP, 1987).

Some definitions of 'pharmacy technician' do not use the term professional

judgment. Another definition offered by the ASHP Task Force is "individuals who are

employed as pharmacy support personnel in an organized health-care setting working

under the supervision of a licensed pharmacist and assisting in the preparing, distributing,

or administering of medications" (ASHP, 1989). Those definitions that use the term

professional judgment seem to be best received. Araque and Latiolais (1985) had Ohio

hospital pharmacy directors rate four definitions of 'pharmacy technician' developed

from the pharmacy literature. The highest rated definition was

someone who under the supervision of a licensed pharmacist assists in the
nonprofessional and nonjudgmental aspects of preparing and dispensing
medications. Such duties include maintaining patient records; setting up,
packaging, and labeling medication doses; filling and dispensing routine orders for
stock supplies for patient-care areas; maintaining drug inventories; adding drugs to
parenteral fluids and similar manipulations. (Araque and Latiolais, 1985, 75)

The lowest rated definition was:

an individual who has received an associate degree in hospital pharmacy
technology which includes academic training in a junior college and formal
hospital training/education including lecture and laboratory assignments. (Araque
and Latiolais, 1985, 75)

Using 'professional judgment' as a means to define what pharmacy technicians are

not capable of doing does not clearly define what they are or should be capable of doing.









In fact it is possible that even technical pharmacy tasks require some amount of judgment

that is specific to pharmacy and thus require professional judgment. It has been

suggested that some functions that pharmacy technicians are now being assigned may

require some "higher level of judgment" (ASHP, 2003). Whitney editorialized this

position in 1986:

To say that all technicians are not allowed to make judgments is imprecise and
illogical .... The word nonjudgmental creates ill will by suggesting that there is no
opportunity for technicians to ever make judgments. This is just not the truth in
actual practice. nothing but absolute futility will be accomplished by
attempting to restrict technicians to nonjudgmental tasks. Pharmacists must
recognize technicians are not only capable of making judgments but that they are
involved in them now on a daily basis. Job descriptions must be written for
technicians that do not limit them to nonjudgmental or nonprofessional duties. ...
(Whitney, 1986, 193-194)

Pharmacists may perform any of the tasks involved in the normal practice of

pharmacy, while technicians may perform only a subset of those tasks. Pharmacists are

overqualified to perform many tasks involved in the dispensing process. Using them to

perform such tasks inhibits them from providing services, which they are uniquely

qualified to provide. Using the term professional judgment in defining what a technician

is not or cannot do does not help us understand what tasks pharmacy technicians should

be performing. The role of the pharmacy technician is in flux and an understanding is

needed.

The main concern for the practice of pharmacy technicians revolves around two

issues: the tasks that pharmacy technicians should ideally perform in community

pharmacy are vaguely defined, and pharmacy technicians are taking on more of the tasks

traditionally involved in the practice of pharmacy. Beginning a process to reach









consensus on the tasks that pharmacy technicians should perform in community

pharmacy is warranted.

Significance

"The Final Report of the ASHP Task Force on Technical Personnel in Pharmacy"

(1989) called for a consensus on pharmacy technicians, including consensus on the use of

the term "pharmacy technician," as well as on "the role, functions, core competencies,

training, supervision, and recognition" of pharmacy technicians. So far this has not

happened. Pharmacy organizations and some states have defined 'pharmacy technician',

but they do so differently (Wilson, 2004). Also many define 'pharmacy technician' by

use of the term 'professional judgment' (Wilson, 2004). The term 'professional

judgment' in the definitions vaguely describes the tasks that pharmacy technicians may or

may not perform. Vaguely describing the tasks that pharmacy technicians may or may

not perform does not help develop a consensus in the use of pharmacy technicians in

community practice. Understanding the tasks that pharmacy technicians should perform

is important for optimizing the use of pharmacy technicians.

Historically pharmacy technicians were regularly employed in hospital pharmacies

before they began being employed widely in community practice (ASHP, 1981). In

addition, the use of pharmacy technicians in hospitals has been better described and

appropriate tasks delineated than has the use of pharmacy technicians in community

pharmacy settings. This is due largely to the American Society of Health-Systems

Pharmacy's efforts when the society was the American Society of Hospital Pharmacy.

However, today there are many more pharmacy technicians in community pharmacy than

there are in hospital pharmacy (ASHP, 1994; Greenberg, 1981; Hogan, 1985; Health

Resources and Services Administration [HRSA], 2000; Meade, 1994). According to the









United States Department of Labor (USDL) Bureau of Labor Statistics (BLS) 211,000

pharmacy technicians held jobs in 2002 in the United States (USDL, 2004). Two-thirds

of these were in retail (USDL, 2004). Understanding the tasks that pharmacy technicians

should perform in community pharmacy is needed.

The pharmacy technician role is expanding due to increased demand for pharmacy

services (APhA and ASHP, 1996; ASHP, 2003; Cooksey et al., 2002). Kalman et al.

(1992) found that by expanding the role of pharmacy technicians along with instituting a

comprehensive quality control program in a hospital setting, the pharmacy department

was able to increase distribution and clinical services with a minor increase in personnel.

However, expansions of the pharmacy technician role should include only those tasks and

all of those tasks that a pharmacy technician should perform. An understanding of the

tasks that both pharmacists and pharmacy technicians believe pharmacy technicians

should perform in community pharmacy will help guide this expansion.

An understanding of the tasks that it is believed pharmacy technicians should

perform in community pharmacy will also allow for better use of pharmacists. Pharmacy

technicians can be best used in performing tasks they are qualified to perform and that

pharmacists are overqualified to perform. The demand for pharmaceutical care and for

pharmaceuticals continues to increase more quickly than the number of pharmacists. The

use of pharmacists to perform technical functions "results in a dilution of pharmaceutical

talents and limits the scope of pharmaceutical services provided" (ASHP, 1987).

An understanding of the types of tasks it is believed that pharmacy technicians

should perform in community pharmacy will help policy makers define the term

'pharmacy technician' in community practice, and mandate appropriate credentialing and









education standards for pharmacy technicians working in community practice. An

understanding of the tasks that a pharmacy technician should perform will aid in

optimizing the actual use of pharmacy technicians. A consensus of beliefs about the

tasks that a pharmacy technician should perform is crucial to the proper education and

credentialing of pharmacy technicians. The education and credentialing of pharmacy

technicians should provide pharmacy technicians with the skills that they need when

performing pharmacy technician tasks. Thus policy makers and educators need to have a

clear understanding of the types of tasks that pharmacy technicians should perform in

community pharmacy.














CHAPTER 2
LITERATURE REVIEW

This chapter describes the current practice of pharmacy technicians, history of

the use of pharmacy technicians and studies measuring the performance of pharmacy

technicians. The practice of pharmacy technicians varies by state. This study focuses

specifically on Florida pharmacy technicians. For that reason the practice of pharmacy

technicians in Florida and of the rest of the United States are described here and

compared.

Practice and Regulation of Pharmacy Technicians in the United States of America

History of Pharmacy Technicians

The use of technicians in American pharmacy is relatively new. Originally

pharmacists worked alone or with a pharmacist apprentice. Supportive personnel began

assisting pharmacists in the mid-1940's (Raehl et al., 1992). In 1981, supportive

personnel were used in all states in hospital pharmacy settings and in 36 states in

community pharmacy settings (ASHP, 1981). Until 1991, eight states did not allow

pharmacy technicians in community pharmacy settings (ASHP, 1985; Fitzgerald et al.,

1991). In 1999 a study performed by Drug Topics magazine found that "virtually all

chain and hospital pharmacies employ pharmacy technicians (Drug Topics, 1999).

In 1991, 25 states reported legally recognizing pharmacy technicians (Fitzgerald

et al, 1991). Fifteen states reported activity to recognize pharmacy technicians

(Fitzgerald et al, 1991). Of the 25 states that did not report legally recognizing pharmacy

technicians, 23 states reported that pharmacy technicians were in use in pharmacy









practice (Fitzgerald et al, 1991). In 1991, six states did not refer to pharmacy technicians

in their state laws (Fitzgerald et al, 1991). Today only one state does not refer to

pharmacy technicians in its state laws (National Association of Boards of Pharmacy

[NABP], 2003).

Initially pharmacy technicians were not regulated. Once introduced, the

regulation of pharmacy technicians increased over time. In 1981, three states had

educational requirements for pharmacy technicians (ASHP, 1981). In 1985, five had

such requirements (ASHP, 1985). In 1991, 25 states had training requirements for

pharmacy technicians (Fitzgerald, 1991). In 1992, 17 states required one or more

qualifications for pharmacy technicians (Raehl et al, 1992). At that time, the types of

requirements included some in-service training (n=6), that pharmacy technicians be high-

school graduates (n=5), three months of on-the-job training (n=4), that the pharmacy

technician be 18 years of age or older (n=3), institutional training (n=3), no criminal

record (n=2), and registration (n=2) (Raehl et al, 1992). In 1992, Raehl et al., (1992) did

not find any requirements for pharmacy technicians in 34 states. Pharmacy technician

licensure has been opposed due to the fear that licensing pharmacy technicians will lead

to a category of practitioners who will want to expand their scope of practice (Ukens,

1996). In 1985, one third of states required a pharmacist-to-technician ratio (ASHP,

1985). In 1992, 18 states (36%) required a pharmacist-to-technician ratio (Raehl et al.,

1992). It has been suggested that ratios be dropped in exchange for a pharmacist's

opinion on how many pharmacy technicians that pharmacist can adequately supervise,

but there is concern that employers, for economic reasons, will schedule more pharmacy

technicians than could be adequately supervised (Ukens, 1996). Today, pharmacy









technicians are regulated to a larger extent and in more states than in the past. Those

current regulations are described in the next section on credentialing.

In addition to increased regulation of pharmacy technicians, specialized pharmacy

technician positions are being created. Such new specialty positions include Ambulatory

Care Infusion Pharmacy Technicians (ASHP, 2000), Clinical Pharmacy Technicians

(Koch, 1998), Data Analyst Pharmacy Technician (Ervin et al., 2001), and Investigational

Drug Services Pharmacy Technicians (Wilson, 2001). More specialization will probably

emerge over time.

Credentialing of Pharmacy Technicians

Pharmacists and pharmacy technicians' beliefs about the tasks that pharmacy

technicians can optimally perform may be affected by the current practice of pharmacy

technicians. The language of credentialing of pharmacy technicians is meaningful and

specific. For those reasons, the current practice of pharmacy technicians in the US and

the language of credentialing are described here.

The current number of practicing pharmacy technicians is unknown. Since 1995,

122,397 pharmacy technicians have been nationally certified (PTCB, 2003). In 1996, the

number of pharmacy technicians in practice was estimated to be 150,000 (APhA &

ASHP, 1996). By 2000, the number was estimated to be 247,000 (Cooksey et al., 2002).

In 1994 prior to the establishment of the Pharmacy Technician Certification Board, 26%

of pharmacy technicians were certified as a pharmacy technician by a pharmacy

organization (ASHP, 1994). The percentage of all pharmacy technicians that are

Nationally Certified Pharmacy Technicians in practice is not known. The number of

currently practicing pharmacy technicians is thought to be considerably larger than both

the number of Nationally Certified Pharmacy Technicians and of the number estimated to









be in practice in 1996. The number of PTCB certified pharmacy technicians in Florida is

9,082, the second highest in the nation (PTCB, 2003).

The terminology of credentialing is meaningful. According to the Council on

Credentialing in Pharmacy (2000), "credentialing is the process by which an organization

or institution obtains, verifies, and assesses a pharmacist's qualifications to provide

patient care services." This definition could be generalized to the process by which an

organization or institution obtains, verifies, and assesses a practitioner's qualifications to

provide the professional services of that practice. A credential is "documented evidence"

of a person's "qualifications." Pharmacy technicians' credentials include diplomas,

certificates, certifications, and licenses (Wilson, 2003). The distinctions between these

are described below.

Pharmacy technicians can pursue formal education programs that grant diplomas

or certificates of completion. Often, technicians are trained by their employers either

formally or informally. Some employers offer certificates of completion for their

technician training programs. It is unknown how many such programs exist. The ASHP

is the accreditation body for pharmacy technician training programs. In 2002 there were

88 accredited programs (ASHP, 2002). It is suggested in the 2003 White Paper on

Pharmacy Technicians that all training programs should be accredited.

The Pharmacy Technician Certification Board (PTCB) offers voluntary

certification to pharmacy technicians. According to the Council on Credentialing in

Pharmacy (2000), certification is the "voluntary process by which a nongovernmental

agency or association formally grants recognition to a [person] who has met certain

predetermined qualifications specified by that organization." Since the PTCB was









founded, 122,397 people have received PTCB certification (PTCB, 2003). Additional

specialization certificates are available to Certified Pharmacy Technicians (CPhT)

through the National Pharmacy Technician Association (NPTA) (NPTA, 2002).

While certification is voluntary, licensure is not. The CCP (2000) defines a license as a

"credential issued by a state or federal body that indicates that the holder is in compliance

with minimum mandatory governmental requirements necessary to practice in a

particular profession or occupation" and licensure as the "process of granting a license."

Registration indicates state licensure. According to the CCP (2000), the term registered

is used to describe a person "who has met state requirements for licensure and whose

name has been entered on a state registry of practitioners who are licensed to practice in

that jurisdiction" (CCP, 2000).

In May of 2000, the National Association of Boards of Pharmacy (NABP)

proposed a national competence assessment for pharmacy technicians. The resolution

urged state boards to use the proposed national competence assessment program as a

criterion for pharmacy technicians practicing in a state (ASHP, 2000). Such a criterion

would not be voluntary. An NABP research team assessed the PTCE to see if the

examination could be used for an NABP competency assessment program for pharmacy

technicians or if the NABP needed to establish its own. The assessment led to the NABP

signing an agreement with the PTCB in February 2002 that made the NABP a full partner

and member of the PTCB Board of Governors. According to the agreement, the NABP

Executive Director/Secretary will now chair the PTCB Certification Council (NABP,

2002).









Current Practice of Pharmacy Technicians

The regulation of pharmacy technicians' designation, credentials and tasks varies

by state. In 1991, only 25 states recognized pharmacy technicians, and only 12 states

clearly defined such personnel in their rules and regulations (Fitzgerald et al., 1991;

Raehl et al., 1992). According to the NABP 2003-2004 Survey of Pharmacy Law, today

Ohio is the only state-of the 50 states, the District of Columbia, Guam, and Puerto

Rico-that does not address the use of pharmacy technicians in its state statutes or

regulations (NABP, 2003).

Wilson (2004) found that 43 states define pharmacy technician in their state

statutes and regulations. Florida does not define pharmacy technicians but does have a

statute on pharmacy technicians. Florida's statute is similar to a definition of a pharmacy

technician in that it describes how pharmacy technicians can be used (Wilson, 2004).

The statute details that a licensed pharmacist may delegate certain tasks to pharmacy

technicians, that pharmacy technicians perform those delegated tasks under the direct

supervision of a licensed pharmacist, and that the ratio of pharmacy technician to

pharmacist is 1:1 unless permission is obtained for more with the maximum being 3:1.

The majority of the 50 states (74%) use the designation pharmacy technician

(NABP, 2003). Among the 50 states, 10 designations are used, of which five are used in

only one state each. Like the majority of states, the designation used in Florida is

pharmacy technician (NABP, 2003) (Table 2-1).

Thirty-five (70%) states either license, register, certify, require PTCB

Certification, and/or have pharmacy technician training or educational requirements.

Two additional states have proposed some such sort of credentialing requirements. One

other state reports that a pharmacist must notify the board of technician employees.









Florida has no such requirements (NABP, 2003). Thirty-two states reported that the

board can revoke, deny or suspend technician registration (NABP, 2003) (Table 2-2).

Table 2-1. Pharmacy Technician Designations Used
Designation Number
Ancillary Personnel 1
Pharmaceutical Technician 1
Pharmacy Personnel 1
Pharmacy Technician 37
Registered Pharmacy Technician 2
Supportive Personnel 3
Technician 1
Unlicensed Person 2
Unlicensed Personnel, Unlicensed Assistant 1
Total 50*
*One state does not address the use of pharmacy technicians in its state statutes or
regulations
(NABP, 2003)

Table 2-2. Pharmacy Technician Credentials Mandated by States (Includes the District
of Columbia, Guam and Puerto Rico)
Credential Number
Unspecified Certification 4
PTCB Certification 2
License 7
Permit 1
Enrolled 1
Register 23*
Training 28**
*Data for one state was missing
**One state responded no to requiring training but had specific training requirements
detailed in the notes
(NABP, 2003)

Despite the low number of states reporting certification requirements in the

NABP survey, a review of all of the data including the notes revealed that many more

than six states mention certification. According to the PTCB, 21 states have PTCB

certification in their regulations (PTCB, 2003). The NABP (2003) survey data did not

clearly reflect this. It seems that some states use the term "certification" interchangeably

with "PTCB certification." Certification was mentioned in entries for 18 states, and









PTCB certification was mentioned in entries for 12 states. Fifteen states' entries and

notes report that certification allows for expanded duties, and twelve states' entries and

notes report that PTCB certification allows for expanded duties. Additionally, three

states' entries and notes report that training allows for expanded duties. Florida was not

one of these states (NABP, 2003).

According to the NABP, 27 states require training of pharmacy technicians

(NABP, 2003). Mississippi indicated that training was not required, but a footnote in the

NABP 2001-2002 Survey of Pharmacy Law detailed the state's training requirements.

Florida does not have training requirements for pharmacy technicians (NABP, 2003).

Eight states (16%) require continuing education (CE) of pharmacy technicians.

(NABP, 2003). One requires six hours of in-service training per year. Two note that

PTCB CE requirements are required or that PTCB certification must be maintained.

PTCB certification requires 20 hours of CE every two years, one of which must be in

pharmacy law (PTCB, 2003). Five states reported that CE requirements had to be met

annually with an average of seven hours per year (low=3, high=10). Three states

reported that CE requirements had to be met biennially with an average of 13 hours per

two years (low=8, high=20). Requirements for three states were unknown. One state

required that a minimum of four hours of the state's required 10 hours be live. Florida

does not require CE of pharmacy technicians (NABP, 2003).

Five states reported having technician exam requirements. Some reported that

PTCB certification was required (n=3), that PTCB certification was one way to become

registered (n=l), that PTCB certification or another board approved exam was required

(n=2), that PTCB certification was necessary for reciprocity (n=l), and that PTCB









certification and a state law exam were necessary (n=l). Florida has no exam

requirements (NABP, 2003).

Thirty-seven states have maximum technician to pharmacist ratios in ambulatory

care settings (NABP, 2003). The highest ratio allowed in an ambulatory care setting is

4:1; the lowest is 1:1. Those with a maximum ratio of 1:1 allow for variances. Thirty-

seven states have maximum technician to pharmacist ratios in institutional care settings.

The highest ratio allowed in an institutional care setting is 5:1; the lowest is 1:1. In seven

states a ratio of more pharmacy technicians to pharmacists is permitted if certification or

education achievements of the technicians as required by the board are met. Florida's

highest ratio in community and hospital settings is 3:1 (NABP, 2003).

Table 2-3. Pharmacy Technician Functions in the Hospital Setting
Yes No Not Addressed If PTCB certified Missing
Accept Called in 6 42 1 1 0
Prescriptions from
Physician's Office
Enter prescriptions into 50 0 0 0 0
Pharmacy Computer
Can Technicians 8 41 0 0 1
Check the Work of
Other Technicians?
Call Physician for 39* 11** 0 0 0
Refill Authorization
Compound 43 3 1 1 2
Medications for
Dispensing
Transfer Prescriptions 6*** 42 0 0 2
via Telephone
*One state reports that techs may not call about controlled substances
**One state reports that techs may call but not receive authorization
***Two states report this acceptable if the technician is "certified"
(NABP, 2003)

The pharmacy technician functions in hospital and ambulatory settings show little

variation. In nearly all states pharmacy technicians may enter prescriptions into

pharmacy computers. In Florida pharmacy technicians may do this. In nearly all states









pharmacy technicians may not accept called in prescriptions from a physician's office. In

Florida pharmacy technicians may not accept called in prescriptions from a physician's

office. The most disagreement among the states about what pharmacy technicians may

do is whether or not they are allowed to call physicians' offices for refills. In Florida

pharmacy technicians may do this. Few states allow pharmacy technicians to transfer

prescriptions. In Florida pharmacy technicians may not transfer prescriptions (NABP,

2003) (Table2- 3 and Table 2-4).

Table 2-4. Pharmacy Technician Functions in the Ambulatory Setting
Yes No Not Addressed but If PTCB certified Missing
Discouraged
Accept Called in 7* 39 1 1 0**
Prescriptions from
Physician's Office
Enter prescriptions into 50*** 0 0 0 0
Pharmacy Computer
Can Technicians Check 5 44 0 0 1
the Work of Other
Technicians?
Call Physician for Refill 33 4 0 1 2
Authorization
Compound Medications for 43 8 1 0 0
Dispensing
Transfer Prescriptions via 6 42 0 0 2
Telephone
Three states report this acceptable if the technician is "certified"
**Two states report pilot programs are underway
***May key in but not enter
(NABP, 2003)

There is little variation in allowing tech-check-tech. Eight states allow it in

institutional settings and five in ambulatory settings. Three additional states report

reviewing or studying tech-check-tech. In Florida pharmacy technicians may not perform

the final check (NABP, 2003). Since it is hard to check a compounded product to ensure

that the appropriate ingredients have been used in the correct quantities, many states do

not permit pharmacy technicians to compound in either the ambulatory setting or the









institutional setting or both. Florida allows pharmacy technicians to compound in both

settings (Table2-3 and Table 2-4).

Empirical Studies of the Optimal Function of Pharmacy Technicians

Studies of the practice of pharmacy technicians have been described, but are

somewhat dated. These works are descriptive and cover a range of issues including

functions and prevalence of pharmacy technicians. The works tend to focus on the

hospital settings since many of the studies were conducted by the American Society of

Health-Systems Pharmacists (ASHP). These works range in date of publications from

the early eighties to the late nineties.

Studies at the National Level

The American Society of Health-Systems Pharmacists (ASHP) conducted

national surveys of pharmacy technician practice in hospitals and community settings in

1981 (Greenberg, 1981) and in 1985 (Hogan, 1985).

Hogan (1985) found that of the 41 ASHP's affiliated state chapter presidents who

responded, all indicated that their states allowed pharmacy technicians to be used in

hospital settings, and all but eight indicated that their states allowed pharmacy

technicians to be used in community settings. The respondents indicated that all but five

of the 25 functions Hogan assessed were permitted in at least 30% of the 41 states. Those

functions that were permitted in at least 30 states included (1) inventory management

tasks, such as unit does packaging and labeling, bulk compounding of medications, and

bulk reconstitution of injectable medications; (2) Processing of medication orders,

including receiving written drug orders, filling new orders, typing labels, physical and

written maintenance of medication profiles, reconstitution, compounding and delivery of

non controlled substances; (3) handling of controlled substances such as the delivery of









controlled substances to patient care areas, and the maintenance of records. The five

tasks that were not so commonly permitted were: (1) the extemporaneous compounding

of medications (n=25); (2) receiving telephone orders (n=6); (3) receiving oral orders

(n=4), (4) transcribing oral orders (n=5), and (5) handling information requests (n=17).

Stolar (1981) conducted a national survey of pharmacy technician practice in

hospitals (Stolar, 1981). Stolar (1981) found that according to the directors of pharmacy

at 462 of 808 randomly selected American hospitals the mean length of employment for a

hospital pharmacy technician was 3.9 years. Of 674 respondents, 75.4% used pharmacy

technicians, with the highest percentage of use (94.6%) of pharmacy technicians

occurring in hospitals with 300 to 499 beds, and the lowest percentage of use (56.6%)

occurring in hospitals with less than 100 beds. Of the technician-user hospitals, 43.8%

indicated that they were in need of additional technicians, with the highest occurrence

(64.1%) among hospitals with more than 500 beds. The most common reason (66%)

given by hospitals reporting technician need was insufficient funds to hire more

pharmacy technicians. Thirty percent of technician-user hospitals reported having

several levels of pharmacy technicians with the incidence increasing with hospital bed

size.

The 1991-1994 Scope of Pharmacy Practice Project described the functions that

pharmacy technicians perform in different settings in all states (ASHP, 1994; Meade,

1994). The study found that the pharmacy technicians interviewed spent 26% of their

time collecting, organizing, and evaluating information; 21% of their time developing

and managing medication distribution and stock; and 7% of their time providing drug









information and education. This study was used to develop the Pharmacy Technician

Certification Examination (Muenzen et al., 1999).

A Drug Topics/Hospital Pharmacist Report survey of more than 600 pharmacists

nationwide found that the most common task performed by pharmacy technicians is to

ring up customers' purchases (96%). Other top duties included stock/update shelves

(94%), place medications into vials (91%), perform clerical duties (89%), place

prescription label on container (85%), and enter prescriptions into pharmacy computer

(84%). The least common duties were prepare medications in cards for nursing homes

(28%), blister-pack medications for future use (26%), compound medications for

dispensing (22%), and accept called-in prescriptions from physician's office (13%).

These results are presented in aggregate despite the setting specific (community versus

hospital setting) nature of many of these tasks (Drug Topics, 1999).

The Pharmacy Practice News' survey found that in 2003 among most pharmacies

surveyed pharmacy technicians performed the following duties: repackaging (93%),

phones (93%), parts of filling process (91%), and inventory/purchasing (90%) (Pharmacy

Practice News, 2003). The least common duties were drug administration (4%), patient

interaction (7%), reimbursement (28%), and parts of checking process (30%).

Studies at the State Level

A few studies have surveyed the prevalence and function of the pharmacy

technicians in more localized areas. The employment and responsibilities of technicians

in hospital and community pharmacies in South Carolina has been described (Ballington

et al., 1990). Ballington et al., (1990) found that 100% of hospital pharmacy directors

(n=78) reported using pharmacy technicians and 63% of community pharmacist

respondents (n=613) reported using pharmacy technicians. The most commonly reported









community pharmacy technician activity was receiving prescriptions from patients

(60%), and the least was filling nursing home medication carts (2%). The low frequency

of the latter is probably confounded by the fact that few community pharmacies perform

such a task. The least commonly reported community pharmacy technician activity that

is typical of community pharmacy practices was compounding (7%). The most

commonly reported hospital pharmacy technician activity was delivering and returning

medications (87%), and the least was chemotherapy (9%). The meaning of

chemotherapy was not defined but the implied meaning is preparing or compounding

chemotherapeutic agents, a dangerous task.

The pharmacy activities that pharmacists delegate to technicians in Tennessee has

been described (Phillips et al., 1988). Phillips et al.(1988) found that in Tennessee the

dispensing task most frequently delegated to pharmacy technicians in community

pharmacies was to file the completed drug order (83% of 767 community pharmacies)

and in hospital pharmacies was delivering drugs (95.1% of 153 hospital pharmacies).

The supportive task most frequently delegated to pharmacy technicians in community

pharmacies and hospital pharmacies was to stock shelves with drug items (84.7% in

community, 98.6 in hospital). Ten percent of the respondents reported permitting five

activities that were required by the Tennessee Board of Pharmacy to be performed only

by a pharmacist: (1) affix label to container, (2) certify written drug order, (3) compound

topical preparations, (4) receive telephone drug order, and (5) reconstitute needed amount

of drug. The most common therapy-related activity delegated by the respondents to

pharmacy technicians was recommending nonprescription products to patients (57.7%

community, 23.3% hospital).









Evaluations of Performance of Pharmacy Technicians

Evaluations of the performance of pharmacy technicians suggest that

appropriately and well-trained pharmacy technicians can perform technical pharmacy

services at a cost savings compared to pharmacists. Such studies include studies of

ambulatory dispensing (count and pour) and tech-check-tech. The studies suggest that

use of trained pharmacy technicians in the dispensing process allows pharmacists more

time to spend on clinical activities as well as saves money.

Community Dispensing Study

McGhan et al., (1983) compared pharmacist and pharmacy technician dispensing

of prescriptions in an ambulatory care setting. Pharmacists and pharmacy technicians

were randomly assigned prescriptions to fill. A pharmacist performed the final check.

The five pharmacists in the study were highly experienced having between four and 19

years of experience. At the time, technician dispensing was uncommon although this is

no longer the case. In order to obtain approval for the study from the state board, the

authors had to train the pharmacy technicians. The technicians participated in a four-

week training program. The study found that pharmacists spent significantly less time

filling prescriptions than the pharmacy technicians (1.86 minutes per prescription versus

2.11). Pharmacy technicians in the study filled more prescriptions than pharmacists in

the study (1011 prescriptions versus 881) with fewer errors (44 technician errors versus

48 pharmacist errors). A chi-square analysis of the errors was insignificant. The

pharmacists were found to spend more time counseling patients per counseling session

after the introduction of pharmacy technician dispensing (2.89 minutes per counseling

session versus 3.88 minutes).









Institutional Tech-Check-Tech Studies

In a systematic review of the literature, Wilson (2003) found 11 studies in 10

publications that evaluated tech-check-tech. In the two studies that Wilson (2003) found

which compared the accuracy rates of pharmacists and pharmacy technicians checking

the same samples, the results disagreed. In one the pharmacists were more accurate, in

the other the technicians were more accurate. In the two studies that Wilson found that

had error detection rates of pharmacists and pharmacy technicians checking different

samples, the pharmacists did not detect as many errors as the technicians did. Wilson

found that overall the studies did not compare the differences between the ability of

pharmacists and technicians to check for accuracy, but that they compared the effects of

training on the technicians' ability to check for accuracy relative to pharmacists who did

not receive training. One study reported that testing its intervention was its goal. Two

had no intervention. Wilson concluded that educational training on checking can

increase accuracy of checking unit-dose dispensing which might be appropriate for

technicians.

The use of tech-check-tech may be used to increase pharmacists time providing

clinical services and to reduce dispensing costs. In 1996 the California Board of

Pharmacy ruled against the practice of tech-check-tech, which had been in use at many of

the state's institutions for years (Gebhart, 1997). Institutional administrators suggest this

resulted in reduction in clinical services by pharmacists, along with increased costs due to

pharmacists performing the final dispensing check (Gebhart, 1997). In addition to

helping fulfill the workforce shortage in pharmacy, technicians could provide cost-

effective drug-dispensing services. Pharmacists' salaries are higher than technicians'. A

cost comparison of technicians and pharmacists checking refills for unit dose medication









and IV admixture refills based on a pharmacist average salary of $25.69/hour (CAN)

($17.21 1994 USD) and a senior pharmacy technician average salary of $18.23/hour

(CAN) ($12.21 1994 USD) plus benefits found a net savings estimated at $21,421 (CAN)

($14352.07 1994 USD) (per year by using technicians to check the final product

(Klammer & Ensom, 1994). The American dollar estimates were calculated by

multiplying the amounts time .67, which was the estimate for conversion generated by a

web based conversion calculator for target dates between January 01, 1994 and June 01,

1994 (International Currency Converter, 2004).

Court Judgment

In 2002 a jury awarded the family of an infant who apparently suffered

neurological damage from an overdose of a medication (Young, 2002). The error was

initially made by a technician and not caught by the pharmacists prior to dispensing. The

award was brought against two of the hospital's pharmacists, and the technician, but not

the hospital.

Technology and Pharmacy Technicians

As discussed above training may be effective in reducing error in tech-check-tech.

Also effective may be technology. Technology such as unit-of-use packaging and

barcodes could be used to enhance the error detection rate of tech-check-tech. The use of

scanners and barcodes in checking medication cassettes has been found to increase

accuracy, increase the speed of checking, and to allow the final verification to transfer

from a pharmacist to a pharmacy technician (Meyer et al., 1991). Unit-of-use packaging

has been found to save pharmacists time, increase accuracy, and increase the use of

pharmacy technicians in the dispensing process (Lipowski et al., 2002).









Due to a lack of published empirical studies that model the optimal function of

pharmacy technicians, this chapter has presented the current function of pharmacy

technicians in the US, and will follow with a description of a model of professional

expertise that was used to examine pharmacy technicians' tasks and role in pharmacy.

Summary

The practice of pharmacy technicians in the United States is relatively new. While

studies have worked to describe the current use of pharmacy technicians little work has

explored what tasks pharmacy technicians should perform. This work investigates

pharmacist and pharmacy technician beliefs on what tasks or functions pharmacy

technicians should perform for Florida. The credentialing of pharmacy technicians is

inconsistent among the 50 states. Pharmacy technician credentials should reflect the

skills and qualities that pharmacy technicians need in order to best serve patients. Such a

skills and qualities should be assessed within a framework. This work not only explores

the types of tasks that Florida pharmacists and pharmacy technicians believe that

pharmacy technicians should perform, but also explores skills and qualities that those

tasks are associated with. The literature contains evaluations of pharmacy technician

performance on prescription entry in community pharmacy and tech-check-tech in

hospitals. Future evaluations of pharmacy technician performance could be also evaluate

pharmacy technician performance and their cost effectiveness of performing the tasks or

types of tasks that pharmacists and pharmacy technicians believe pharmacy technicians

should perform.














CHAPTER 3
THEORETICAL FRAMEWORK OF PROFESSIONAL EXPERTISE

This chapter discusses the theoretical framework of professional expertise that was

used in this study. Using theoretical framework to address the questions posed by this

research allowed the work to go beyond a basic descriptive state. If no theoretical

framework were available the groundwork of developing a framework would be needed

before an instrument to evaluate the tasks and functions of pharmacy technicians within a

context of professional expertise could be developed. The domains of functions filled by

professionals such as pharmacists and pharmacy technicians need to be evaluated in

terms of the beliefs of those professionals. Pharmacist and pharmacy technician beliefs

on the tasks and functions that a pharmacy technician should do need to be evaluated

within a theoretical framework that logically fits those tasks and functions.

Overview

The way the term professional judgment is used to define pharmacy technicians

and those tasks that pharmacy technicians can and can not do suggests that in the

pharmacy context, the term is being used to describe a level of expertise or some 'tool

kit' of knowledge and skills. Examination of the literature revealed no work in pharmacy

describing a conceptual foundation for professional judgment. Related work examining

pharmacists' perceptions of their "professional responsibility" in patient care has been

conducted (Planas et al., 2001). Work in other health care fields has defined and

examined related concepts of "expertise" and "expert practice". The Jensen, Gwyer,

Shepard and Hack Model of Expert Practice in Physical Therapy examines the domains









of "expertise" in physical therapy and seems to offer a foundation for examining expert

or professional practice in pharmacy (Jensen et al., 1999; Jensen et al., 2000). For that

reason the Jensen Model of Expert Practice is adapted to pharmacy in this work.

Description of the Theoretical Framework of Professional Expertise

Jensen et al. (1999) used the Grounded Theory Approach to study expertise.

They studied clinical expertise in four clinical specialty areas in physical therapy:

geriatric, neurology, orthopedic and pediatric practice (Jensen et al., 1999; Jensen et al.,

2000). The study identified four dimensions of professional expertise: knowledge,

clinical reasoning and judgment, movement, and virtues (Figure 3-1). The framework

was specific for physical therapy but seems to capture the nature of professional expertise

for all health care fields. In the following section, the framework is described as Jensen

et al. (1999) described it. Then it is adapted to describe the professional expertise of

pharmacy practice.



Knowledge Clinical
Reasoning



Philosophy
of practice




Movement Virtues




Figure 3-1. Model of Expert Practice for Physical Therapy (Adapted from Jensen et al.,
1999)











Knowledge

One dimension of professional expertise involves the sources and types of

knowledge experts use in clinical practice. Knowledge involves the knowledge of

practice procedure specific to the professional's practice. It is continually developing. It

is multidimensional and focuses on the patient.

This knowledge goes beyond the expert's professional education, and involves

continued learning. Experts have a "deep understanding" of their field, and they work to

increase that understanding.

The first year out of school, I immediately felt like I had to go back to things I
learned in physical therapy school and refile everything, because everything I
learned was from one perspective and I need to immediately pull it out by
diagnosis ... I realized when I did that what I had for any given diagnosis was
incomplete. ., so I went to the library and started looking up spinal bifida or any
diagnosis and just pouring through the articles. This was a completely different
type of learning and I just loved it. (Jensen et al., 2000, 35)

Experts are reflective. They seek answers to problems that patients are having.

When an intervention fails, experts try to understand why. Knowledge includes a

reflective process where the professional gains new knowledge from experience. Experts

learn from mistakes and from successes through reflection.

I was at this clinic doing what I had learned in school and from a long-term
course, and what I would find is that patients I would treat and could not help
would go to see another practitioner. Then, in 2 or 3 months, I would see them
and they would say they saw this practitioner and were helped in 1 or 2 visits. I
said to myself, "I have to find out what that person is doing." (Jensen et al., 2000,
35)

The patient is an important and trusted source of knowledge. Knowledge of the

patient beyond the health problem or mechanism of the problem is important. This

knowledge includes understanding the patients' support system, work and home









activities, and other health problems and therapies. Experts consider the skill of listening

to patients as essential to evaluation. It is important for an expert to understand a

patient's problem in order to teach the patient how to manage the problem.

You get a lot of good information. .You just let your patients talk and give it to
you as they want it to come out. (Jensen et al., 2000, 35)

Clinical Reasoning and Judgment

Another dimension of professional expertise is the clinical-reasoning and

judgment or decision-making method experts use when collaborating with providers,

patients and caregivers. It is used in problem solving. It is patient centered.

Clinical reasoning is a process the expert uses to solve the problems that patients

challenge them with. Experts' services include figuring out solutions to patients'

problems. It is a collaborative process with the patient.

I feel I spend the majority of time explaining to people what the problem is and
then teaching them the ideas behind the therapy and then getting them to help me
design their exercise program. They do all the work. When they come back, I
check their progress. The more I explain to them the idea behind the intervention,
the more they buy into it. (Jensen et al., 2000, 38)

Clinical reasoning and judgment involves practical reasoning and moral

reasoning. Still, experts are not afraid to take risks.

You learn to teach yourself. You need to ask questions, to think about what you
are doing. I can see 2 people with a vestibular injury, and their test results look
the same. And these 2 people are completely different in terms of how they're
doing with treatment. Why is that? How can I explain that? Trying to figure it
out helps you to begin to identify the problem, and that makes for good scientific
inquiry. (Jensen et al., 2000, 38)

Clinical reasoning is patient specific. The expert focuses on the patient. The

expert values the activities or goals of the patient. Clinical reasoning is a collaborative

process between the expert and the patient. It focuses on what is happening to the patient









functionally. The professional has to consider the patient's diagnosis, needs and goals in

evaluating and developing an intervention.

The diagnosis [medical] itself is not as important as functionally what am I seeing
that is happening. I like to know the diagnosis, especially when it comes to
fractures and other conditions. .,but what is the reason their mobility is
jeopardized? Is it a little bit of arthritis? Is it a little bit of neurological problems?
Is it a little bit of stenosis? (Jensen et al., 2000, 38)

Movement

Another dimension of professional expertise is the process of evaluating a

patient's problem and teaching the patient how to manage the problem. In physical

therapy the evaluation is done through the assessment of movement. The problem itself

is movement. The solving of a problem is done by teaching the patient how to move.

The therapist also uses movement of his own body to do these things.

The physical therapist must make an assessment of the patient's movement

Movement is a tool for problem assessment and data gathering. Experts must interact

with patients in order to obtain the information that they need to evaluate the patients'

problems.

I have to feel what the patient is doing. Somebody will say, 'Well, what do you
think is wrong?' or 'what can I do to make his gait better?' and I say, 'Well, I
don't know, let me feel.' And then I can say, 'There's not enough weight shift.
You need to facilitate this aspect of the movement and so on.' (Jensen et al., 2000,
38)

Experts seek to make the intervention patient specific. Experts must obtain

information to develop interventions that patients can manage.

[From video observation] You see here I am allowing the patient to move the way
she wants to move. [Patient is going down stairs by leaning forward using both
handrails and descending step over step.] I have had patients who have never
gone up their stairs step over step with alternating legs, so I'm not going to teach
them something new. (Jensen et al., 2000, 39)









Virtues

Another dimension of professional expertise is the virtue of caring. Experts value

their clinical practice and their patients.

Experts are intrigued by their practice. They have high motivation and internal

drive. Experts set high standards for themselves. They are driven to stay current in their

field. They are driven to do what is best for the patient.

I look at the patient as being a mystery. I love to get a new patient because it is a
new problem to solve. It is exciting, and if it wasn't, I wouldn't be practicing
today. (Jensen et al., 2000, 39)

Experts value their patients. They communicate a sense of caring for and

commitment to their patients. Experts do not judge their patients, they seek to solve the

patients problem. Part of an expert's professional role is as an advocate for the patient.

Experts spend time working to obtain the best care and resources for patients. They may

have to deal with providers, caregivers or payers to do this.

I have spoken with the MD at the rehab center who is following the patient and
told her about the discharge from home care and my anticipation that she would
be followed by outpatient therapy. The MD said she would write the prescription.
Then I made a follow-up call to the secretary. The patient did not have the
prescription yet from the MD. So a week and one half later, I made another
contact with the physician, and she wrote it then while I was with her. Then I
checked with the secretary, and she still didn't have the prescription. Now, I am
going to have to call the MD again. (Jensen et al., 2000, 39)

Adapted Framework of Expert Practice for Pharmacy

The Jensen et al., 1999 Model of Expert Practice in Physical Therapy is made up

of four dimensions: knowledge, clinical reasoning and judgment, movement, and virtues.

Jensen's framework is specific for physical therapy but can be adapted to represent

professional expertise for all health care fields.









The dimension of movement in the framework captures the need of the physical

therapist to move the patient to evaluate the problem. The therapist must then guide the

patient in how to move in order to solve the problem. This dimension of movement can

be viewed as comprising patient assessment and education. In this way the expert must

communicate with the patient in order to understand the problem, determine how to make

a patient specific intervention and then to teach the changes involved to the patient. The

focus of movement is redefined in order to apply the model to the context of pharmacy

practice. The four dimensions of the adapted model are (1) knowledge and skills, (2)

reasoning and judgment, (3) patient assessment and education, (4) and virtues.

Knowledge and Skills

One dimension of professional expertise involves the sources and types of

knowledge pharmacy professionals use in pharmacy practice. Knowledge involves the

knowledge of practice procedure specific to the professional's practice. It is continually

developing. It is multidimensional and focuses on the patient, product and service.

Pharmacy practice is a rapidly changing field. New drugs, devices, knowledge

and techniques are developed. Pharmacy professionals must update their knowledge and

skills regularly to keep abreast of the profession. Educational articles, presentations, on

site experience, fellow professionals, reference books, package inserts, the Internet and

training sessions are means of acquiring new knowledge in pharmacy practice.

The patient is a trusted source of information. When a pharmacy professional

notices that a patient is refilling a prescription 14 days early, he asks the patient about his

use of the drug. The patient is the one who has the most knowledge about his use of his

medicines and pharmacy professionals use that source.









Pharmacy professionals often have to speak to third party payers, other health

care providers and other pharmacies to obtain information they need to properly care for

a patient. When something does not make sense they follow up on it to ensure proper

patient care.

Pharmacy professionals are themselves a trusted source of knowledge. Other

health care providers and patients consult with pharmacy professionals when making

decisions or seeking solutions to problems.

Reasoning and Judgment

Another dimension of professional expertise in pharmacy practice is the clinical-

reasoning and judgment or decision-making experts use when collaborating with

providers, patients and caregivers. It is used in problem solving. It is patient centered.

Pharmacy practice involves a great deal of problem solving. Pharmacy

professionals are often relied on as a safety net to catch errors or potential problems that a

patient may have with a drug therapy. Other health care professionals and patients rely

on and expect pharmacy professionals to catch and prevent potential problems.

Pharmacy professionals must evaluate drugs and their potential use during the

dispensing process. It is often in the reading of prescriptions that problems come to light

and must be solved. Pharmacy professionals must then consider alternatives and

solutions.

Pharmacy professionals use reasoning and judgment to provide patient care.

Pharmacists talk to patients about their drugs and disease and try to help the patients

predict problems of adherence and use ahead of time. Patients often seek pharmacy

professionals to help them solve problems with their therapy or condition. Patients often









seek the pharmacists to ask questions about the appropriateness of their therapy,

alternative therapy, or side effects.

Patient Assessment and Education

Another dimension of professional expertise is the process of evaluating a

patient's problem and teaching the patient how to manage the problem. Recall that in

physical therapy, the evaluation is done through the assessment of movement. For

pharmacy this construct is the more general one of patient assessment and education.

Pharmacy professionals assess information about patient therapy. This

information is used to help in the dispensing process and in assessing the need for

interventions in order to meet therapeutic goals. Assessments come in many forms.

Pharmacy personnel must assess if the patient prefers generics, and if they have drug

allergies. Pharmacists must assess if the patient has potential problems with taking the

medication. They also must evaluate potential problems that may be hidden from patient

knowledge such as interactions with over-the-counter drugs that the patient may be

taking. They may find that the diagnosis that the patient reports is not congruent with the

medication that has been prescribed.

Once assessments have been made it may be necessary to help the patient change

the way they use their medications. Interventions such as educating patients on how to

use a drug properly, how to improve compliance, or how to administer a drug must be

targeted to the patient.

Virtues

Another dimension of professional expertise is the virtue of caring. Experts value

their clinical practice and their patients.









Pharmacy personnel care about the job they are doing. They do not want to harm

patients. Pharmacy personnel work to dispense a precise and accurate product. They

care for their patients' health and will contact other health care providers and payers to

ensure that the patient gets optimal care.

Research Questions

The research questions of this project were intended to contribute towards a

conceptual understanding of pharmacy technicians. They questions address the

differences and similarities between the beliefs of pharmacists and pharmacy technicians

on the tasks and functions that pharmacy technicians should perform in a community

setting, and how those beliefs factor relevant to the adapted theoretical framework of

profession expertise. The questions were designed to evaluate the beliefs of pharmacists

and pharmacy technicians relative to proposed concepts, as well as to explore for

concepts if needed to guide the understanding of pharmacy technician work.

In examining the Model of Expert Practice as it applies to pharmacy, this study

addressed the following research questions:

1. Do pharmacists' and pharmacy technicians' beliefs on tasks that pharmacy

technicians should perform in community practice differ?

2. Does the Framework of Expert Practice for Pharmacy fit pharmacists' and

pharmacy technicians' beliefs on the tasks that pharmacy technicians should

perform in community practice?

3. Do pharmacists' and pharmacy technicians' beliefs differ on the categories of

tasks that pharmacy technicians should perform in community practice?






36


Conclusion

The Jensen et al. (1999) Model of Expert Practice in Physical Therapy was

developed using grounded theory. It is specific for physical therapy but can be adapted to

represent professional expertise for all health professionals. The framework is made up

of four dimensions: knowledge, clinical reasoning and judgment, movement, and virtues.

The concept of movement can be viewed as the processes involved in assessing patient's

medication related problem and educating the patient to prevent or resolve medication

related problems.
















CHAPTER 4
METHODOLOGY

Introduction

This study used a mail questionnaire to survey Florida community pharmacists and

Florida community PTCB certified pharmacy technicians. The study developed and

attempted to validate an instrument: The Community Pharmacy Technician Use

Questionnaire. The validation study involved confirmatory factor analyses and compared

the beliefs of two groups-pharmacist and pharmacy technicians-about what pharmacy

technicians should do in community pharmacy practice sites.

The methodology for this study is described in this section. First, the sampling

procedure is outlined. Next, the instrument development as well as the means of

determining reliability and validity of summated scales are described. Statistical analyses

appropriate to the research questions are described.

Subjects

In order to investigate the research questions pharmacists and pharmacy

technicians working in community pharmacy were identified for inclusion in this study.

Address labels for community pharmacists and their home addresses was purchased from

a seller of commercial lists. The seller claimed that the address labels were a random

selection of all community pharmacists working in the state of Florida for which a

mailable home address existed. The list was purchased in late March of 2004. A random

sample of Pharmacy Technician Certification Board (PTCB) certified pharmacy









technicians who reported to the board that they worked in a community pharmacy setting

and who had a Florida home address was used. The PTCB supplied the list of 2000

PTCB certified community pharmacy technicians living in Florida in late June of 2004.

Study Variables and Operationalization of Constructs

Instrument Development

The development of the instrument, The Community Pharmacy Technician Use

Questionnaire, is described here. The instrument items were developed through an

iterative process. They were developed based on the Jensen et al., Model of Professional

Expertise. Jensen described the framework and its development in their book "Expertise

in Physical Therapy Practice" (1999).

Original Item Pool

The items are limited to the scope of community pharmacy practice. First a list of

the types of tasks that are performed in community pharmacy was created. The list was

created by imagining all possible tasks within a community pharmacy, then revised

through peer review. Items representing each task were then written. The items were

then grouped under the four constructs of the framework according to the description of

the framework given by Jensen et al. (1999). An expert committee reviewed the items

and 57 items were selected for testing.

Focus Group

Four one-on-one interviews and a focus group of 10 pharmacists were conducted to

explore how pharmacists think of the role of pharmacy technicians (Wilson et al., 2003).

One of the goals of the interviews and focus group were to investigate if pharmacists

thought about pharmacy technicians in terms that fit the Jensen et al., framework.

Among other questions, the subjects were asked to describe the best and worst pharmacy









technicians they had ever worked with, which tasks that they felt confident delegating to

each of those types of pharmacy technicians, why they felt confident doing so, which

tasks they did not feel confident delegating to each of those types of pharmacy

technicians, and why they did not feel confident doing so. Content analysis of the

transcripts from the five data collections resulted in the conclusion that pharmacists do

think of pharmacy technicians in terms of the framework. Some of the comments from

the focus group were used in writing the items.

The content analysis of the five transcripts from the four one-on-one interviews and

the focus group of 10 pharmacists found that the framework fit 179 (65%) of the 276

pharmacists' comments that were about pharmacy technicians. The comments that the

framework did not fit were discussions of turnover (n=20), where to find bi-lingual techs

(n=l), a bad technician (n=l), models of practice such as military (n=10), pharmacy laws

relevant to pharmacy technicians (n=56), and pharmacy technician pay (n=9). The text

units that the framework fit sometimes contained more than one construct thus the

numbers below cannot be summed.

The content analysis identified four concepts that fit the construct Patient

Assessment and Education. They were (1) Answer patient questions, (2) Gather

information from patients, (3) Interact with or help patients, and (4) Provide information

to patients. Examples of pharmacist statements are:

Pharmacist: "We allow them to do some sort of talking with the customer about
things...you know what is this medication for? This is for your blood
pressure... What kind of drug is this? Oh this is a beta blocker. We have no
problems saying just very categorical things."

Pharmacist: "If somebody had one insurance and something came up and it was
wrong, they were able to go and tell this person, 'Hey this is going on and it's not









right.' And then the person at the end is saving a lot of money. Because they had
that input from this particular technician to let them know this is wrong."

The content analysis identified five concepts that fit the construct Knowledge and

Skills. They were (1) Have an aptitude for learning, (2) Have certification, education,

experience, and training, (3) Have knowledge of pharmacy practice, (4) Know the limits

of their knowledge and services, and (5) Seek new knowledge. Other than Have an

aptitude for learning the constructs of the Knowledge and Skills domain focused on

knowledge in terms of pharmacy. Examples of pharmacist statements are:

Pharmacist: "That is my definition of a good technician...well trained."

Pharmacist: "We encourage them to try and learn the drugs, know what they're
for."

Pharmacist: "They need to think through it but ultimately they need to ask you or
consult with you."

The content analysis identified five concepts that fit the construct Judgment and

Reasoning. They were (1) Can work on more than one thing at a time, (2) Evaluate and

recognize problems, (3) Have an effective and efficient approach to solving problems, (4)

Make decisions, and (5) Work independently. Examples of pharmacist statements are:

Pharmacist: "... a prescription that is issued correctly, written correctly, ready to
go is not a big deal. It's the ones that, anytime a pharmacist has to get involved in
prior to checking it, that's a big deal. And any technician should be able to
manage everything right up until I sign off on it. And that is my definition of a
good technician, who's well trained. Trouble shoot anything, and you don't have
to step in."

Pharmacist: "What [pharmacist's name] said is correct, they do have black and
white decisions, but there is an avenue of judgment that goes with any job."

The content analysis identified five concepts that fit the construct Virtues. They

were (1) Are team players, (2) Care about and are respectful of patients, (3) Have a good









personality and disposition, and enjoy communicating with people, (4) Have integrity,

and (5) Have a rapport with patient. Examples of pharmacist statements are:

Community pharmacist: "The technician I count on the most is the one that I say,
'Hey can you do X,Y,Z? X,Y,Z gets done. And I don't ever hear Oh, I didn't
have time... .They're not excuse makers. They do what needs to be done and say
here's your work done. What else can I do?'"

Community pharmacist: "It's good for the technicians to know that he cannot say
certain things that may offend the customers."

Another goal of the focus group was to pilot test the 57 items developed for The

Community Pharmacy Technician Use Questionnaire. The focus group participants

completed an early version of the instrument and discussed it in terms of readability and

understandability. The participants were asked to indicate whether a pharmacy

technician should perform each of the 57 tasks using a 6-point Likert-type scale that

ranged from strongly disagree (1) to strongly agree (6). Items that had missing or

unusable responses were deleted from the pool of items. Items that were discussed in the

focus group as being unclear or meaningless were also deleted.

Items that appeared to overlap constructs were deleted. Items that represented

constructs that the participants repeatedly discussed were added. Care was taken to root

each item in a pharmacy task and to isolate aspects of only one scale. One or two items

for each scale were included that were thought to be beyond the capabilities of a

pharmacy technician but within the capabilities of a pharmacist based on their education.

Pretests

The set of items developed from the focus group was evaluated through expert

review and pretested on pharmacists at two continuing education programs attended

primarily by community pharmacists. No factor analyses were performed on the

pretested data. After the first data collection, charts showing the distributions of









responses for each item were visually scanned for variability of response (Table 4-1).

Items with low variability were rewritten for the second testing (Table 4-2).

The reliability of the summated scales was tested in the two protests. For each

scale the item ratings were added for each subject. The internal consistency reliabilities

of the summated scales for the four domains were determined using Cronbach's

coefficient alpha. Alpha coefficients below .6 were considered low. The contribution of

an item to alpha was examined by estimating alpha for each scale

Table 4-1. Item Means from First Testing
Item Item Standard N
Average Deviation
Enter data into the computer accurately. 5.41 1.37 34
Apply insurance rules when processing a new claim 5.47 1.21 34
Obtain information from a patient needed to fill a 5.47 1.26 34
prescription.
Deal with patients in a caring manner 5.56 1.21 34
Assess when a patient needs to speak to a pharmacist 5.12 1.57 34
about their medication.
Understand the difference between an ace-inhibitor 2.74 1.40 34
and a beta-blocker.
Evaluate the reason for a denied claim. 5.21 1.19 33
Answer simple patient questions about their 3.88 1.65 34
medication (ex. Q: What is this medicine for? A: This
is for your blood pressure.)
Go out of their way to assist a patient in obtaining aid 3.77 1.71 34
to pay for their prescriptions.
Identify the common side effects of a beta-blocker. 2.38 1.50 34
Determine when a prescription can be refilled. 5.00 1.41 34
Explain to a patient insurance claim that had a problem 5.47 .99 34
Evaluate circumstances that suggest the possibility of 4.97 1.29 34
drug diversion and alerting the pharmacist.
Include the appropriate information when labeling 5.21 1.49 34
prescription vials.
Evaluate whether a computer generated DUR needs to 4.33 1.99 36
be shown to the pharmacist.
Assess a patient's actual medication use. 2.89 1.43 36
Evaluate the reason for a denied claim. 5.21 1.19 33
Answer simple patient questions about their 3.88 1.65 34
medication (ex. Q: What is this medicine for? A: This
is for your blood pressure.)









Table 4-1. Continued


Item Item Standard N
Average Deviation


Table 4-2. Item Means from Second Testing
Item


Enter data into the computer accurately.
Assess insurance rules when processing a new claim*
Obtain information from a patient needed to fill a
prescription.
Show caring for patients when assisting them*
Assess when a patient needs to speak to a pharmacist
about their medication.
Understand the difference between an ace-inhibitor
and a beta-blocker.
Evaluate the reason for a denied claim.
Answer simple patient questions about their
medication (ex. Q: What is this medicine for? A: This
is for your blood pressure.)
Go out of their way to assist a patient in obtaining aid
to pay for their prescriptions.


3.77 1.71 34


Go out of their way to assist a patient in obtaining aid
to pay for their prescriptions.
Identify the common side effects of a beta-blocker.
Determine when a prescription can be refilled.
Explain to a patient insurance claim that had a problem
Evaluate circumstances that suggest the possibility of
drug diversion and alerting the pharmacist.
Include the appropriate information when labeling
prescription vials.
Evaluate whether a computer generated DUR needs to
be shown to the pharmacist.
Assess a patient's actual medication use.
Be discrete with patients' health information
Link the trade name with the generic name of a drug.
Evaluate a patient's medication therapy.
Educate a patient on the appropriate use of their
medication.
Recognize the therapeutic class of a prescribed
medication.
Feel a personal responsibility to resolve a patient's
drug therapy problems.
Assess which medication a patient wants to have
refilled when the patient does not know the name of
the drug.


Item
Average
5.81
5.38
5.81

5.86
5.38

2.62

5.29
4.05


3.90


1.50
1.41
.99
1.29


Standard
Deviation
.68
1.02
.68


2.38
5.00
5.47
4.97

5.21

4.33

2.89
5.70
5.22
2.63
2.83

3.25

3.11

3.97









Table 4-2. Continued
Item Item Standard N
Average Deviation
Identify the common side effects of a beta-blocker. 2.19 .98 21
Determine when a prescription can be refilled. 5.50 1.00 20
Explain to a patient the reason a prescription cannot be 5.67 .73 21
filled under the patient's insurance plan*
Evaluate circumstances that suggest the possibility of 4.86 1.35 21
drug diversion and alerting the pharmacist.
Include the appropriate information when labeling 5.28 1.01 21
prescription vials.
Evaluate whether a computer generated DUR needs to 3.71 2.05 21
be shown to the pharmacist.
Assess a patient's actual medication use. 3.00 1.52 21
Protect confidential patient information from 6.0 0.00 20
unauthorized disclosure*
Link the trade name with the generic name of a drug. 5.19 .98 21
Evaluate a patient's medication therapy. 2.05 1.02 21
Educate a patient on the appropriate use of their 2.43 1.29 21
medication.
Recognize the therapeutic class of a prescribed 3.10 1.38 21
medication.
Feel a personal responsibility to resolve a patient's 2.29 1.27 21
drug therapy problems.
Assess which medication a patient wants to have 3.90 1.70 21
refilled when the patient does not know the name of
the drug.
*Item re-written after first testing

after that item alone was deleted. Item-corrected total correlations were used to evaluate

the correlation of an item with the sum of the other items in its scale. Item-corrected total

correlations of below .3 were considered low. However, because of the low number of

subjects in the two administrations, we loosened the criteria somewhat and looked at the

pattern of performance for an item and scale across the two administrations. All statistics

were calculated using SPSS.

From the first testing, the reliability coefficient for the scale Patient Assessment

and Education (n=34) was .64 while the standardized item alpha was .63 (Table 4-3).

This is acceptable. For the second testing, the reliability coefficient for the scale Patient









Assessment and Education (n=21) was .47 while the standardized item alpha was .59. In

the first testing, the item "Obtain information from a patient needed to fill a prescription"

had a low item-corrected total correlation but its deletion had little effect on alpha for the

scale. The item performed better on the second testing with an acceptable item-corrected

total correlation and did not suppress alpha. On the second testing but not the first

testing, the items "Assess when a patient needs to speak to a pharmacist about their

medication", "Answer simple patient questions about their medication (ex. Q: What is

this medicine for? A: This is for your blood pressure.)", and "Assess which medication a

patient wants to have refilled when the patient does not know the name of the drug" had a

low item-corrected total correlation, but little effect on alpha when deleted from the scale

with the exception of the last item. However, this item performed well on the first

administration. All of the items from this scale were included in the final questionnaire

in the same form that they had during the second pre-testing.

Table 4-3. Item Analysis for the Patient Assessment and Education Scale on the Pre-tests
Item First Testing (a=.64) Second Testing (a=.63)
Item- Alpha if Item- Alpha if
corrected item deleted corrected item
total total deleted
correlation correlation
Obtain information from a .16 .65 .49 .38
patient needed to fill a
prescription.
Assess when a patient needs to .32 .61 .11 .48
speak to a pharmacist about their
medication.
Answer simple patient questions .44 .57 .26 .42
about their medication (ex. Q:
What is this medicine for? A:
This is for your blood pressure.)
Explain to a patient an insurance .35 .61
claim that had a problem. *









Table 4-3. Continued
Item First Testing (a=.64) Second Testing (a=.63)
Item- Alpha if Item- Alpha if
corrected item deleted corrected item
total total deleted
correlation correlation
Explain to a patient the reason a .51 .37
prescription cannot be filled
under the patient's insurance
plan. *
Assess a patient's actual .30 .61 .36 .36
medication use.
Educate a patient on the .35 .60 .35 .37
appropriate use of their
medication.
Assess which medication a .53 .53 -.09 .61
patient wants to have refilled
when the patient does not know
the name of the drug.
This item was rewritten between first and second administration

In the first testing the reliability coefficient for the scale Knowledge and Skills

(n=32) was .60 while the standardized item alpha was .61 (Table 4-4). This is an

acceptable level. It was slightly lower in the second testing. In the second testing the

reliability coefficient for the scale Knowledge and Skills (n=21) was .57 while the

standardized item alpha was .59. The items "Enter data into the computer accurately",

and "Identify the common side effects of a beta-blocker" had low item-corrected total

correlations on the first testing but not on the second testing. In both pre-testings, the

item "Include the appropriate information when labeling prescription vials" had low

item-corrected total correlations but eliminating that item resulted in a reduction in alpha

for the scale. The items "Link the trade name with the generic name of a drug", and

"Recognize the therapeutic class of a prescribed medication" had low item-corrected total

correlations on the second testing but not the first testing. All of the items from this scale

were included in the final questionnaire.









Table 4-4. Item Analysis for the Knowledge and Skills Scale on the Pre-tests
Item First Testing (a=.60) Second Testing (a=.57)
Item- Alpha if item Item- Alpha if
corrected deleted corrected item deleted
total total
correlation correlation
Enter data into the computer .16 .63 .44 .50
accurately.
Identify the common side 16 .63 .49 .45
effects of a beta-blocker.
Include the appropriate .25 .60 .22 .56
information when labeling
prescription vials.
Link the trade name with the .49 .51 .00 .64
generic name of a drug.
Recognize the therapeutic class .51 .47 .28 .55
of a prescribed medication.
Understand the difference .52 .48 .55 .40
between an ace-inhibitor and a
beta-blocker.

In the first testing the reliability coefficient for the scale Reasoning and Judgment

(n=32) was .41 while the standardized item alpha was .50 (Table 4-5). This is low. In

contrast in the second testing the reliability coefficient for the scale Reasoning and

Judgment (n=20) was .71 while the standardized item alpha was .76. The item "Apply

insurance rules when processing a new claim" had a low item-corrected total correlation

on the first testing, but a rewritten version of the item had an adequate item-corrected

total correlation on the second testing. The items "Evaluate a patient's medication

therapy", "Evaluate circumstances that suggest the possibility of drug diversion and

alerting the pharmacist", and "Evaluate whether a computer generated DUR needs to be

shown to the pharmacist" had low item-corrected total correlations on the first testing but

eliminating any of the items did not substantially increase alpha for the scale and the

items item-corrected total correlations on the second testing were not low. All of the









items from this scale were included in the final questionnaire in the same form that they

had during the second pre-testing.

Table 4-5. Item Analysis for the Reasoning and Judgment Scale on the First Pre-test
Item First Testing (a=.41) Second Testing (a=.71)
Item- Alpha if item Item- Alpha if
corrected deleted corrected total item
total correlation deleted
correlation
Apply insurance rules .21 .37
when processing a new
claim. *
Assess insurance rules .57 .65
when processing a new
claim. *
Determine when a .33 .28 .49 .67
prescription can be
refilled.
Evaluate a patient's -.04 .54 .38 .69
medication therapy.
Evaluate circumstances .30 .32 .47 .67
that suggest the
possibility of drug
diversion and alerting the
pharmacist.
Evaluate the reason for a .37 .30 .65 .64
denied claim.
Evaluate whether a .21 .37 .38 .75
computer generated DUR
needs to be shown to the
pharmacist.
This item was rewritten between first and second administration.

In the first testing, the reliability coefficient for the scale Virtues (n=34) was .42

while the standardized item alpha was .49 (Table 4-6). This is low. In the second testing

the reliability coefficient for the scale Virtues (n=20) was .35 while the standardized item

alpha was .44 (Table 4-11). This is also low. In the first and second testing, the item

"Feel a personal responsibility to resolve a patient's drug therapy problems" had a low

item-corrected total correlation, but it affected alpha for the scale only on the first testing.









Table 4-6. Item Analysis for the Virtues Scale on the First Pre-test
Item First Testing (a=.42) Second Testing (a=.35)
Item- Alpha if item Item- Alpha if item
corrected deleted corrected deleted
total total
correlation correlation
Feel a personal .03 .60 .20 .28
responsibility to resolve a
patient's drug therapy
problems.
Go out of their way to .36 .19 .26 .18
assist a patient in obtaining
aid to pay for their
prescriptions.
Be discreet with patient .32 .29
health information. *
Protect confidential patient ** **
information from
unauthorized disclosure. *
Deal with patients in a .32 .28
caring manner. *
Show caring for patients .30 .30
when assisting them. *
This item was rewritten between first and second administration.
** This item had no variability on the second pre-test thus it was not included in the item
analysis

In first testing the item "Feel a personal responsibility to resolve a patient's drug

therapy problems" had a low item-corrected total correlation and suppressed alpha. On

the second administration that item had a higher item-corrected total correlation and did

not substantially suppress alpha. That item was reworded for the final questionnaire as

"Assume personal responsibility to resolve a patients' drug therapy problems." In the

second testing but not the first testing the item "Go out of their way to assist a patient in

obtaining aid to pay for their prescriptions" had a low item-corrected total correlation.

On the second administration that item did not substantially suppress alpha. In the

second testing the item "Protect confidential patient information from unauthorized

disclosure" had zero variance and thus was not included in the item analysis. The









wording from the first testing was retained in the final instrument. The item "Deal with

patients in a caring manner" from the first testing contributed more to alpha than did the

rewritten version used in the second testing. The wording from the first testing was

retained in the final instrument.

Three items were added to the instrument's Knowledge and Skills scale after the

pre-testing based on the National Association of Boards of Pharmacy 2003-2004 Survey

of Pharmacy Law and the importance that these tasks play in pharmacy. Those items are

"Transfer a patient's prescription.", "Accept called in prescriptions from physicians'

offices.", and "Call physicians for refill authorization." The final number of items

included in The Community Pharmacy Technician Use Questionnaire was 26. The final

instrument was developed through expert review and the use of the data from the protests.

Data Collection Procedures


All subjects were contacted by mail. A cover letter, a copy of The Community

Pharmacy Technician Use Questionnaire and a business reply envelope were mailed to

each subject in two separate mailings. The first mailing for the pharmacists went out on

August 10, 2004; and the first mailing for the technicians went out on August 12, 2004.

Subjects were asked to participate and return the instrument in the provided envelope

(Appendix A and Appendix B). After two weeks, subjects were sent a letter that thanked

those who had responded, and asked those who had not yet responded to complete the

survey and return it (Appendix C). A second questionnaire and business reply envelope

were included. The second mailing for both groups went out on August 25, 2004. The

data collection for this analysis was closed on September 17, 2004.









Questionnaire

The questionnaire was designed to be straightforward, easy to understand, and

professional in appearance. It was reviewed by five individuals and approved by the

University of Florida's Institutional Review Board. The questionnaire was four pages.

The first page was a cover bearing the title "Pharmacy Technician Responsibility

Instrument" and the seal of the University of Florida's College of Pharmacy (Appendix D

and Appendix E). The second page included questions about the subjects' practice

experience. These questions were specific to the type of subject (pharmacists versus

pharmacy technicians). Pharmacist subjects were asked to indicate the number of years

they have practiced, their type of practice site, the number of technicians that they have

supervised in their career, the number of competent technicians they have supervised in

their career, if they have supervised a pharmacy technician with Pharmacy Technician

Certification Board certification (CPhT), and if they have supervised a pharmacy

technician with a two year associates degree in pharmaceutical sciences. Competence

was not defined for the subjects. Supervision was defined as direct, personal and

immediate supervision. The pharmacy technician subjects were asked to indicate the

number of years they have practiced, their type of practice site, and their pharmacy

credentials and education.

The third and fourth pages of the questionnaire were composed of The Community

Pharmacy Technician Use Questionnaire. An area for comments was included for the

subj ects.

The Community Pharmacy Technician Use Questionnaire

The Community Pharmacy Technician Use Questionnaire presented subjects with

pharmacy tasks relevant to the framework of professional expertise. The subjects









indicated their beliefs on whether a capable pharmacy technician should perform tasks

that were selected and pretested to represent the constructs of the framework. The

subjects indicated their beliefs on whether a capable pharmacy technician should perform

each task by selecting one through six on a six point Likert-type scale ranging from

'strongly disagree' to 'strongly agree.' Using a six point scale ensures that the

respondents have enough choice to allow for some variation in responses while

preventing them from choosing a neutral position. The questionnaire attempted to

measure the subjects' beliefs about whether or not they agreed that a pharmacy technician

should or should not perform the tasks represented by the items. The leading statement

for the items read, "A capable pharmacy technician should:" A brief statement preceding

the stem encouraged the subjects to think of what a capable pharmacy technician should

do assuming each task were allowed by law. That statement was: "Please assume that all

tasks listed in this survey are not restricted under the law. Assume that all of the tasks

listed below are permitted by law."

Instrument Validation


The framework of professional expertise is useful in describing functions of

pharmacists and pharmacy technicians. The instrument that measures the constructs

relevant to pharmacy technicians was investigated in terms of its abilities to measure

these constructs. Such an investigation is part of the validation of the instrument.

This work attempted to measure the validity of interpretations made on the basis of

data collected using an instrument designed to measure the beliefs of pharmacists and

pharmacy technicians about what types of tasks a capable pharmacy technician should

perform in community practice. It is important that the construct validity of the









interpretations drawn based on the data collected with the instrument be measured. That

is to say, it is important to evaluate how accurate the instrument's operationalization of

the construct is. The construct validity was evaluated using confirmatory factor analysis.

The primary goal of this research requires the development and testing of an

instrument using a framework of the professional expertise of pharmacy. To do this the

Jensen et al., framework of professional expertise described in Chapter 3 was used. The

items representing the framework constructs are described above in the instrument

development section, but are included here in a visual form (Figure 4-1). In Figure 4-1

the Ci represent the error variances (small rectangles) on the observed variables (items in

long rectangles), while the i (small rectangles) represent the error variances on the latent

variables (constructs in big squares). Curved lines represent correlated latent variables.

First, the two groups were compared to see if the variables loaded on the same

factors in both samples. In doing this we checked to see if the model for four factors fits

for the two groups. In other words we wanted to know if we were measuring the same

underlying factors for both groups. In this analysis, the factor loadings for each variable

were constrained to be equal for both groups. Goodness of Fit indices were used to

decide whether the constrained model adequately fit the data. These indices are

described in detail later. It is a way to check to see if we have the same configural

invariance. Since this step failed to find evidence that the groups have the same factors

an exploratory factor analysis was performed. Multiple group CFA is used to investigate

measurement invariance. Measurement invariance is "whether a set of indicators assess

the same latent variables in different groups" (Kline, 1998). Group membership may
















Assess when a patient needs to speak to a pharmacist about their medication

Obtain information from a patient needed to fill a prescription.

Answer simple patient questions about their medication (ex. Q: What is this
medicine for? A: This is for your blood pressure.)

Explain to a patient an insurance claim that had a problem.


n. C1

C2


4 -- c3

4 -- c4


Assess a patient's actual medication use. 4

Educate a patient on the appropriate use of their medication.

Assess which medication a patient wants to have refilled when the patient does
not know the name of the drue.


Enter data into the computer accurately.

Identify the common side effects of a beta-blocker.

Include the appropriate information when labeling prescription vials.

Link the trade name with the generic name of a drug.

Recognize the therapeutic class of a prescribed medication.

Understand the difference between an ace-inhibitor and a beta-blocker.

Transfer a patient's prescription.

Accept called in prescriptions from physicians' offices.

Call physicians for refill authorization.




Apply insurance rules when processing a new claim.

Determine when a prescription can be refilled.

Evaluate a patient's medication therapy.

Evaluate circumstances that suggest the possibility of drug diversion and
alerting the pharmacist.

Evaluate the reason for a denied claim.

Evaluate whether a computer generated DUR needs to be shown to the
pharmacist.


Assume personal responsibility to resolve a patient's drug therapy
problems.


Go out of their way to assist a patient in obtaining aid to pay for their prescriptions.

Be discreet with patient health information.

Deal with patients in a caring manner, -

Figure 4-1. Model Targeted in the Confirmatory Factor Analysis


C21

Ce22









affect the relations between the latent variables and the items. Whenever the sample

comprised identifiable subgroups and we are concerned about whether the observed

variables measure the same factors in the subgroups, separate factor analyses should be

conducted for the subgroups. We are concerned about whether the relationships of the

observed variables and the factors are

the same in the two groups. For this reason, the CFAs were performed separately for the

two groups.

Analyses

Descriptive Analyses

The first research question was evaluated using Chi-square difference tests. That

question was: 1) "Do pharmacists and pharmacy technician beliefs on tasks that

pharmacy technicians should perform in community practice differ?". A cut point was

set to determine which items the groups feel technicians should perform. The scale was 1

(strongly disagree) to 6 (strongly agree). For each response-number an anchor was

provided: (1) strongly disagree, (2) disagree, (3) somewhat disagree, (4) somewhat agree,

(5) agree, and (6) strongly agree. Responses of 1-3 were considered "disagree that a

technician should perform". Responses of 4-6 were considered "agree that a technician

should perform". The data from the two groups on each item were then compared using

Chi-square difference tests. Since there were 26 tests the p-value for a significant result

was set at .05/26
task that a capable pharmacy technician should perform or should not perform in

community practice depend on whether or not the belief comes from pharmacists or from

pharmacy technicians.









Confirmatory Factor Analysis

The second research question was addressed using confirmatory factor analysis

(CFA). That research question is: "Does the Framework of Expert Practice for Pharmacy

fit pharmacists' and pharmacy technicians' beliefs on the tasks that pharmacy technicians

should perform in community practice?". The CFA was performed using LISREL.

First only cases with complete data were included in this analysis. Contrary to

what is almost always done in CFA, in this case, the comparison of groups on the same

scale, the covariance matrix was analyzed, not the correlation matrix. If you start with

variables that have been constructed in the same fashion, then separately standardize

them, the variables are not comparable for the two groups. That is what would have

happened if we had used the correlation matrix for the comparison. We used the same

instruments for both groups, so the measure was the same so long as we did not

standardize the two groups' data separately. Thus this comparison used the covariance

matrix in order to maintain the same units of measurement for the two groups.

Since we used the covariance matrix we had to set the scale by setting the factors

to one. We set the scale by setting one factor loading for each factor to one. We did not

set the scale by setting the factor variances equal to one, since we were using the

covariance matrix in the analysis.

The way that the groups are combined in the combined group CFA is by analyzing

the two groups separately and then combining the fit indexes. LISREL reports the

Standardized Root Mean Square Residual (SRMR) separately for each group, but reports

the Root Mean Square Error of Approximation (RMSEA), Non Normed Fit Index

(NNFI), the Comparative Fit Index (CFI) and the Minimum Fit Function Chi-Square for

the two groups combined. The SRMR was set a priori at SRMR








since the number of subjects in each group was below the number of 1000 subjects

needed to require a more stringent SRMR of
still under 1000, thus the NNFI was set a priori as NNFI >/= 0. 95. The more stringent

NNFI is usually >/=.96. The CFI was set a priori at CFI >/= 0.95. The standard

procedure for testing for invariant factor loadings is the Minimum Fit Function Chi-

Square in which the null hypothesis is that the model with loadings constrained to be

equal fits the data and the alternative hypothesis is that the model with out between-group

equality constraints fits the data. Rejecting the null hypothesis implies that the factor

loadings vary across groups. If the null hypothesis is rejected then researchers often use

more subjective comparisons of goodness of fit indices such as SRMR and CFI for the

two models. If the indices for the two models are then judged to be sufficiently similar,

the conclusion is usually that the factor loadings vary only a little across the two groups.

The procedures used to measure fit in each step of the CFA are described here.

The first step of the CFA checks if the variables load on the same factors in both samples.

The goodness of fit statistics were calculated using LISREL. The second step is to see if

the factor loadings are equal. This would have been tested by calculating the Wald

Statistic in MS Excel using the factor loadings and variances for the two groups for each

variable, which would have been calculated using LISREL.

The second CFA was also performed using LISREL. Cases with incomplete data

were included in this analysis. The data were entered for the two groups separately into

LISREL and the target model was forced. Then a null model, in which each item loaded

on its own factor was forced. LISREL provided the Root Mean Square Error of

Approximation (RMSEA), the Minimum Fit Function Chi-Square, degrees of freedom









and p-value for the Minimum Fit Function Chi-Square for each model. The NNFI and

CFI for the fit of the two groups model simultaneously were calculated using Excel.

Exploratory Factor Analysis

After the first step of the confirmatory factor analysis found that the two groups'

factor configurations were not invariant then the CFA was stopped and an exploratory

factor analysis was performed to see how many factors the two groups' items fit onto.

The data from the two groups were analyzed separately. The results of the confirmatory

factor analysis will be described in greater detail in the results section. The exploratory

factor analyses were performed using SPSS. Analysis of the correlation matrices were

used to determine the number of eigenvalues greater than one and to generate scree plots.

Based on the scree plot multiple models were possible. The number of factors was

determined with logic based on the number of eigenvalues greater than one and the

number of factors that appear to be distinct on the scree plot. The number of factors were

then forced using principle axis method and promax oblique rotation of the correlation

matrix to compare the loadings of the models. The factors were expected to be correlated

based on previous work with the qualitative data and a logical understanding of what the

factors represent.

The factor pattern were examined to determine which items loaded on which

factors by looking for high loadings and logical groupings. The pattern matrix presents

the observed variables' importance to the factors with the influence of the other observed

variables partialled out.

The second research question was answered by the failure of the CFA, but the third

question still needed to be answered following the exploratory factor analysis. Again the

third research question is: "Do pharmacists' and pharmacy technicians' beliefs differ on









the categories of tasks that pharmacy technicians should perform in community

practice?". Obviously to do this models that were the same for the two groups needed to

be determined. This was not possible.

Internal Consistency Reliability

Reliability measures how free from error a measure is and how consistently that

measure can obtain the same results. It does not ensure that we are measuring what we

intend to measure. Measurement error can occur when the items of a test do not measure

the same concept. As a check on the reliability of the factors, the internal consistency of

the instrument was measured using Cronbach's alpha. The final factors' reliabilities were

estimated for the two groups separately. This was done using SPSS vIO. An alpha of .6

and above was considered an adequate level of reliability. The alpha values of the factors

after deleting each item singly from a factor for the two groups were also estimated. The

item-corrected total correlations were also examined. The reliability of the factors were

tested separately for the two groups. Item-corrected total correlations of below .3 were

considered low, but if a factor had an alpha of .6 and above no change was made to the

factor.

Inter-Factor Correlations

The correlations among the factors scores from the two groups' four-factor models

were examined separately. For each complete case a summated score was created by

adding a subject's responses to the items within a factor together. The models'

correlations were examined separately for the two groups. The correlations were

examined for strength of correlation and significance to develop an understanding of the

relationships among the factors within the two models. The correlations were made using

SPSS vl0.









Within-Group Comparisons of Summated Scores by Type of Experience

Types of work experience that were logically thought to predict pharmacists'

summated scores and pharmacy technicians' summated scores were examined. The

summated scores that were used to calculate the correlations within groups between

factors in the analysis described above were used to make comparisons within groups by

types of work experience.

Pharmacist work experience variables were compared with the pharmacist

summated scores. The pharmacists' summated scores were compared based on four

types of work experience: (1) the number of years they reported having worked as a

licensed pharmacist, (2) the calculated percent of competent pharmacy technicians that

reported having supervised, (3) whether or not they reported having supervised a PTCB

certified pharmacy technician, and (4) whether or not they reported having supervised a

pharmacy technician with an AA in pharmaceutical technology. Pharmacy technician

work experience variables were compared with the pharmacy technician summated

scores. The pharmacy technicians' summated scores were compared based on four types

of work experience: (1) the number of years they reported having worked as a pharmacy

technician, (2) whether or not they reported having education beyond a high school

diploma, (3) whether or not they reported having completed a formal training program

(either ASHP approved or employer designed, but not on-the job training), and (4)

whether or not they reported having an pharmacy technician certificates beyond PTCB

certification.

Correlations were made among continuous variables (e.g. number of years and

summated scores), and independent samples t-tests between dichotomous and continuous









variables (e.g. training yes/no and summated scores). For each comparison cases were

eliminated list-wise. The correlations and t-tests were made using SPSS vIO.

Response Bias

Response bias was investigated by comparing the results of the early and late

responders to the questionnaire. Responses received by the second mailing August 26,

2004 were considered early responses and those received on the 27th or later but by the

cut-off point were considered late responders. Late responders may be more similar in

their beliefs to non-responders than early responders are to non-responders. Differences

between early and late responders were tested within groups using Chi-square difference

tests. In these tests we check for differences that may exist between the groups. Since

we do not want to fail to detect any instances when such a difference exists we chose to

set the p-value for the tests at .05 for each test.

Sample Size Estimation

In order to perform the confirmatory factor analysis at least 5 subjects were needed

per item (Haire et al., 1998). This suggests that at least 130 subjects were needed per

group for the confirmatory factor analysis.

A more conservative number of 10 subjects per item were sought for this study.

Since the instrument has 26 items at least 260 subjects per group (pharmacists and

technicians) were sought. Two thousand subjects in each group were contacted initially.

This allowed for a minimally needed response rate of 13% for each group. The expected

response rate was 30% for each group, based on previous work with pharmacists.

Summary

The study used a self-administered mail questionnaire. A random sample of

pharmacists and PTCB certified pharmacy technicians working in a community









pharmacy practice site in the state of Florida were surveyed. Non-identifiable follow-up

was performed to ensure an adequate response rate. The validity and reliability of the

instrument were evaluated. Analyses were conducted to explore on what tasks

pharmacists and pharmacy technicians agree and disagree that pharmacy technicians

should perform. Confirmatory factor analysis was used to investigate if the Framework

of Professional Expertise for Pharmacy fits the way that pharmacists and pharmacy

technicians think about the types of tasks that pharmacy technicians should perform.

Exploratory factor analysis was used to estimate a model that fit the data for the two

groups after the confirmatory factor analysis failed. It was not possible to construct one

model that fit both groups. The internal consistency of the factors generated by the

exploratory factor analyses were estimated. The correlations among the factors from the

two groups data derived models were examined. The effects of types of work experience

on the groups' summated scores were examined. Possible response bias was also

explored.














CHAPTER 5
RESULTS

This chapter presents the results of the analyses described in the previous chapter.

First the descriptive statistics are presented then the analyses are presented.

Questionnaire Response

From the 4000 subjects targeted 1072 questionnaires were returned. Nine

pharmacists' and no technician questionnaires were returned as undeliverable. Of the

1072 returned questionnaires, 503 were from the pharmacist group and 569 were from the

technician group. The response rate of the pharmacist group was 25%; and that of the

technician group was 29%. The overall response rate was 27%.

Not all of the returned questionnaires were used. Two hundred thirty-five

questionnaires were excluded because respondents did not meet the inclusion criteria for

the study for the following reasons: (1) the subjects reported that they did not work in

community pharmacy (pharmacists n=147 and technician n=70); (2) the subjects reported

that they were not pharmacists but students (n=2); (3) the subjects reported that they were

retired or not working in pharmacy (pharmacists n=12 and technician=4). Thus, there

were 837 usable cases. There were 344 usable cases in the pharmacist group, of which

314 had complete data. There were 495 usable cases in the technician group, of which

449 had complete data. Cases with complete data were usable cases that had a response

for each item in the Community Pharmacy Technician Use Questionnaire. The revised

response useable rate from the pharmacist group was 17%; and that of the technician

group was 23%.









Descriptive Data

Work Experience

Of the 314 included pharmacists, 295 (94%) responded to the question "How long

have you been practicing pharmacy as a licensed pharmacist?". For those pharmacists

the average work-years reported was 21.2 (sd=13.2), with a low of less than one year and

a high of 56 years. Of the 449 included pharmacy technicians, 401 (89%) responded to

the question "How long have you been working as a pharmacy technician?". For those

pharmacy technicians the average work-years reported was 8.1 (sd=6.9), with a low of

less than one year and a high of 50 years. The majority of the included pharmacists and

pharmacy technicians reported that they worked in retail chain pharmacies, followed by

independent pharmacies. For the pharmacists and the pharmacy technicians the next

most common type of reported work place was supermarket pharmacies, followed by

discount store pharmacies (Table 5-1).

Table 5-1. Reported Community Work Experience of Subjects in Sample
Type of pharmacy Pharmacist Technician
n (%) n (%)
Discount store 12 (4) 39 (8.7)

Independent 61 (19) 44 (9.8)

Retail chain 195 (62) 364 (81.1)

Supermarket 55 (18) 40 (8.9)

Total 323* 446**

*Some pharmacist reported working in multiple settings
**Not all technicians reported their work experience
Pharmacist Reported Pharmacy Technician Supervisory Experience

Of the 314 included pharmacists, 303 (96%) responded to the question: "How

many technicians have you directly supervised in your career? Supervised here means









direct, immediate and personal supervision." For those pharmacists the average reported

number of technicians supervised was 32.8 (sd=50.2), with a low of one technician and a

high of 500 technicians.

Pharmacist Reported Pharmacy Technician Competency. Three hundred

pharmacists (96%) responded to the question: "How many of those technicians do you

feel were competent?". The percent of competent technicians was calculated by taking

the reported number of competent technicians supervised divided by the reported number

of technicians supervised. Two hundred ninety-nine pharmacists responded to both

questions. The average calculated pharmacist reported percentage of competent

pharmacy technicians was 66% (sd=26), with a low of .04% and a high of 100%.

Pharmacist Reported Type of Pharmacy Technician Supervised

Of the 314 included pharmacists, 310 (98.7%) responded to the question: "Have

you supervised a pharmacy technician who was certified by the Pharmacy Technician

Certification Board? (CPhT)". Of those pharmacists 267 (86.1%) reported that they had

supervised a PTCB certified pharmacy technician; 31 (10%) reported that they had not;

and 12 (3.9%) reported that they did not know. The same number of subjects who

responded to the above question responded to the question: "Have you supervised a

pharmacy technician who had an AA in Pharmacy Technician Sciences?". Of those

pharmacists 35 (11.3%) reported that they had supervised a pharmacy technician with

such an AA; 218 (70.3%) reported that they had not; and 57 (18.4%) reported that they

did not know.

Pharmacy Technician Reported Credentials

Pharmacy technician reported education. Recall that all pharmacy technicians

in the targeted sample were PTCB certified. This means that all were required to have a









high school diploma or General Equivalency Diploma (GED). The subjects reported

having education in the following response categories: (1) some college n=182 (41%); (2)

AA/AS general n=95 (21%); (3) AA in Pharmacy Technician Sciences n=14 (3%); (4)

BA/BS n=35 (8%); (5) graduate degree/professional degree n= 16 (4%); and (6)

Pharmacy degree from another country n=2 (0.4%). In addition to the above response

categories several pharmacy technicians wrote in different forms education in the "other"

slot: (1) tech school diploma n=7 (2%); (2) in pharmacy school n=3 (1%); (3) category

checked but not described n=2 (0.4%); (4) MD from another country n=l (0.2%); (5)

chemical engineer from another country n=l (0.2%); three year degree in Laboratory

Medicine Technology n=l1 (0.2%); and (7) working on BA n=l1 (0.2%).

Pharmacy technician reported training. Subjects were prompted to report the

type of training they had. The subjects reported having training in the following response

categories: (1) on the job training n=395 (88%); (2) employer developed training program

n=197 (44%); and (3) ASHP approved program n=32 (7%).

Pharmacy technician reported certificates. The pharmacy technicians were

asked to write in any non-PTCB pharmacy technician certificates that they have. Thirty

instances of certificates are not described here because they are not pharmacy related.

The 47 pharmacy-related certificates were made up of three categories: (1) employer

issued certificates; (2) government agency issued certificates; and (3) organization issued

certificates. The employer issued certificates were: (1) technician certificate n=29; (2)

level two technician or senior technician certificate n=5; (3) specialty technician

certificates n=3; (4) technician continuing education certificates n=2; and (5) military

certificates n=2. The government agency issued certificates were: (1)









certificate/licensure from another state n=2; and (2) certificate/licensure from a

protectorate n=l. The organizational issued certificates were: (1) the National

Association of Chain Drug Stores (NACDS) n=l; and (2) PCCA (presumably the

Professional Compounding Centers of America) aseptic techniques n=1.

Item Level Descriptive Data

The means and standard deviations for the two groups' responses on the items in

The Community Pharmacy Technician Use Questionnaire were calculated (Table 5-2).

The scale used was 1 (strongly disagree) to 6 (strongly agree), so larger item means

represent more positive group belief that a capable pharmacy technician should perform

the task represented by the item. Likewise smaller item means represent greater group

belief that a capable pharmacy technician should not perform the task represented by the

item.

Ten of the items were ranked on average by the pharmacist and pharmacy

technician groups as a five (agree) or above. Those items were: (1) "Enter data into the

computer accurately.", (2) "Apply insurance rules when processing a new claim.", (3)

"Obtain information from a patient needed to fill a prescription.", (4) "Deal with patients

in a caring manner.", (5) "Assess when a patient needs to speak to a pharmacist about

their medication.", (6) "Evaluate the reason for a denied claim.", (7) "Explain to a patient

an insurance claim that had a problem.", (8) "Include the appropriate information when

labeling prescription vials.", (9) "Be discrete with patients' health information." and (10)

"Call physicians for refill authorization." The pharmacy technician group ranked on

average two additional items as a five (agree) or above. Those items were: (1)

"Determine when a prescription can be refilled.", and (2) "Link the trade name with the










generic name of a drug." The pharmacist and pharmacy technician groups ranked on

average one item as a two (disagree) or lower. That item was: "Assume personal

Table 5-2. Item Means from the Pharmacist Group (n=314) and the Pharmacy
Technician Group (n=449) on The Community Pharmacy Technician Use
Questionnaire


Item


Enter data into the computer accurately.
Apply insurance rules when processing a new
claim
Obtain information from a patient needed to
fill a prescription.
Deal with patients in a caring manner
Assess when a patient needs to speak to a
pharmacist about their medication.
Understand the difference between an ace-
inhibitor and a beta-blocker.
Evaluate the reason for a denied claim.
Answer simple patient questions about their
medication (ex. Q: What is this medicine for?
A: This is for your blood pressure.)
Transfer a patient's prescription.
Go out of their way to assist a patient in
obtaining aid to pay for their prescriptions.
Identify the common side effects of a beta-
blocker.
Determine when a prescription can be refilled.
Explain to a patient insurance claim that had a
problem
Accept called in prescriptions from
physician's offices.
Evaluate circumstances that suggest the
possibility of drug diversion and alerting the
pharmacist.
Include the appropriate information when
labeling prescription vials.
Be discrete with patients' health information
Evaluate whether a computer generated DUR
needs to be shown to the pharmacist.
Assess a patient's actual medication use.


Pharmacist Group


Item
Average
5.58
5.65

5.67

5.64
5.11

2.94

5.40
3.66


3.15
4.57

2.42

4.77
5.57

2.34

4.82


5.03

5.70
3.90


Standard
Deviation
0.78
0.68

0.69

0.74
1.23

1.44

0.94
1.56


1.79
1.32

1.32

1.25
0.65

1.52

1.24


1.07

0.76
1.76


Pharmacy
Technician Group
Item Standard
Average Deviation
5.87 0.50
5.69 0.73


5.83

5.78
5.43

4.43

5.57
4.70


3.99
4.05

3.64

5.46
5.61

3.39

4.66


5.59

5.83
4.86


0.60

0.68
1.11

1.31

0.86
1.48


1.71
1.58

1.48

0.94
0.83

1.80

1.41


0.78

0.60
1.49


3.21 1.48 3.80 1.65


3.21 1.48


3.80 1.65









Table 5-2. Continued
Item Pharmacist Group Pharmacy
Technician Group
Item Standard Item
Average Deviation Average
Link the trade name with the generic name of 4.97 1.21 5.52 0.85
a drug.
Evaluate a patient's medication therapy. 2.20 1.30 3.11 1.56
Educate a patient on the appropriate use of 2.60 1.48 3.42 1.61
their medication.
Recognize the therapeutic class of a prescribed 3.63 1.40 4.38 1.42
medication.
Assume personal responsibility to resolve a 1.88 1.15 2.48 1.43
patient's drug therapy problems.
Assess which medication a patient wants to 3.78 1.43 4.60 1.51
have refilled when the patient does not know
the name of the drug.
Call physicians for refill authorization. 5.29 1.05 5.48 1.07

responsibility to resolve a patient's drug therapy problems." The pharmacist group

ranked on average four additional items as a two (disagree) or lower. Those items were:

(1) "Identify the common side effects of a beta-blocker.", (2) "Accept called in

prescriptions from physician's offices.", (3) "Evaluate a patient's medication therapy.",

and (4) "Educate a patient on the appropriate use of their medication."

Analyses

Chi-Square Tests

The first research question was evaluated using the Chi-square tests. That question

is: 1) "Do pharmacists and pharmacy technician beliefs on tasks that pharmacy

technicians should perform in community practice differ?". Recall that the scale used in

the questionnaire was 1 (strongly disagree) to 6 (strongly agree); and, that for each

response-number an anchor was provided: (1) strongly disagree, (2) disagree, (3)

somewhat disagree, (4) somewhat agree, (5) agree, and (6) strongly agree. For this

analysis both groups' scores on the items were dichotomized using a cut point to









determine which items the groups believe technicians should or should not perform.

Items scored one through three by subjects were considered "disagree" and items scored

four through six by subjects were considered "agree". Chi-square tests were then applied

to the dichotomized results. Since there were 26 tests performed a p-value of

0.05/26=.002 was necessary to show evidence that the null hypothesis (belief is not

dependent on group membership) should be rejected (Table 5-3). The results of the Chi-

Squared test on the dichotomized results from the two groups found that 16 (62%) of the

beliefs on the tasks that pharmacy technicians should perform in community practice

depend on whether or not the belief comes from pharmacists or from pharmacy

technicians.

For eight of those, while the difference in the groups' beliefs were statistically

significant, most of the pharmacists and most of the pharmacy technicians felt that the

tasks should be performed by a pharmacy technician. Those tasks were: (1) "Answer

simple patient questions about their medication (ex. Q: What is this medicine for? A:

This is for your blood pressure.)"; (2) "Go out of their way to assist a patient in obtaining

aid to pay for their prescriptions."; (3) "Determine when a prescription can be refilled.";

(4) "Include the appropriate information when labeling prescription vials." ;(5) "Evaluate

whether a computer generated DUR needs to be shown to the pharmacist."; (6) "Link the

trade name with the generic name of a drug."; (7) "Recognize the therapeutic class of a

prescribed medication."; and (8) "Assess which medication a patient wants to have

refilled when the patient does not know the name of the drug."

Of the other eight significantly different items most of the pharmacists felt that

pharmacy technicians should not perform the task, while for six of them most pharmacy










technicians felt that pharmacy technicians should perform the task. Those six tasks were:

(1) "Understand the difference between an ace-inhibitor and a beta-blocker."; (2)

Table 5-3. Dichotomized Means from the Pharmacist Group (n=315) and Pharmacy
Technician Group (n=448) on the Items of The Community Pharmacy
Technician Use Questionnaire
Item Group No Yes Chi-Square
difference test


Enter data into the computer accurately.

Apply insurance rules when processing a
new claim
Obtain information from a patient needed
to fill a prescription.
Deal with patients in a caring manner

Assess when a patient needs to speak to a
pharmacist about their medication.
Understand the difference between an
ace-inhibitor and a beta-blocker.
Evaluate the reason for a denied claim.

Answer simple patient questions about
their medication (ex. Q: What is this
medicine for? A: This is for your blood
pressure.)
Transfer a patient's prescription.

Go out of their way to assist a patient in
obtaining aid to pay for their
prescriptions.
Identify the common side effects of a
beta-blocker.
Determine when a prescription can be
refilled.
Explain to a patient insurance claim that
had a problem
Accept called in prescriptions from
physician's offices.
Evaluate circumstances that suggest the
possibility of drug diversion and alerting
the pharmacist.
Include the appropriate information when
labeling prescription vials.
Be discrete with patients' health
information


Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist


Technician 78 371


x = 3.5
p = .06
x2 1.3
p =.25
x2= .23
p =.63
x2 .31
p =.58
x2 = 4.5
p =.04
x2= 145.5
p < .001
x2= .50
p =.48
x2= 46.4
p < .001


x2 = 42.8
p < .001
x2 = 24.7
p < .001

x2 = 104.4
p < .001
x2 20.1
p < .001
x2 = 4.3
p =.04
x2 =71.8
p < .001
x2 = 4.2
p =.04


Pharmacist
Technician
Pharmacist
Technician

Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician

Pharmacist
Technician
Technician
Technician


22.3
.001
2.3
.13









Table 5-3. Continued
Item

Evaluate whether a computer generated
DUR needs to be shown to the
pharmacist.
Assess a patient's actual medication use.

Link the trade name with the generic
name of a drug.
Evaluate a patient's medication therapy.

Educate a patient on the appropriate use
of their medication.
Recognize the therapeutic class of a
prescribed medication.
Assume personal responsibility to resolve
a patient's drug therapy problems.
Assess which medication a patient wants
to have refilled when the patient does not
know the name of the drug.
Call physicians for refill authorization.


Group

Pharmacist
Technician

Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist
Technician
Pharmacist


Chi-Square
difference test
x2 = 54.5
p < .001

x2 14.4
p < .001
x2= 17.7
p < .001
x2 = 55.3
p < .001
x2 = 37.5
p < .001
x2 = 17.4
p < .001
x2 =27.1
p <.001
x2 = 32.8
p < .001

x2 = 0.51


Technician 30 419 p = .47

"Transfer a patient's prescription."; (3) "Identify the common side effects of a beta-

blocker."; (4) "Accept called in prescriptions from physician's offices."; (5) "Assess a

patient's actual medication use."; and (6) "Educate a patient on the appropriate use of

their medication." The two items for which there was a statistically significant difference

of beliefs between the groups and on average both groups felt that pharmacy technicians

should not perform the task were (1) "Evaluate a patient's medication therapy."; and (2)

"Assume personal responsibility to resolve a patient's drug therapy problems."

Confirmatory Factor Analysis

The second research question was evaluated using confirmatory factor analysis.

That question was: "Does the Framework of Expert Practice for Pharmacy fit

pharmacists' and pharmacy technicians' beliefs on the tasks that pharmacy technicians

should perform in community practice?".









The variables were tested to see if they loaded on the same four factors in both

samples. The pharmacist's data inadequately fit the model (SRMR=0.19), as did the

technician's data (SRMR=0.14). The goodness of fit statistics for both groups measured

simultaneously were generally consistent with the SRMR statistics of the individual

groups. The other fit indexes suggested inadequate fit. The P-value for the test of close

fit (RMSEA <0.01) was significant, indicating that the data significantly differ from the

target model. This suggests that we should reject the hypothesis that the variables loaded

on the same targeted factors in both samples. The Non-Normed Fit Index (NNFI or TLI

=0.59) and the Comparative Fit Index (CFI =0.61) indicated that simultaneously

modeling the two groups does not have adequate fit. This suggests that the data do not fit

the targeted four factors for both groups. The goodness of fit Minimum Fit Function Chi-

Square test for this model was 2 = 6690.68 (df =622) p<0.01. This test measures the

goodness of fit statistics for both groups simultaneously. The Chi-Square test was

significant. This suggests that the model does not fit. The contribution to the Chi-Square

for the pharmacist group was 1550.30 (23.17%), and for the technician group was

5140.38 (76.83%).

Confirmatory factor analyses were also performed using all of the data available

for the two groups. The P-value for the test of close fit (RMSEA <0.01) was significant

for pharmacist target model (n=344). The Non-Normed Fit Index (NNFI or TLI =0.55)

and the Comparative Fit Index (CFI =0.55) indicated that fit was about halfway between

the pharmacist target model and the null or saturated model. The goodness of fit

Minimum Fit Function Chi-Square test for the pharmacist target model was x = 1740.13

(df=293) p<0.01. The P-value for the test of close fit (RMSEA <0.01) was significant









for pharmacy technician target model (n=495). The Non-Normed Fit Index (NNFI or

TLI =0.59) and the Comparative Fit Index (CFI =0.63) indicated that fit was about

halfway between the pharmacy technician target model and the null or saturated model.

The goodness of fit Minimum Fit Function Chi-Square test for the pharmacy technician

target model was x2 = 1479.54 (df =269) p<0.01.

Exploratory Factor Analysis

Since the first step of the confirmatory factor analysis found that the two groups'

factor configurations vary from the proposed four factor model, exploratory factor

analysis was performed to see how many factors the model that fits the data has.

Pharmacist data

The correlation matrix was used to run the exploratory factor analysis on the

pharmacist data. The analysis found that the number of eigenvalues over one was six,

explaining 60% of the variability in the data (Table 5-4). The scree plot representation of

the eigenvalues was less clear. It suggested three to six factors might be extracted from

the data, with four or five factors appearing to be most probable. The approximate Chi-

square was significant (X2=3218.23, df=325, p<.001).

Table 5-4. Eigenvalues for Factors Extracted from the Pharmacist Data
Factor Initial Eigenvalues Rotation Sums of Squared
Loadings
Total % of Variance Cumulative % Total
1 7.038 27.07 27.07 5.115
2 3.722 14.32 41.39 4.634
3 1.434 5.52 46.90 4.213
4 1.330 5.12 52.02 2.890
5 1.062 4.09 56.10 3.647
6 1.005 3.87 59.97 1.009
7 .880 3.38 63.35
8 .815 3.14 66.49
9 .791 3.04 69.53
10 .743 2.86 72.39










Table 5-4. Continued
Initial Eigenvalues Rotation Sums of Squared
Factor Loadings
Total % of Variance Cumulative % Total
11 .694 2.67 75.06
12 .666 2.56 77.62
13 .597 2.30 79.91
14 .589 2.27 82.18
15 .563 2.17 84.35
16 .530 2.04 86.38
17 .493 2.00 88.28
18 .457 1.76 90.04
19 .418 1.61 91.65
20 .401 1.54 93.19
21 .364 1.40 94.59
22 .338 1.30 95.89
23 .306 1.18 97.07
24 .295 1.13 98.20
25 .256 .99 99.19
26 .212 .81 100.00
Extraction Method: Principal Axis Factoring
When factors are correlated, sums of squared loadings cannot be added to obtain a total
variance.


Scree Plot











2 0
*111 __ __ __ _


Factor Number


Figure 5-1. Scree Plot of the Eigenvalues for the Factors Extracted from Pharmacist Data










Pharmacist Model Development

Six-factor pharmacist model

The six-factor model was extracted in 22 iterations. The rotated solution converged

in eight rotations. The six-factor model had one factor that had only one item load on it

in the pattern matrix (Table 5-5). That item was :"Go out of their way to assist a patient

in obtaining aid to pay for their prescription." The Pattern matrix suggested that the item

"Assess when a patient needs to speak to a pharmacist about their medication." might

also load on that sixth factor. Some items' did not clearly load on only one factor. The

factors seemed to represent: (1) clinical pharmacy knowledge tasks, (2) tasks, functions

and virtues typical of pharmacy technicians in current practice, (3) taking transfers, new

prescriptions, and refill authorizations over the phone, (4) patient or therapy assessment,

(5) unclear meaning, and (6) one item or unclear meaning.

Table 5-5. Pattern Matrix for 6-Factor Model from the Pharmacist Data
Factor
Clinical Tasks, functions Unclear Taking Patient or One item
pharmacy and virtues typical meaning transfers, new therapy
knowledge of pharmacy prescriptions, assessment
tasks technicians in and refill
current practice authorizations
over the phone
Enter data into the computer .775
accurately.
Apply insurance rules when .850
processing a new claim.
Obtain information from a patient .741
needed to fill a prescription.
Deal with patients in a caring .565
manner.
Assess when a patient needs to
speak to a pharmacist about their -.392
medication.
Understand the difference between
an ace-inhibitor and a beta- .641
blocker.
Evaluate the reason for a denied .660
claim.
Answer simple patient questions
about their medication (ex. Q:
What is this medicine for? A: This
is for your blood pressure.)











Table 5-5. Continued


Clinical
pharmacy
knowledge
tasks


Transfer a patient's prescription.
Go out of their way to assist a
patient in obtaining aid to pay for
their prescriptions.
Identify the common side effects
of a beta-blocker.
Determine when a prescription can
be refilled.
Explain to a patient an insurance
claim that had a problem.
Accept called in prescriptions
from physicians' offices.
Evaluate circumstances that
suggest the possibility of drug
diversion and alerting the
pharmacist.
Include the appropriate
information when labeling
prescription vials.
Be discreet with patient health
information.
Evaluate whether a computer
generated DUR needs to be shown
to the pharmacist.
Assess a patient's actual
medication use.
Link the trade name with the
generic name of a drug.
Evaluate a patient's medication
therapy.
Educate a patient on the
appropriate use of their
medication.
Recognize the therapeutic class of
a prescribed medication.
Assume personal responsibility to
resolve a patient's drug therapy
problems.
Assess which medication a patient
wants to have refilled when the
patient does not know the name of
the drug.
Call physicians for refill
authorization.


Tasks, functions
and virtues typical
of pharmacy
technicians in
current practice


Factor
Unclear Taking
meaning transfers, new
prescriptions,
and refill
authorizations
over the phone
.851


Patient or One item
therapy
assessment


.716


.250 .241

.718


.594


.574



.606


.509


.582


.403


.615


.811


.612


.465


.866


.544


.329 .318


.329


.318











Five-factor pharmacist model

The five-factor model was extracted in 25 iterations. The rotated solution

converged in seven. The five-factor model had one factor on which two seemingly

unrelated items loaded in the pattern matrix (Table 5-6). Those items were: "Go out of

their way to assist a patient in obtaining aid to pay for their prescription."; and "Assess

when a patient needs to speak to a pharmacist about their medication." Some items' did

not clearly load on only one factor. The factors seemed to represent: (1) clinical

pharmacy knowledge tasks, (2) tasks and functions typical of pharmacy technicians in

current practice, (3) taking transfers, new prescriptions, and refill authorizations over the

phone, (4) pharmacy practice judgment, and (5) unclear meaning.

Table 5-6. Pattern Matrix for 5-Factor Model from the Pharmacist Data
Factor
Clinical Tasks and functions Pharmacy Taking transfers, new Unclear
pharmacy typical of pharmacy practice prescriptions, and meaning
knowledge technicians in current judgment refill authorizations
tasks practice over the phone
Enter data into the computer .700
accurately.
Apply insurance rules when processing .876
a new claim.
Obtain information from a patient .704
needed to fill a prescription.
Deal with patients in a caring manner. .523
Assess when a patient needs to speak -.400
to a pharmacist about their medication.
Understand the difference between an .662
ace-inhibitor and a beta-blocker.
Evaluate the reason for a denied claim. .724
Answer simple patient questions about
their medication (ex. Q: What is this 515
medicine for? A: This is for your blood
pressure.)
Transfer a patient's prescription. .861
Go out of their way to assist a patient
in obtaining aid to pay for their .322
prescriptions.
Identify the common side effects of a .790
beta-blocker.
Determine when a prescription can be .272 .256
refilled.







79


Table 5-6. Continued
Factor
Clinical Tasks and functions Pharmacy Taking transfers, new Unclear
pharmacy typical of pharmacy practice prescriptions, and meaning
knowledge technicians in current judgment refill authorizations
tasks practice over the phone
Explain to a patient an insurance claim .808
that had a problem.
Accept called in prescriptions from .553
physicians' offices.
Evaluate circumstances that suggest
the possibility of drug diversion and .597
alerting the pharmacist.
Include the appropriate information 630
when labeling prescription vials.
Be discreet with patient health .513
information.
Evaluate whether a computer generated
DUR needs to be shown to the .538
pharmacist.
Assess a patient's actual medication
use.
Link the trade name with the generic .639
name of a drug.
Evaluate a patient's medication 829
therapy.
Educate a patient on the appropriate .741
use of their medication.
Recognize the therapeutic class of a 401 399
prescribed medication.
Assume personal responsibility to
resolve a patient's drug therapy .759
problems.
Assess which medication a patient
wants to have refilled when the patient .422
does not know the name of the drug.
Call physicians for refill authorization. .394 .322


Four-factor pharmacist model

The four-factor model was extracted in 11 iterations. The rotated solution

converged in 13. The four-factor model seemed to have logical loadings in the pattern

matrix (Table 5-7). The factors seemed to represent: (1) clinical pharmacy knowledge

tasks, (2) tasks and functions typical of pharmacy technicians in current practice, (3)

pharmacy information evaluation and management skills, and (4) pharmacist only task as


specified by law.







80


Table 5-7. Pattern Matrix for 4-Factor Model from the Pharmacist Data
Factor
Clinical pharmacy Tasks and functions typical Pharmacy Pharmacist only
knowledge tasks of pharmacy technicians in information tasks as specified
current practice evaluation by law
and
management
skills
Enter data into the computer .740
accurately.
Apply insurance rules when processing .816
a new claim.
Obtain information from a patient .704
needed to fill a prescription.
Deal with patients in a caring manner. .606
Assess when a patient needs to speak .473
to a pharmacist about their medication.
Understand the difference between an .425
ace-inhibitor and a beta-blocker.
Evaluate the reason for a denied claim. .655
Answer simple patient questions about
their medication (ex. Q: What is this
medicine for? A: This is for your blood
pressure.)
Transfer a patient's prescription. .637
Go out of their way to assist a patient
in obtaining aid to pay for their .316
prescriptions.
Identify the common side effects of a .560
beta-blocker.
Determine when a prescription can be .379
refilled.
Explain to a patient an insurance claim .740
that had a problem.
Accept called in prescriptions from .491
physicians' offices.
Evaluate circumstances that suggest
the possibility of drug diversion and .396
alerting the pharmacist.
Include the appropriate information .388
when labeling prescription vials.
Be discreet with patient health .403
information.
Evaluate whether a computer generated
DUR needs to be shown to the .642
pharmacist.
Assess a patient's actual medication .548
use.
Link the trade name with the generic .457
name of a drug.
Evaluate a patient's medication .801
therapy.
Educate a patient on the appropriate .736
use of their medication.
Recognize the therapeutic class of a 664
prescribed medication.










Table 5-7. Continued
Factor
Clinical pharmacy Tasks and functions typical Pharmacy Pharmacist only
knowledge tasks of pharmacy technicians in information tasks as specified
current practice evaluation by law
and
management
skills
Assume personal responsibility to
resolve a patient's drug therapy .642
problems.
Assess which medication a patient
wants to have refilled when the patient .542
does not know the name of the drug.
Call physicians for refill authorization. .440

Pharmacist Model Selection

The four-factor technician model was selected as the best model of the data based

on interpretation. Since the six-factor pharmacist model had a factor on which only one

item loaded it was eliminated from the choices. The five-factor model had one factor on

which two seemingly unrelated items loaded making interpretation of the factor unclear.

The four-factor model had no such problems. In conclusion, the four-factor model was

selected as the most logical structuring of the items based on the loadings from the

exploratory factor analysis, the scree plot of eignevalues and theoretical interpretation of

the data.

Pharmacy Technician Data

The correlation matrix was used to run the exploratory factor analysis on the

technician data. The number of eigenvalues over one was five, explaining 59% of the

variability in the data (Table 5-8). The scree plot representation of the eigenvalues was

less clear. It suggested three or four factors might be extracted from the data. Figure 5-2.

The approximate Chi-square was significant (X2=5529.98, df=325, p<.001).









Table 5-8. Eigenvalues for Factors Extracted from the Technician Data
Factor Initial Eigenvalues Rotation
Sums of
Squared
Loadings
Total % of Variance Cumulative % Total
1 8.069 31.04 31.04 5.981
2 3.734 14.36 45.40 5.196
3 1.381 5.31 50.71 3.978
4 1.166 4.49 55.20 5.242
5 1.062 4.09 59.28 2.839
6 .992 3.81 63.09
7 .890 3.42 66.52
8 .808 3.11 69.63
9 .795 3.06 72.68
10 .655 2.52 75.20
11 .645 2.48 77.68
12 .629 2.42 80.10
13 .553 2.13 82.23
14 .539 2.08 84.30
15 .506 1.95 86.25
16 .467 1.80 88.05
17 .427 1.64 89.69
18 .418 1.61 91.30
19 .368 1.42 92.71
20 .345 1.33 94.04
21 .322 1.24 95.28
22 .307 1.18 96.46
23 .270 1.04 97.49
24 .239 .92 98.41
25 .225 .87 99.28
26 .188 .72 100.00
Extraction Method: Principal Axis Factoring
When factors are correlated, sums of squared loadings cannot be added to obtain a total
variance.











Scree Plot
10


81


6,


4.

D 2

TO 0
1 3 5 7 9 11 13 15 17 19 21 23 25

Factor Number


Figure 5-2. Scree Plot of the Eigenvalues for the Factors Extracted from Technician Data

Pharmacy Technician Model Development

Five-factor technician model

The five-factor model was extracted in 16 iterations. The rotated solution

converged in eight rotations. The five-factor model had one factor on which two

seemingly unrelated items loaded in the pattern matrix (Table 5-9). Those items were:

"Go out of their way to assist a patient in obtaining aid to pay for their prescription."; and

"Assess when a patient needs to speak to a pharmacist about their medication." Some

items' did not clearly load on only one factor. The five-factor model also had a factor

that was difficult to lable. That factor seemed to deal with prescription data management,

but it included items that are different such as "Deal with patients in a caring manner."

The factors seemed to represent: (1) prescription data management or unclear meaning,

(2) clinical pharmacy knowledge tasks, (3) general drug knowledge, (4) prescription

processing, and (5) pharmacist only tasks as specified by law.










Table 5-9. Pattern Matrix for 5-Factor Model from the Technician Data
Factor
Prescription Clinical General drug Prescription Pharmacist
data pharmacy knowledge processing only tasks
management knowledge tasks as specified
by law
Enter data into the computer .953
accurately.
Apply insurance rules when processing .534
a new claim.
Obtain information from a patient .733
needed to fill a prescription.
Deal with patients in a caring manner. .734
Assess when a patient needs to speak .321
to a pharmacist about their medication.
Understand the difference between an .789
ace-inhibitor and a beta-blocker.
Evaluate the reason for a denied claim. .647
Answer simple patient questions about
their medication (ex. Q: What is this
medicine for? A: This is for your blood
pressure.)
Transfer a patient's prescription. .796
Go out of their way to assist a patient
in obtaining aid to pay for their .234 .242
prescriptions.
Identify the common side effects of a .833
beta-blocker.
Determine when a prescription can be .624
refilled. .
Explain to a patient an insurance claim .680
that had a problem.
Accept called in prescriptions from .736
physicians' offices.
Evaluate circumstances that suggest
the possibility of drug diversion and .413
alerting the pharmacist.
Include the appropriate information 595
when labeling prescription vials.
Be discreet with patient health .843
information.
Evaluate whether a computer generated
DUR needs to be shown to the .512
pharmacist.
Assess a patient's actual medication .732
use.
Link the trade name with the generic .420
name of a drug.
Evaluate a patient's medication
therapy.
Educate a patient on the appropriate .696
use of their medication.
Recognize the therapeutic class of a 444
prescribed medication.










Table 5-9. Continued
Factor
Prescription Clinical General drug Prescription Pharmacist
data pharmacy knowledge processing only tasks
management knowledge tasks as specified
by law
Assume personal responsibility to
resolve a patient's drug therapy .720
problems.
Assess which medication a patient
wants to have refilled when the patient .418
does not know the name of the drug.
Call physicians for refill authorization. .390


Four-factor technician model

The four-factor model was extracted in 28 iterations. The rotated solution

converged in eight. The four-factor model seemed to have logical loadings in the pattern

matrix (Table 5-10). Some items' did not clearly load on only one factor. Two items had

low (below .3) loadings. The factors seemed to represent: (1) tasks and functions typical

of pharmacy technicians in current practice, (2) clinical pharmacy knowledge tasks, (3)

general drug knowledge, and (4) pharmacist only tasks as specified by law.

Table 5-10. Pattern Matrix for 4-Factor Model from the Technician Data
Factor
Tasks and functions Clinical pharmacy General drug Pharmacist only tasks as
typical of pharmacy knowledge tasks knowledge specified by law
technicians in current
practice
Enter data into the computer .880
accurately.
Apply insurance rules when .712
processing a new claim.
Obtain information from a patient .837
needed to fill a prescription.
Understand the difference between
an ace-inhibitor and a beta- .766
blocker.
Evaluate the reason for a denied .694
claim.
Answer simple patient questions
about their medication (ex. Q: .264
What is this medicine for? A: This
is for your blood pressure.)
Transfer a patient's prescription. .854
Go out of their way to assist a
patient in obtaining aid to pay for .256
their prescriptions.







86


Table 5-10. Continued
Factor
Tasks and functions Clinical pharmacy General drug Pharmacist only tasks as
typical of pharmacy knowledge tasks knowledge specified by law
technicians in current
practice
Deal with patients in a caring .711
manner.
Assess when a patient needs to
speak to a pharmacist about their .341
medication.
Identify the common side effects .780
of a beta-blocker.
Determine when a prescription can .571
be refilled.
Explain to a patient an insurance .750
claim that had a problem.
Accept called in prescriptions .660
from physicians' offices.
Evaluate circumstances that
suggest the possibility of drug .368
diversion and alerting the
pharmacist.
Include the appropriate
information when labeling .591
prescription vials.
Be discreet with patient health .738
information.
Evaluate whether a computer
generated DUR needs to be shown .511
to the pharmacist.
Assess a patient's actual .731
medication use.
Link the trade name with the .485
generic name of a drug.
Evaluate a patient's medication .828
therapy.
Educate a patient on the
appropriate use of their .696
medication.
Recognize the therapeutic class of 433
a prescribed medication.
Assume personal responsibility to
resolve a patient's drug therapy .744
problems.
Assess which medication a patient
wants to have refilled when the
patient does not know the name of
the drug.
Call physicians for refill .538
authorization.