COVID-19 has changed almost everything in pharmacy practice. Pharmacists are providing the patient care services they have been trained for, but inadequate staff and far-from-ideal working conditions have brought many to a breaking point during the pandemic. “It’s a multi-factorial problem that requires all parties to realign around a mindset of health care and not commoditized product distribution,” said Christian Tadrus, PharmD, owner of Sam’s Health Mart Pharmacies in Moberly, MO. A nationwide pulse survey of pharmacists conducted by APhA found that 40% of survey respondents felt they do not have adequate support staff to safely offer COVID-19 vaccines. Over one in four survey respondents (27%) reported that their practice has closed or decreased operating hours due to staffing shortages. The top factors affecting the ability to safely administer COVID-19 vaccines include high patient demand (18%) and staffing shortages (17%). Although 22% of survey respondents indicated workload exhaustion prior to the pandemic, that number skyrocketed to 78% of respondents citing workload exhaustion during the pandemic. Pharmacists in all settings are stressed and stretched while remaining focused on protecting their patients and communities from COVID-19. “The message isn’t that pharmacists can’t do more,” said Lemrey “Al” Carter, MS, PharmD, RPh, executive director of the National Association of Boards of Pharmacy (NABP). “We need to use pharmacists in this greater way, but [they need to] have adequate support staff and better working conditions.” As the primary access point for COVID-19 boosters and COVID-19 tests in their communities over the past several months, pharmacies are at capacity for what they can reasonably and safely provide. In the retail community pharmacy setting, pharmacists and pharmacy technicians have left their jobs at an alarming rate. Pharmacies, especially those in rural and underserved areas, have had to close because of inadequate staffing. Some stores adjusted operating hours, such as closing on weekends, out of necessity. According to the most recent analysis from the White House, pharmacies have administered about two-thirds of all COVID-19 vaccines nationally. The National Association of Chain Drug Stores said that roughly two out of three COVID-19 vaccine shots occur at the pharmacy. An October 2021 poll from Morning Consult, a global privately held data intelligence company, found that nearly one in five health care workers (18%) have quit their jobs since February 2020. In the poll, 79% of health care personnel said shortages have affected them and their workplace. According to a November 2021 survey from the National Community Pharmacists Association, 70% of independent pharmacies are struggling to fill staff positions. Chris Schiller, PharmD, CEO of Economy Pharmacy, Inc. in Muskogee, OK, said multiple chain pharmacies have closed near them. Some patients’ prescriptions were trapped at these locations as well—he said one patient came to them needing insulin after the chain pharmacy they normally go to shut down for several days, but Schiller struggled to order this $500 drug for the patient a second time because of insurance restrictions. APhA stated that pharmacy burnout is a significant patient safety issue because it means patients experience delayed prescription fulfillment, unacceptable waits for vaccines and testing, and potential errors due to high volume, long hours, and pressure to meet performance metrics. Carter said burnout is a priority for them at NABP because it affects patient safety. “With our mission to protect public health, it’s a growing concern with the board of pharmacy over the last two or three years or so,” Carter said. State and national pharmacy organizations know that time is of the essence to come up with solutions to this pressing issue. NABP’s Task Force on Workplace Safety and Well-Being has begun looking at changing regulation to reduce burdens on pharmacy staff, as well as working with industry partners to find tools available to improve workplace conditions and mental health. The Wisconsin Department of Health Services awarded a grant to the Pharmacy Society of Wisconsin to provide mental health services to pharmacy professionals.“Burnout and mental health [are] critical concern[s] for state pharmacy associations,” said Sarah Sorum, PharmD, executive vice president and CEO of the Pharmacy Society of Wisconsin. “As state health departments consider the support of health care providers, it is important pharmacists and technicians are considered in the group included in support services.” Carter said it’s also become clear from the NABP’s Task Force on Workplace Safety and Well-Being meetings that more open dialogue on this issue needs to take place. “Pharmacists have the right to protect public safety and they need to have ownership of that,” Carter said. Pharmacists have whistleblower protections, he noted, and some states like Oklahoma have tools in place with which pharmacists can make anonymous complaints. In October 2021, APhA and National Alliance of State Pharmacy Associations (NASPA) launched the Pharmacy Workplace and Well-being Reporting (PWWR) portal, a confidential and anonymous way pharmacy personnel can report positive and negative experiences in pharmacy practice as well as suggested solutions (see sidebar). The Indiana Academy of Community Pharmacists (IACP) within the Indiana Pharmacist Association is launching focus groups for pharmacists and technicians all across the state. Participation is anonymous to allow a safe place for open discussion. “If the data are there and policies are needed, how do we leverage the influence—state and national—to improve pharmacy practice?,” said Stephanie J. Arnett, PharmD, from Purdue University College of Pharmacy. “It’s up to all of us working together,” said Carter. “That was loud and clear from our taskforce.” On the state level, boards are starting to put an emphasis on workplace conditions. A 2021 Ohio Board of Pharmacy survey led to the formation of the Pharmacist Workload Advisory Committee. The Virginia Board of Pharmacy also held a work group meeting on workplace conditions, and other states are following suit. “We are providing actionable solutions to the board so that they maybe can provide legislation [concerning] this,” said Jason Opritza, RPh, an advisory member on Ohio’s Workload Advisory Committee. “Pharmacists feel unsafe all day long,” said Opritza. Yelling and harassment has only increased during the pandemic. “From a safety standpoint, every hour the pharmacy is open, a pharmacy technician needs to be there with the pharmacists—at a minimum,” said Opritza. While some community pharmacies have had to limit store hours recently because of staff shortages, Opritza said this shouldn’t be something done out of necessity. “Physicians’ offices have limited hours,” he said. “Dark hours” could be another option where pharmacists can catch up on work while the pharmacy is still closed to the public. “Independent pharmacies can do this more easily,” noted Opritza. In Indiana, some community pharmacies have already transitioned to required closures for lunch, and others are starting that transition now without policy requirements. Arnett and other members of IACP said they continue to support telepharmacy and technology advancement such as central fill services that free up local pharmacists to take care of more urgent needs in the pharmacy. Schiller, who is also president of the Oklahoma Pharmacists Association, said they are working to address pharmacist burnout in Oklahoma. For instance, the Oklahoma Board of Pharmacy put out a form through which inadequate staffing can be reported. “Everyone is tired and exhausted,” said Arnett. “But if we don’t address this, who will? If we don’t address burnout, we will continue to see a shortage of pharmacists and technicians.” In October 2020, HHS granted pharmacy technicians in every state the authority to administer vaccines to individuals ages 3 years and older under the supervision of a pharmacist and with certain requirements met, such as completion of a training program approved by the Accreditation Council for Pharmacy Education. The guidance was issued under the PREP Act for the COVID-19 public health emergency in the United States. “Just like everyone else, it’s increased workloads for techs—no staff [increase], and information changing by the minute,” said Angela Faszczewski, CPhT-Adv, from Ehardt’s Pharmacy and Medical Supply in Croswell, MI. “Every day it’s something new and it’s stressful.” In addition to the pressures in pharmacy brought on by the pandemic, Faszczewski noted that pharmacy technicians are also affected by stresses at home such as childcare issues when schools have to close. There is also the added fear of being exposed to COVID-19 at work and bringing it home. “From what we’ve gathered, what pharmacy technicians are feeling is not dissimilar from [what’s felt by] other health care providers, especially pharmacists on the community side,” said Bill Schimmel, executive director and CEO of the Pharmacy Technician Certification Board (PTCB). “Pharmacists and pharmacy technicians work so closely together; they are a team that’s been brought closer together as they work through new challenges. These new services they are both involved in were already increasing before the pandemic, and when you layer in testing and vaccines for COVID, the workload obviously increases and takes stress to another level.” A shortage of pharmacy technicians has not only affected community pharmacy, but also hospital pharmacy. “We have a big shortage of pharmacy technicians,” said Brenda Denson, PharmD, BCPPS, FASHP, a pharmacy educator at Children’s of Alabama in Birmingham. “In addition to the pandemic-related issues in pharmacy in general, the technician issue has been really challenging. We’ve seen some other entities like insurance companies offering technicians more money and perks like working from home.” Denson goes out of her way to tell pharmacy technicians at her hospital “thank you.” “I’ve gone around taking Starbucks orders and telling technicians ‘thank you’ and what a great job they are doing,” she said. In Alabama, there’s now a permanent rule for pharmacy technicians’ expanded authority to vaccinate. “I think the partnership between technicians and pharmacists in the trenches has always been strong, and [the pandemic] has only solidified it at the ground level,” said Faszczewski. But low wages and lack of advancement opportunities are two big areas of discontentment for technicians, according to Faszczewski. “We lose high-quality technicians to other opportunities like nursing. They see wage opportunities and advancement in other areas,” said Faszczewski. Schimmel said that while there are some pharmacy technicians who choose to pursue other areas even during the pandemic, data showed that PTCB-certified technicians were renewing their credentials at a high rate, with numbers similar to what they’ve seen prior to COVID-19. “Despite the added challenges of COVID, our certified technicians continue to be committed to their roles and dedicated to renewing their credentials so they can keep up with best practices regarding patient safety,” said Schimmel. “There’s a misconception that being a technician is a stop-over, but technicians like working with patients and most want to keep doing it. This is one of the primary reasons we’re constantly working to address the evolving needs of the industry so technicians have more opportunities to advance their careers.” “Our health care culture is to take care of others first,” said Arnett. “We can’t help others if we don’t care for ourselves.” There are so many contributing factors to the issue of burnout experienced by pharmacists and pharmacy personnel right now, noted Nancy Alvarez, PharmD, BCPS, FAPhA, associate professor of pharmacy practice and science and associate dean of academic and professional affairs at the University of Arizona R. Ken Coit College of Pharmacy. “While it’s not only on the individual to solve for what is experienced in pharmacies and other workplaces, we are the aspect we can control,” said Alvarez, editor and co-author of a new book from APhA called Bypass Pharmacy Burnout: Changing Your Trajectory to Enhance Your Experience. Alvarez said that while the book is certainly not a “holy grail” for pharmacists and pharmacy personnel burnout, it does raise awareness about burnout as a real issue, release some of the stigma associated with it, and offers pharmacists and other pharmacy staff advice and techniques to mitigate the development of burnout. The authors write on topics ranging from physical and mental wellness practices to developing leader skills and deepening professional engagement to building community and focusing on “bigger-picture” goals. “Addressing burnout doesn’t mean being disengaged,” said Alvarez. “Building community can be helpful, as well as being connected and engaged in professional and personal endeavors.” Policy changes take time but deepening connections to peers and colleagues is something that is accessible right now for pharmacists and pharmacy staff. New findings support need to reform pharmacy workplace conditionsAPhA and NASPA recently released findings from the 2022 National Pharmacy Workplace Survey and Pharmacy Workforce and Well-being Reporting (PWWR). These surveys examine workplace conditions that increase the risk of medication errors and allow pharmacy personnel to discuss workplace concerns without fear of retribution.The findings from the 2022 National Pharmacy Workplace Survey will surprise no one, as they echo the feelings of intense frustration that pharmacy personnel recognize.Issues identified by the survey include ▪Increased demands, harassment, and bullying by patients/consumers▪Concern due to insufficient and ill-trained staff▪Employer focus upon production results▪Constant interruptions or calls to insurance companies that disrupt the ability to evaluate appropriateness of treatments▪Addition of services with inadequate support for these servicesIt would be prudent for pharmacy managers and directors to heed these concerns, although meaningful policy and reform is needed to address the toxicity of the current pharmacy workplace.It is evident that the current working conditions are unsustainable and will lead to burnout and medication errors.“Support of pharmacy team members and pharmacies is needed—especially now as the pandemic continues—from employers, insurers, lawmakers, and the public to ensure adequate resource availability, address patient safety issues, and reduce stress and increase satisfaction of pharmacy personnel both now and in the future,” said Scott J. Knoer, MS, PharmD, FASHP, APhA executive vice president and CEO.“Organizations need to immediately review their policies and procedures dealing with these situations, articulate support of their team members, and provide guidance to and training for pharmacy personnel and nonpharmacy management,” said Rebecca Snead, RPh, executive vice president and CEO of NASPA.Key findings from the first PWWR, which has collected over 400 reports from 43 states since October 2021, echo the results of the 2022 workplace survey.First, lines of communication are perceived to be unilateral. Among the 70% of respondents who discussed recommendations with a supervisor, the majority said that recommendations were not considered, applied, or valued.Second, harassment of pharmacy personnel by patients is much too common and ranges from verbal threats to physical harm and/or sexual harassment.“Workplace issues across pharmacy practice and their relationship to personal well-being and patient safety continue to be a critical, complex issue,” said Knoer. “The more than 400 deidentified reports submitted since the October 2021 launch of PWWR tell a collective, powerful story that we hope will spark change and improvement in the pharmacy workplace.”He said that this first report identifies that those who submitted positive experiences indicated that those experiences would have a long-term positive effect on their well-being. The negative experiences submitted make a call for needed attention and provided a path for dialogue, change, and improvements.“Pharmacists have asked for a safe space to talk about what workplace issues that they are experiencing and to learn about solutions colleagues have instituted to make real changes in their pharmacy practice in order to better take care of their patients,” said Snead. “PWWR is that safe place that gives voice and amplification to pharmacy personnel concerns and suggested solutions while mitigating the fear of reporting.”This first PWWR trends and findings report is a call to action to model the positive experiences across pharmacy practice and take steps to address concerns such as harassment of pharmacy staff in the workplace, said Snead. APhA and NASPA recently released findings from the 2022 National Pharmacy Workplace Survey and Pharmacy Workforce and Well-being Reporting (PWWR). These surveys examine workplace conditions that increase the risk of medication errors and allow pharmacy personnel to discuss workplace concerns without fear of retribution. The findings from the 2022 National Pharmacy Workplace Survey will surprise no one, as they echo the feelings of intense frustration that pharmacy personnel recognize. Issues identified by the survey include ▪Increased demands, harassment, and bullying by patients/consumers▪Concern due to insufficient and ill-trained staff▪Employer focus upon production results▪Constant interruptions or calls to insurance companies that disrupt the ability to evaluate appropriateness of treatments▪Addition of services with inadequate support for these services It would be prudent for pharmacy managers and directors to heed these concerns, although meaningful policy and reform is needed to address the toxicity of the current pharmacy workplace. It is evident that the current working conditions are unsustainable and will lead to burnout and medication errors. “Support of pharmacy team members and pharmacies is needed—especially now as the pandemic continues—from employers, insurers, lawmakers, and the public to ensure adequate resource availability, address patient safety issues, and reduce stress and increase satisfaction of pharmacy personnel both now and in the future,” said Scott J. Knoer, MS, PharmD, FASHP, APhA executive vice president and CEO. “Organizations need to immediately review their policies and procedures dealing with these situations, articulate support of their team members, and provide guidance to and training for pharmacy personnel and nonpharmacy management,” said Rebecca Snead, RPh, executive vice president and CEO of NASPA. Key findings from the first PWWR, which has collected over 400 reports from 43 states since October 2021, echo the results of the 2022 workplace survey. First, lines of communication are perceived to be unilateral. Among the 70% of respondents who discussed recommendations with a supervisor, the majority said that recommendations were not considered, applied, or valued. Second, harassment of pharmacy personnel by patients is much too common and ranges from verbal threats to physical harm and/or sexual harassment. “Workplace issues across pharmacy practice and their relationship to personal well-being and patient safety continue to be a critical, complex issue,” said Knoer. “The more than 400 deidentified reports submitted since the October 2021 launch of PWWR tell a collective, powerful story that we hope will spark change and improvement in the pharmacy workplace.” He said that this first report identifies that those who submitted positive experiences indicated that those experiences would have a long-term positive effect on their well-being. The negative experiences submitted make a call for needed attention and provided a path for dialogue, change, and improvements. “Pharmacists have asked for a safe space to talk about what workplace issues that they are experiencing and to learn about solutions colleagues have instituted to make real changes in their pharmacy practice in order to better take care of their patients,” said Snead. “PWWR is that safe place that gives voice and amplification to pharmacy personnel concerns and suggested solutions while mitigating the fear of reporting.” This first PWWR trends and findings report is a call to action to model the positive experiences across pharmacy practice and take steps to address concerns such as harassment of pharmacy staff in the workplace, said Snead. A model that was stretched to its limit prior to COVID-19: APhA Board of Trustees discusses the underlying issuesA significant contributing factor that causes understaffing and unrealistic performance metrics is a misaligned payment system that rewards volume and not value. Pharmacists and pharmacies are primarily reimbursed for dispensing a product, not for addressing the clinical needs of the patient. The payment system for pharmacy services is fundamentally flawed.PBM issuesPBMs are intermediaries who have siphoned tremendous profits from the prescription drug system, leaving pharmacies to depend upon unrealistically high transaction volumes with minimally viable staffing to stay in business. Pharmacy teams have been meeting a significant need within their communities during the pandemic through the provision of acute and chronic medications and associated services, including testing, vaccination, and treatments. These services are provided on top of a model that was stretched to its limit prior to COVID-19 due to the misaligned payment model.Provider statusPharmacists strive to optimize medication use and ensure that medications are taken correctly, but coverage is lacking for these clinical services. Pharmacists are health care professionals with training, experience, and knowledge as medication experts, and they provide clinical care related to those medications and the conditions they treat.Pharmacists are not able to bill Medicare for their clinical services because they are not recognized as eligible providers under the Social Security Act. Other health care professions—including physicians, nurse practitioners, physician assistants, audiologists, and nurse-midwives—are all eligible providers who can bill for their services.SolutionsShort- and long-term remediesFirst: Employers must immediately address working conditions. Signing bonuses and free pizza aren’t enough. Pharmacies must be staffed appropriately so that pharmacists and pharmacy technicians have dedicated time for the safe dispensing of medication, safe delivery of clinical services such as COVID-19 vaccine administration, and adequate time to talk with and counsel patients about their medications.Second: APhA is engaging in direct conversations with chain pharmacy leadership and other influencers to address the issues related to workload and well-being.Third: Boards of pharmacy must engage in conversation with pharmacy team members, pharmacy management, and organization executives to examine the following: ▪Staffing levels needed to safely provide care and sustain timely public access to needed medications and patient care▪Performance measures that jeopardize care delivery▪Use of technology▪Administrative policies and procedures that distract pharmacy teams from the delivery of patient careFourth: The underlying payment issues must be rectified. This includes reining in adverse PBM business practices and recognizing pharmacists as patient care providers in Medicare as well as Medicaid and private insurance plans. Until then, pharmacists will continue to run on fumes with high burnout and inadequate support.Visit apha.us/BoardStatement for the full statement. A significant contributing factor that causes understaffing and unrealistic performance metrics is a misaligned payment system that rewards volume and not value. Pharmacists and pharmacies are primarily reimbursed for dispensing a product, not for addressing the clinical needs of the patient. The payment system for pharmacy services is fundamentally flawed. PBMs are intermediaries who have siphoned tremendous profits from the prescription drug system, leaving pharmacies to depend upon unrealistically high transaction volumes with minimally viable staffing to stay in business. Pharmacy teams have been meeting a significant need within their communities during the pandemic through the provision of acute and chronic medications and associated services, including testing, vaccination, and treatments. These services are provided on top of a model that was stretched to its limit prior to COVID-19 due to the misaligned payment model. Pharmacists strive to optimize medication use and ensure that medications are taken correctly, but coverage is lacking for these clinical services. Pharmacists are health care professionals with training, experience, and knowledge as medication experts, and they provide clinical care related to those medications and the conditions they treat. Pharmacists are not able to bill Medicare for their clinical services because they are not recognized as eligible providers under the Social Security Act. Other health care professions—including physicians, nurse practitioners, physician assistants, audiologists, and nurse-midwives—are all eligible providers who can bill for their services. First: Employers must immediately address working conditions. Signing bonuses and free pizza aren’t enough. Pharmacies must be staffed appropriately so that pharmacists and pharmacy technicians have dedicated time for the safe dispensing of medication, safe delivery of clinical services such as COVID-19 vaccine administration, and adequate time to talk with and counsel patients about their medications. Second: APhA is engaging in direct conversations with chain pharmacy leadership and other influencers to address the issues related to workload and well-being. Third: Boards of pharmacy must engage in conversation with pharmacy team members, pharmacy management, and organization executives to examine the following: ▪Staffing levels needed to safely provide care and sustain timely public access to needed medications and patient care▪Performance measures that jeopardize care delivery▪Use of technology▪Administrative policies and procedures that distract pharmacy teams from the delivery of patient care Fourth: The underlying payment issues must be rectified. This includes reining in adverse PBM business practices and recognizing pharmacists as patient care providers in Medicare as well as Medicaid and private insurance plans. Until then, pharmacists will continue to run on fumes with high burnout and inadequate support. Visit apha.us/BoardStatement for the full statement.