Pharmacist Attitudes on Technician Responsibilities

Text of Research report by Jim Middleton, Pharmacist

(an MCTE project at Ferris State University, 2001)

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Introduction
      Prescription volumes are increasing.  The estimate of 4 billion annual prescriptions by 2004, up from the projections of 2.9 billion prescriptions for 2001, represents nearly a 38% increase when pharmacist numbers are expected to increase only by 6 percent during the same period (18,19).  At the same time, requirements for cognitive services and pharmaceutical care are making further demands on the pharmacist's daily work load (15, 21).  Highly publicized medication errors (1, 7, 9) and discussions of pharmacist liability (8) that have accompanied the staffing shortage (10) are even prompting Congressional inquiry (20).
      Pharmacists have long made use of pharmacy technicians to help lighten their workload (14, 16).  However, until the late 1970s, there was no real mechanism to ascertain a technician's competency within the discipline (17).  Michigan led the way by introducing a Certified Pharmacy Technician program, sponsored by the Michigan Pharmacists Association, with national contracting of the service in 1981.  The initial 15 states participating helped in establishing a nationally recognized certification exam by 1995 (6).   As of November, 2000, nearly 71,000 technicians were certified nationally (6).
      However, the existence of an exam did not make certification mandatory, nor did it establish any structured educational requirements for taking the exam.  Some states, such as California, Nebraska (2), and Utah, have required state licensure for pharmacy technicians in addition to the exam certification; others, such as Texas and Oregon, require certification but no licensure; and still others follow Virginia (5), making certification of pharmacy technicians voluntary.  Michigan, the state that began the certification program, falls under that last category.  Several states have colleges which offer certificate or associate's degree course work for pharmacy technicians; again, there are no set guidelines for these programs. In fact, California offers no fewer than six different ways to become eligible for registry as a pharmacy technician.
      National discussions on requiring certification have created friction between certified or licensed technicians wanting more recognition for their education and ability, and pharmacists concerned over competition for their jobs (7), as controversy remains over the proper pharmacist-to-technician working ratio (3, 4).  While Michigan has surveyed its pharmacists in the past regarding certification of specific pharmacy services (13) within its discipline (ie diabetes education, cancer chemotherapy, radiopharmacy), it has not yet examined the pharmacists' attitudes regarding mandatory certification or licensure of pharmacy technicians, nor of a structured program of education for pharmacy technicians.
      The purpose of this study was to survey pharmacists’ attitudes toward pharmacy technician duties as well as conduct a needs assessment within the pharmacy profession regarding the development of a college-based program for training pharmacy technicians.

The specific research questions that were explored included:
 1. What is the profile of the pharmacist involved in the study, inclusive of academic, demographic, and employment information?
 2. What is the importance that pharmacists place on specific activities performed by pharmacy technicians?
 3. What is the importance that pharmacists place on specific educational needs for a pharmacy technician?
 4. What is the pharmacist attitude toward the potential for licensure of pharmacy technicians?
 5. What is the relationship between selected academic, demographic and employment variables of pharmacists and their attitude toward a formalized education program for pharmacy technicians and their possible licensure?

Methodology and Procedures
      This survey was a non-experimental, descriptive study comparing differences in attitudes among a cross-section of Michigan pharmacists.  The descriptive study made use of a self-developed questionnaire, first tested with three pharmacists and a researcher from Ferris State University.   A copy of the complete survey follows as an appendix to this report.
      The population surveyed were those pharmacists of residence within the State of Michigan, with active licensure, as of 12 February 2001.  The pharmacists' names were drawn from the database on file at the Michigan Pharmacists Association.   This represented a  pharmacist population of approximately 8100.   A random sampling of 1000 pharmacists was chosen from this database; a time frame of 3 weeks was allowed for the response to the survey, at which point 455 usable responses were obtained.  367 minimum responses were necessary to achieve a margin of error of +/- 5% in such a population.
      The final results were analyzed statistically, making use of means, frequencies, percentages, charts and graphs, and chi-square.

Results of the Survey–Demographics
      The average age (mean) of the respondents was 48.48 years, with a range of 24 to 80 years. 69.2% were male, 30.8% were female.  Graduates from Ferris State University predominated, at 61.8%, followed by graduates from Wayne State University (20.7%) and the University of Michigan (9.2%).  Non-Michigan pharmacy graduates accounted for 8.4%, with 1.1% coming from Ohio State University.  41.5% of respondents had been practicing for over 25 years, 36.5% had been at work from 11-25 years, and 17.2% had been pharmacists for 6-10 years.  4.8% of the respondents had been working for 5 years or less.
      Bachelor’s degrees also predominated, at 85.5%.  Another 10.5% had obtained some graduate work beyond their Bachelor’s degree, not necessarily toward a PharmD.  PharmD degrees accounted for 2.6% of respondents, with another 1.3% having pursued education beyond the PharmD level.
      Pharmacists in the retail setting accounted for 65.9% of the respondents, further broken down into independent (37.8%) and community chain (28.1%, a chain being defined as more than 3 pharmacies).  Hospital pharmacists represented 23.1%, with 3.7% serving in a consultant capacity and 0.7% focused on long-term care.  6.6% fell into the “other” category, with hospital management, pharmaceutical representative, and semi-retired being cited as specific occupations.
      96% of the respondents worked with pharmacy technicians; 33.4% worked with five or more.  Further, of those surveyed, 54.9% indicated that they worked in a pharmacy with at least one certified pharmacy technician (17.1% indicated that they worked in a pharmacy with five or more certified technicians).

Results of the Survey--Responses to the survey questions
      There were a total of 40 questions posed in the questionnaire related to pharmacists’ attitudes regarding various aspects of technician duties, training, educational requirements, and licensure.    A general summary of the responses follows:
      Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Table I.
Statement: “A pharmacy technician's duties should include...”

Duty	Agree	Disagree	No Opinion
1. Answering the telephone	98% (85.3%)	0.9% (0.2%)	1.1%
2. Taking refills from patients over the phone	93.4% (80%)	1.5% (0.4%)	5.1%
3. Taking refills from doctor’s office or nursing station over the phone	69% (35.4%)	25.3% (5.1%)	5.7%
4. Taking new prescriptions over the phone from doctor’s office or nursing floor	35.6% (12.7%)	60.9% (25.7%)	3.5%
5. Computer data entry of prescription/drug order information	89.5% (56.9%)	7.5% (2.4%)	3.1%
6. Interpreting insurance company information for computer entry	92.7% (70.1%)	1.7% (0.4%)	5.5%
7. Interpreting drug interactions	9.2% (1.1%)	86.8% (40.9%)	4%
8. Calculating doses based on age or weight	22% (2.6%)	68.8% (27.5%)	9.2%
9. Calculating IV administration rates	37.4% (6.4%)	44.1% (18.7%)	24%
10. Contacting physician or office regarding hospital or formulary requirements	64% (23.7%)	24% (6.2%)	12.1%
11. Contacting insurance companies for vacation overrides (retail setting)	91% (58.7%)	2.7% (0.9%)	6.4%
12. Contacting insurance companies for prior authorization on non-formulary drugs (retail)	83.5% (50.3%)	8.4% (1.8%)	8.1%
13. Checking other technician work prior to dispensing	27% (6.6%)	61.8% (25.1%)	11.2%
14. Advising on OTC use	18.5% (2.2%)	72.6% (21.3%)	9%
15. Advising on nutritional or dietary supplements	19.1% (1.8%)	67.7% (21.3%)	13.2%
16. Teaching use of glucometers	56.5% (7.9%)	31.3% (8.4%)	12.3%
17. Teaching use of MDIs (ie albuterol)	44% (6.2%)	46.1% (6.8%)	9.9%

 Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Table II.
Statement: “A pharmacy technician should...”

Statement	Agree	Disagree	No Opinion
1. Receive all of his or her training on-site	23.5% (3.7%)	60.2% (7%)	16.3%
2. Receive additional training in a formalized classroom setting	69.9% (12.1%)	14.5% (1.5%)	15.6%
3. Hold at least a certificate degree (2-3 semester program) from a college setting	28.1% (7.3%)	51% (6.4%)	20.9%
4. Hold at least an associate's degree (4 semesters) from a college setting	9.9% (2.9%)	66% (13%)	24.2%
5. Be certified	59.1% (18.2%)	29% (3.1%)	11.9%
6. Be licensed by the State of Michigan	36.3% (12.7%)	43.7% (10.5%)	20%

 Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Table III.
Statement: “A Certified Pharmacy Technician should...”

Statement	Agree	Disagree	No Opinion
1. Still have on-site training before taking on additional responsibilities	96.9% (43.7%)	1.1% (0.2%)	2%
2. Be paid more than a non-certified technician	84% (46.4%)	7.2% (0.2%)	8.8%
3. Be allowed to perform routine dispensing functions under minimal supervision by a pharmacist	52.1% (11%)	36.5% (7%)	11.4%

 Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Table IV.
Statement: “A pharmacy technician's training should include...”

Course work	Agree	Disagree	No Opinion
1. Pharmacology	57.6% (9.5%)	26.4% (4.2%)	16%
2. Organic Chemistry	13.6% (1.8%)	62.1% (11.6%)	24.2%
3. Algebra	59.6% (16.7%)	24.6% (2.4%)	15.8%
4. Drug interactions	66.8% (12.3%)	22.4% (2.4%)	10.8%
5. Biology	53.4% (4.4%)	25.7% (2.6%)	20.9%
6. Anatomy and physiology	56.9% (5.3%)	24.4% (2.2%)	18.7%
7. Herbal medicine	57.1% (6.8%)	20.2% (1.3%)	22.6%
8. Nutritional supplements and OTC products	69.5% (8.8%)	15.4% (1.1%)	15.2%
9. Preparation toward a pharmacist's degree	17.6% (2.4%)	45.3% (6.6%)	37.1%

 Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Table V.
Statement: “Regarding pharmacy technicians...”

Statement	Agree	Disagree	No Opinion
1. Certification of a pharmacy technician is unnecessary	29% (4.6%)	58.9% (17.4%)	12.1%
2. Certification of a pharmacy technician means the same whether done by a national examination or by an on-site program	24% (3.5%)	60.7% (11.9%)	15.4%
3. Certification and licensure of technicians represents a threat to pharmacist job security	5.7% (1.5%)	86.5% (33.8%)	7.7%
4. I encourage my technicians to become certified	74.1% (30.8%)	9.7% (1.1%)	16.3%
5. I encourage my technicians to obtain advanced, formalized training	73.8% (26.2%)	10.6% (0.9%)	15.6%

Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

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Results of the Survey--Correlations
 The demographics of “pharmacy school,” “degree held,” “years of practice,” and “type of pharmacy practice” were further examined.  Using a chi-square analysis of the results, the following correlations emerged as being statistically significant.  Unless stated otherwise, the total agreement or disagreement percentage is given, with the portion of that percent being “strongly agree” or “strongly disagree” being placed in parentheses.

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1. Pharmacy School Demographic
      Four statements demonstrated a significant difference in responses among the various pharmacy school graduates.

      When it came to technicians teaching patients the proper use of multi-dose inhalers, 57.2% of University of Michigan graduates disagreed (14.3% strongly), while Ferris graduates were 45.9% in disagreement (10% strongly), and 38.2% of Wayne graduates took issue with the statement (19.1% strongly).

Table VI:
Technicians teaching MDI use

Pharmacy school	Agree	Disagree
University of Michigan	38.1% (8.1%)	57.2% (14.3%)
Ferris State University	45.5% (6.4%)	45.9% (10%)
Wayne State University	45.7% (5.3%)	38.2% (19.1%)

Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”
 
 

      When asked whether a technician should “hold at least an associate’s degree (4 semesters) from a college setting,” 71.4% of University of Michigan graduates disagreed (11.9% strongly), with Ferris graduates dissenting at 67.1% (12.1% strongly) and Wayne State graduates disagreeing at 57.5% (16% strongly).

Table VII:
Technicians holding Associate’s Degree

Pharmacy School	Agree	Disagree
University of Michigan	11.9% (2.4%)	71.4% (11.9%)
Ferris State University	7.1% (1.4%)	67.1% (12.1%)
Wayne State University	17.1% (4.3%)	57.5% (16%)

Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”
 
 

      When discussing possible course work for pharmacy technicians, University of Michigan graduates found disagreement with  organic chemistry at 71.5% (16.7% strongly), with Wayne State disagreeing at 62.8% (12.8% strongly), and Ferris State at 59.8% (8.9% strongly).

Table VIII:
Organic Chemistry in Course work

Pharmacy School	Agree	Disagree
University of Michigan	11.9% (2.4%)	71.5% (16.7%)
Ferris State University	16.3% (1.4%)	59.8% (8.9%)
Wayne State University	6.4% *	62.8% (12.8%)

     * no “strongly agree” responses indicated
Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”
 

      On the other hand, biology as a subject drew agreeable responses from 56.4% of Wayne graduates (2.1% strongly), 53.4% of Ferris graduates (5% strongly), and 45.2% of University of Michigan graduates.

Table IX:
Biology in Course work

Pharmacy School	Agree	Disagree
University of Michigan	45.2% *	31% (4.8%)
Ferris State University	53.4% (5%)	27.4% (1.4%)
Wayne State University	56.4% (2.1%)	20.2% (5.3%)

 * no “strongly agree” responses indicated
Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

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 2. Pharmacy Degree demographic
      Two possible correlations emerged when analyzing the respondent’s degree held and his or her response.
      When examining potential technician course work, respondents holding a PharmD agreed that algebra should be included 83.3% of the time (33.3% strongly).  Bachelor’s degree pharmacists agreed at 57% (14.1% strongly), and Bachelor’s degree pharmacists who have obtained further education agreed at a 70.5% rate (33.3% strongly).
 

Table X:
Algebra in Technician Course work

Degree	Agree	Disagree
Bachelor’s	57% (14.1%)	26.8% (2.6%)
Pharm D	83.3% (33.3%)	16.7% *
Bachelor’s with graduate work	70.5% (33.3%)	12.5% (2.1%)

* no “strongly disagree” responses indicated
Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”
 

      The statement, “I encourage my technicians to become certified” also demonstrated a significant variety of responses based on pharmacy degree.  91.7% of PharmD graduates agreed (41.7% strongly), while Bachelor’s degree graduates who have gone for further education agreed 85.4% (62.5% strongly), and 71.9% of Bachelor’s degree only agreed (26.7% doing so strongly).
 

Table XI:
Encourage Technicians to Become Certified

Degree	Agree	Disagree
Bachelor’s	71.9% (26.7%)	10.3% (1.3%)
Pharm D 91.7%	(41.7%)	none
Bachelor’s with graduate work	85.4% (62.5%)	6.3%*

* no “strongly disagree” responses indicated
Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

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 3. Years of practice demographic
 Six statements showed possible correlations between response and number of years in pharmacy practice.
      A technician giving advice on which “OTC cough or cold preparation to take” had the least disagreement with those who have worked over 25 years, with 61.4% (of that, 17.5% strongly disagreeing).  Respondents in practice from 6 to 10 years disagreed the most, at 86.4% (40.9% strongly).
      The tables below summarize the information for each practice category.  The number in parentheses is, again, the portion of agreement or disagreement that is “strong.”

Table XII: Statement: A technician “advising a patient which OTC cough or cold preparation to take.”

Years of Practice	Agree	Disagree
0-5	13.6%*	81.8% (40.9%)
6-10	11.4%*	86.4% (40.9%)
11-15	2.9%*	82.4% (20.6%)
16-20	13.8%*	81.3% (32.5%)
21-25	16.3% (1.2%)	75.6% (25.6%)
over 25	25.9% (4.2%)	61.4% (17.5%)

* no “strongly agree” responses were indicated
Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Similarly, the statement “advising a patient on which dietary or nutritional supplement to take” showed a significant variance between these groups.

   Table XIII: Statement, “advising a patient on which dietary or nutritional supplement to take”

Years of Practice	Agree	Disagree
0-5	9.1%*	77.3% (36.4%)
6-10	9.1%*	86.4% (40.9%)
11-15	8.8%*	73.5% (14.7%)
16-20	17.5%*	77.6% (31.3%)
21-25	10.5%*	73.3% (18.6%)
over 25	29.1% (4.2%)	54.5% (13.2%)

      *no “strongly agree” responses were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Significant variations emerged on technicians teaching glucometers, both in agreement and disagreement:

   Table XIV: Statement, “instructing a patient on the proper use of a glucometer”

Years of Practice	Agree	Disagree
0-5	40.9% (4.5%)	45.4% (22.7%)
6-10	47.7% (9.1%)	40.9% (18.2%)
11-15	64.7% (2.9%)	26.5% (5.9%)
16-20	52.6% (3.8%)	42.6% (8.8%)
21-25	52.3% (5.8%)	31.4% (7%)
over 25	62.4% (11.6%)	23.3% (5.3%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

  And with multiple dose inhaler teaching:
   Table XV: Statement, “instructing a patient on the proper use of a multi-dose inhaler”
 

Years of Practice	Agree	Disagree
0-5	27.3%*	59.2% (18.2%)
6-10	31.8% (6.8%)	69.5% (22.7%)
11-15	38.2% (2.9%)	44.1% (14.7%)
16-20	37.6% (3.8%)	58.8% (13.8%)
21-25	40.7% (4.7%)	46.5% (9.3%)
over 25	54% (9%)	34.9% (9.5%)

      * no “strongly agree” responses were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Regarding potential technician course work, years of practice indicated variances in the need to include algebra.
   Table XVI: Technician training should include algebra

Years of Practice	Agree	Disagree
0-5	77.3% (40.9%)	13.6% (4.5%)
6-10	75.9% (18.2%)	25%*
11-15	58.9% (11.8%)	17.6%*
16-20	67.6% (21.3%)	18.8%*
21-25	65.1% (18.6%)	20.7% (4.7%)
over 25	49.2% (11.6%)	31.2% (3.2%)

      *no “strongly disagree” responses were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances again emerged when asked whether nutritional supplement and OTC products should be part of a technician training:

   Table XVII: Technician training should include nutritional supplements and OTC products

Years of Practice	Agree	Disagree
0-5	90.9% (18.2%)	0%**
6-10	63.6%*	22.7%*
11-15	54.7% (11.8%)	23.5%*
16-20	60% (7.5%)	23.8% (1.3%)
21-25	65.1% (9.3%)	22.1% (1.2%)
over 25	75.1% (9.5%)	7.4% (1.6%)

     * no “strongly” agree or disagree statements were indicated
     ** no disagreement of any sort indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

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4. Type of pharmacy practice demographic.
 The types of pharmacy practice examined were “community chain (3 or more pharmacies),” “community independent,” “hospital,” “long-term care,” “consultant,” and “other.”
 Chi-square analysis revealed several questions with responses statistically unique among the three categories of “community chain,” “community independent,” and “hospital.”

       a. Technician Duties
       Variances emerged when asked whether a technician should take new orders over the phone from a doctor’s office or nursing floor
   Table XVIII: Taking new orders from a doctor’s office or nursing floor

Type of Practice	Agree	Disagree
Chain	42.2% (13.3%)	55.5% (20.3%)
Independent	41.8% (18%)	54% (17.4%)
Hospital	20.9% (6.9%)	76.2%% (38.1%)

Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances emerged when asked whether a technician should interpret drug interactions
   Table XIX: Technicians interpreting Drug Interactions

Type of Practice	Agree	Disagree
Chain	10.9% (2.3%)	85.9% (35.9%)
Independent	12.2% (1.2%)	82% (32%)
Hospital	6.7% *	90.5% (50.5%)

     * no “strongly agree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances were noted when asked whether technicians should calculate administration times for IV drugs
   Table XX: Technicians calculating IV administration times
 

Type of Practice	Agree	Disagree
Chain	21.9% (1.6%)	47.6% (20.3%)
Independent	16.3% (2.3%)	55.2% (25%)
Hospital	62.8% (17.1%)	27.6% (8.6%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

Variances emerged when asked whether technicians should check other technicians prior to having drugs dispensed from the pharmacy.
   Table XXI: Technicians checking other technicians prior to dispensing

Type of Practice	Agree	Disagree
Chain	20.3% (4.7%)	67.2% (25.8%)
Independent	28.5% (6.4%)	59.3% (22.7%)
Hospital	31.5% (4.8%)	59.1% (24.8%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances emerged when asked whether technicians should advise on OTC cough and cold preparations.
    Table XXII: Technicians advising on OTC cough and cold preparations
 

Type of Practice	Agree	Disagree
Chain	11% (0.8%)	79.7% (22.7%)
Independent	27.3% (3.5%)	66.3% (21.5%)
Hospital	18.1% (1.9%)	69.5% (27.6%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances emerged when asked whether technicians should advise on nutritional or dietary supplements
   Table XXIII: Technicians advising on nutritional or dietary supplements
 

Type of Practice	Agree	Disagree
Chain	16.4% (0.8%)	71.8% (19.5%)
Independent	26.2% (2.9%)	61.1% (16.9%)
Hospital	12.4% (1%)	68.6% (22.9%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances appeared when asked whether technicians should instruct patients on the proper use of a glucometer.
   Table XXIV: Technicians instructing patients on glucometer use

Type of Practice	Agree	Disagree
Chain	57.1% (6.3%)	30.5% (7.8%)
Independent	65.7% (8.7%)	22.1% (4.1%)
Hospital	46.6% (5.7%)	41% (14.3%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

 Variances also appeared when asked whether technicians should instruct patients on proper use of multi-dose inhalers (MDI).
   Table XXV: Technicians instructing patients on MDI use

Type of Practice	Agree	Disagree
Chain	43% (5.5%)	46.9% (10.2%)
Independent	53.5% (7.6%)	38.9% (8.7%)
Hospital	33.3% (1.9%)	54.2% (17.1%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

        b. Technician Education
       Variances emerged when asked whether technicians should hold at least a certificate-level (2-3 semesters) of training
   Table XXVI: Technicians holding certificate-level training

Type of Practice	Agree	Disagree
Chain	24.2% (7%)	54.7% (4.7%)
Independent	18.1% (4.1%)	57.6% (9.3%)
Hospital	41.9% (10.5%)	40% (4.8%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

  Variances appeared when asked whether technicians should be certified
   Table XXVII: Certification of technicians

Type of Practice	Agree	Disagree
Chain	56.3% (17.2%)	28.9% (1.6%)
Independent	42.5% (7.6%)	42.4% (5.2%)
Hospital	83.8% (34.3%)	10.5% (1%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

  Variances also appeared when asked whether technicians should be licensed by the State of Michigan.
   Table XXVIII: Licensing technicians by the State

Type of Practice	Agree	Disagree
Chain	32% (11.7%)	42.2% (7%)
Independent	29.7% (7.6%)	49.8% (12.2%)
Hospital	47.6% (19%)	40% (12.4%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

        c. Comments on certified technicians
       Variances emerged when pharmacists were asked whether a certified pharmacy technician should be paid more than a non-certified technician.
  Table XXIX: Certified technicians should be paid more than non-certified technicians

Type of Practice	Agree	Disagree
Chain	89.6% (40.6%)	4.7% *
Independent	72.1% (27.3%)	12.8% (0.6%)
Hospital	93.3% (49.5%)	1.9% *

     * no “strongly disagree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

       d. Technician training
      Variances on technician training revolved around the subjects of pharmacology, algebra, anatomy and physiology, and nutritional and OTC products.
   Table XXX: Pharmacology

Type of Practice	Agree	Disagree
Chain	57.8% (8.6%)	24.4% (2.3%)
Independent	47.1% (6.4%)	34.9% (6.4%)
Hospital	70.4% (15.2%)	18.1% (2.9%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

   Table XXXI: Algebra

Type of Practice	Agree	Disagree
Chain	60.1% (11.7%)	24.3% (1.6%)
Independent	44.2% (8.7%)	34.9% (4.1%)
Hospital	78.1% (31.4%)	13.3% *

     * no “strongly disagree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

   Table XXXII: Anatomy and Physiology

Type of Practice	Agree	Disagree
Chain	54.7% (5.5%)	28.2% (1.6%)
Independent	48.9% (4.7%)	29.7% (3.5%)
Hospital	63.8% (6.7%)	17.1% *

     * no “strongly disagree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

   Table XXXIII: Nutritional and OTC products

Type of Practice	Agree	Disagree
Chain	63.3% (7%)	18.8% *
Independent	68.6% (9.3%)	15.7% (1.7%)
Hospital	76.2% (10.5%)	9.5% *

     * no “strongly disagree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

       e. General comments on pharmacy technicians
      Variances emerged when the pharmacists were asked about whether technician certification was necessary, whether they encouraged their technicians to become certified and obtain further education, and whether certification and licensure of technicians represented a threat to pharmacist job security.

   Table XXXIV: Certification of technicians is unnecessary

Type of Practice	Agree	Disagree
Chain	29.7% (3.1%)	56.2% (14.8%)
Independent	42.5% (7.6%)	44.2% (11.6%)
Hospital	11.5% (1%)	81% (32.4%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

   Table XXXV: Encourage technicians to become certified

Type of Practice	Agree	Disagree
Chain	74.2% (25.8%)	9.4% (0.8%)
Independent	59.3% (20.9%)	15.1% (1.7%)
Hospital	90.5% (50.5%)	1.9% *

     * no “strongly disagree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

   Table XXXVI: Encourage technicians to obtain advanced, formalized training

Type of Practice	Agree	Disagree
Chain	70.3% (21.1%)	14.1% (0.8%)
Independent	65.1% (15.1%)	14.6% (1.2%)
Hospital	86.7% (43.8%)	1.9% *

     * no “strongly disagree” statements were indicated
     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

   Table XXXVII: Certification and licensure of technicians represent a threat to pharmacist job security

Type of Practice	Agree	Disagree
Chain	4.7% (0.8%)	92.9% (32%)
Independent	8.1% (2.3%)	80.8% (26.7%)
Hospital	3.8% (1.9%)	86.7% (44.8%)

     Note: Values in parentheses represent the portion of the percent that is “strong agreement” or “strong disagreement”

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Interpretations and Conclusions
      On basic clerical functions, Michigan pharmacists are willing to give their technicians a large latitude of independence.  Particularly, answering the telephone (98%), taking refill orders from patients (93.4%), interpreting insurance information for computer entry (92.7%), dealing with insurance companies for vacation requests (91%), and, to a lesser degree, contacting insurance companies on formulary issues (83.5%) all are considered very acceptable activities.  Less enthusiasm is shown for technicians taking new prescriptions over the phone (35.6%), interpreting drug interactions (9.2%), calculating doses based on weight (22%), checking other technician’s work (27%), advising OTC use (18.5%), or nutritional supplements (19.1%).  In dealing with the public, however, educating patients on glucometers has a 56.5% overall approval; doing the same with multiple dose inhalers (albuterol, et al), offers ambivalence– 44% agree, while 46.1% disagree whether this is an acceptable technician duty.
      Regarding education, certification, and State licensure, most pharmacists (60.2%) disagree that on-site experience offers adequate training; 69.9% agree that additional training in a formalized classroom setting is necessary, and 60.7% agree on-site certification is not equivalent to a nationally-based examination; however, the same pharmacists don’t seem to think this extra training or education should lead to either a certificate (51% disagreement) or associate’s degree (66% disagreement) at a college level.  With 74.1% of the respondents agreeing that their technicians should be encouraged toward certification and a similar number encouraging formalized training (73.8%), only 59.1% indicate that they should be certified; even fewer (36.3%) agree that technicians should be licensed by the State.   However, 86.5% of the respondents do not believe that certification or licensure of technicians would represent a threat to a pharmacist’s job security.
      Once a technician is certified, 96.9% agree that additional on-site training is necessary, 84% feel that additional pay is warranted, and just over half (52.1%) agree that a certified technician can perform routine dispensing functions with minimal supervision by a pharmacist.
      Education on nutritional supplements and OTCs heads the list of learning objectives at 69.5%.   In fact, over half agree that pharmacology (57.6%), algebra (59.6%), drug interactions (66.8%), biology (53.4%), anatomy and physiology (56.9%), and herbal medicine (57.1%) are important in a technician’s training.  Only organic chemistry drew a predominantly negative response (13.6%).
      Those portions of the study that can be further broken down with statistical confidence reveal some interesting trends.  University of Michigan graduates are more resistant (57.2%) to having their technicians train patients with multiple dose inhalers (albuterol, et al) than graduates from Ferris (45.9%) or Wayne State (38.2%).  University of Michigan graduates also are in greater general disagreement (71.4%, vs Ferris’ 67.1% and Wayne State’s 57.5%) to having a technician obtain an associate’s degree in his or her discipline; and, if they do, they take the greatest issue with including organic chemistry (71.5%) as part of the curriculum when their responses are compared with their Ferris (59.8%) or Wayne State (62.8%) brethren.
      The pharmacy degree demographic reveals two significant trends among bachelor’s degree, bachelor’s degree with graduate work, and PharmD respondents.  Algebra as a part of a technician’s curriculum is encouraged with greater enthusiasm as the respondent’s own education progressed from bachelor’s (57%), to bachelor’s with graduate work (70.5%), to PharmD (83.3%).  Holders of a PharmD were the most likely (91.7%) to encourage their technicians to become certified as well (bachelor’s degree respondents agreeing at 71.9% and bachelor’s with graduate work at 85.4%).
      A trend also emerges that associated itself with years of practice in pharmacy (tables XII through XVI).  Those respondents practicing more than 25 years appear more willing to relax their restraint on technician duties when compared to the rest of the responding population.  They show less resistance to having a technician advise on OTC cough or cold preparations (61.4% general disagreement to the statement, compared with 86.4% of the 6-10 year population), suggesting dietary supplements (54.5% vs 86.4% in the 6-10 year population), instructing on glucometer usage (23.3% vs 45.4% of the 0-5 year group), and proper use of a multi-dose inhaler (34.9% vs 69.5% of the 6-10 year group).   This data is represented both in bar graphs and as line graphs in the appendix to this report.
      The greatest number of statistical variances comes when analyzing the type of pharmacy practice demographic.  Twenty of the survey statements (tables XVII through XXXVII) showed significant differences among pharmacists who work in retail chain, retail independent, and hospital environments.  Hospital pharmacists are least likely to have a technician take new telephone prescription orders (20.9%) than chain (42.2%) or independent (41.8%) pharmacists.   They are also least likely to have a technician interpret drug interactions (6.7% vs 10.9% for chain and 12.2% for independent pharmacists).  In a task more specific to the hospital environment, IV administration time calculation, they are more likely (62.8% vs 21.9% for chain and 16.3% for independent pharmacists) to assign this as a technician task.  A program of technicians checking other technicians meets with general disagreement with all three categories of pharmacists, with chain pharmacists leading at 67.2%, followed by independents at 59.3% virtually tied with hospital pharmacists at 59.1%.  Independent pharmacists show the greatest agreement with having technicians instruct patients on multiple-dose inhaler use (53.5% vs chain’s 43% and hospital’s 33.3%) and in teaching patients about glucometers (65.7% vs chain’s 57.1% and hospital’s 46.6%).  Similarly, while all groups disagreed in general, independent pharmacists disagreed least when it came to having technicians advise on OTC cough and cold preparations (66.3% vs chain pharmacists’ 79.7% and hospital pharmacists’ 69.5%) and nutritional or dietary supplements (61.1% vs chain’s 71.8% and hospital’s 68.6%).
      The pharmacy practice demographic varied with technician’s proposed education levels.  While all disagreed that technicians should have certificate-level training, the least enthusiasm was shown by independents (at 18.1%, with chain respondents 24.2% and hospital 41.9%).  Independents were also least enthusiastic about the statement “technicians should be certified,” with the total of agreement responses 42.5%, followed by chain pharmacists at 56.3%, and hospital pharmacists at 83.8%.  Licensing technicians was also regarded with the least acclamation by independents, with a 29.7% agreement comparing to the chain pharmacists’ 32% and the hospital pharmacists’ 47.6%.
      However, once a technician has become certified, all three categories agree that he or she should be paid more than a non-certified technician.  Nevertheless, even with this question, the variances split among the practice sites: independent respondents agreed at 72.1%, chain respondents at 89.6%, and hospital respondents at 93.3%.
 When exploring potential technician course work, the type of practice again influenced the pharmacists’ response.  Of the options presented, “pharmacology,” “algebra,” “anatomy and physiology,” and “nutritional and OTC products” all show significant variation (tables XXX through XXXIII), with nearly two-thirds or more of hospital pharmacists agreeing with the need for this sort of training, and a majority of chain pharmacists in accord.  Independent pharmacists agreed less than half the time with each these presented choices, with the one exception being “nutritional and OTC products.”
      Finally, four of the closing survey comments (tables XXXIV through XXXVII) indicate that hospital pharmacists are least likely to find certification of technicians unnecessary (11.5% vs 29.7% of chain and 42.5% of independent pharmacists), are most likely to encourage their technicians to become certified (90.5% vs 74.2% of chain and 59.3% of independents) and to obtain advanced, formalized training (86.7% vs 70.3% of chain and 65.1% of independents).  In addition, hospital pharmacists are least likely to find certification or licensure of pharmacy technicians to be a threat to pharmacist job security (3.8% vs 4.7% for chain pharmacists and 8.1% of independent pharmacists).

Conclusion
      The fact that most pharmacists encourage their technicians to pursue certification and to obtain advanced formalized training appears incongruent with the generally negative responses shown when they are asked whether this training should culminate in a certificate or associate’s level degree.  This is additionally perplexing with a 69.9% agreement that a technician’s additional training should be in a “classroom setting.”
      The particular comparative resistance registered by independent pharmacists is also interesting. Their possible reluctance to an expanded technician role (with certification, possible licensure, and the generally agreed accompaniment of enhanced salary) could be based on their intimacy with fiscal concerns not shared by hospital and chain pharmacists, but this would have to be explored specifically in a different study.
      And while considering new studies, some trends witnessed here beg additional questions.  For example, while it is pointedly expressed by pharmacists that organic chemistry would not be a useful part of a technician’s training, it would be interesting to pursue why graduates of the University of Michigan in particular believe so, just as why they appear more resistant to having technicians teach patients on the use of  multi-dose inhalers.
      Michigan began the trend for pharmacy technician certification over 20 years ago, and many states are following, even elaborating upon, its example.  However,  Michigan pharmacists seem to be struggling with the amount of freedom to grant their technicians, as well as defining their role as coworkers.

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Postscript--2003
     One of the nicest things about the internet is that it enables me to get this entire survey put out for all to see, instead of the somewhat truncated version that made it into print previously.  It also allows those few who turn to these ramblings to contact me quickly and directly--and perhaps give some insight on attitudes beyond the borders of Michigan.
     Pharmacy as a profession keeps getting publicized as being so attractive for its high salary.  I have yet to see where anyone has explored the consequences of the high salaries, insane volumes of prescriptions, and the abysmal reimbursement (if any at all) for "cognitive services" at at what point will the high salaries be regarded as not "cost effective."  Chains are certainly making such projections in their board meetings, and there will come a time where someone will grease the right politician's palm (or governmental agency) and with a single stroke, the mandate for an on-site pharmacist in a pharmacy could go "poof."  Who will be left?  When the last independent pharmacy closes its doors...watch out.
     I received only one dissenting comment about this attitude survey, and that came from an area where PharmD degrees and hospitals predominate, where technicians are actually held in high regard, and their training is encouraged, quantified, and certified.  I went back to the raw data and determined that this area's collection of zip codes (one of my survey questions) actually held these convictions.   It would be more comforting to know that the rest of the one-time progressive State of Michigan held the same opinions.
     In retrospect, there are some questions I should have included, namely a quick check on the surveyed pharmacists' attitudes toward clinical services by the profession in general, and whether they thought a well-trained, licensed, or even certified technician would afford them the opportunity to focus more on patient care.  Some other time, perhaps.....
     The above survey is now two years old.  I would like to think that the attitudes are changing, but alas, it seems there is still resistance, at least in the casual surveys I've undertaken since this report's publication.  The disturbing trend is that pharmacists are finding their attitudes dismissed by third-party payors and governmental direction.  Recently a call to the Medicaid HMO First Health's "clinical line" was greeted with the official message that "a Certified Pharmacy Technician will be available to discuss your clinical question."  The longer the profession waits to determine its role in health care, the quicker that determination will be made by others interested solely in money and marketing, and not in the best interest of the patients we all serve.

Jim Middleton, Pharmacist
January, 2003