In many of my hospitals, my pharmacy department interacted with three groups. They dealt with the doctors, they dealt with the nurses, and sometimes they dealt with the patients.
And dealing with the patients has only been done recently. It has only been several years (10-15 years at the most) where clinical pharmacists talked directly to the patients. Before that, pharmacy dealt solely with physicians and nursing.
Nursing on the other hand interacted with doctors, patients, patients’ family members, and visitors. In addition, they dealt with various hospital departments which included: pharmacy, lab, x-ray, radiology, physical therapy, speech and hearing, social work, and dietary. They were bombarded from all sides.
What’s more nursing had to keep all these groups “happy” in order to work with them. And nursing was always on the front line. They were the first groups to get besieged with complaints, even when it was not their fault.
So I respected nursing. I understood what they were going through. Yet I noticed something about the pharmacy-nursing relationship. Regardless of which hospital I worked in, pharmacy and nursing always clashed.
I don’t know why. I mean they were both there for the patient. They both wanted to make sure that the patients received their correct medications on time.
And yet pharmacy and nursing seemed to be constantly at odds with one another.
Giving In To The Nurses
My pharmacy viewed nursing as they were always getting their way. There was no compromise. Whatever nursing wanted— nursing got.
And it didn’t even have to be an entire nursing unit or a majority of nurses. Many times it was only one or two nurses that invoked a procedural change.
For many years, my pharmacy technicians delivered medications directly to the nursing units. They’d fill paper bags with the patient’s medications. Then they’d leave these paper bags on top of the medication carts on the individual nursing units. The nurses would then go through the bags and sort the medications into the correct patient drawers.
This was the procedure in the late 1980s, early 1990s. Now, I’ll admit, this procedure would never have been done this way today. But back then, we had done it this way for many, many years. And nobody had a problem with it.
Until one nurse complained about sorting the meds. She was having a bad day. The nurse got yelled at by a doctor. The lab was late in providing a patient’s test results. A patient’s family was giving her grief. Another patient got the wrong meal from dietary. And they were short one nurse on her unit due to a sick call.
Either she was too busy or too upset, or didn’t feel like sorting out the patients’ medications that the pharmacy tech had left on the medication cart.
So the nurse complained. She complained to her head nurse and the vice-president over nursing. She complained to me (the pharmacy manager) and to my boss (the Director of Pharmacy). She even complained to the vice-president over pharmacy.
I must say I was a bit surprised. We had performed this process for many years. There had never been an issue. There had never been anything missing. No one, from either pharmacy or nursing, had ever had a problem with it.
Surely one complaint after several years of performing a specific procedure was not going to change the way things were done, right?
Wrong! It was made into a security issue. Administration and nursing stated that it wasn’t safe to leave unattended medications on top of a medication cart. So it became the pharmacy technician’s responsibility. Thus, the pharmacy technician had to spend time sorting the medications and placing them in the proper patient drawers.
What’s more the medication cabinets were always locked. And nursing refused to give the medication cart combinations out to the pharmacy technicians. So the pharmacy technicians had to spend additional time tracking down nurses to open the carts.
And note, I did say “nurses to open the carts.” Because this no longer involved one particular nurse and one particular medication cart. Instead it became a hospital-wide process. All the pharmacy technicians were now responsible for tracking down individual nurses to open the medication carts and sorting the patients’ medications into every medication cart.
Obviously my pharmacy technicians were not happy with how this procedure had mushroomed. But we were not surprised. It was clearly another situation where nursing didn’t want to do something and it became the pharmacy’s job.
Getting Stung By The Rules
One of the rules that we had in our hospital was that “the pharmacy was responsible for the procurement, preparation, storage, distribution, and control of all drugs throughout the hospital”. Prior to the introduction of med cabinets, which securely provided the medications, this was a monumental task.
Imagine a medication room on a nursing unit. Except for a locked cabinet for controlled substances, this room was seldom locked. It had individual shelves and an array of bins. It also had a small sink and a medication refrigerator (also unlocked).
Very few medication rooms had drugs stored in a neat and organized manner. Most medications were literally scattered amongst the shelves or thrown inside the refrigerator. It was not unusual to find:
- Floor stock meds mixed with patient meds,
- Duplicate vials and bottles of individual patient meds,
- Several opened and undated vials of medication in the refrigerator (and sometimes on the shelf).
- Many outdated products.
The medication rooms on the nursing units were a mess. So who should be responsible for dealing with this mess on the nursing units? Not the nurses. But the pharmacy, of course. Why? Because “the pharmacy was responsible for the procurement, preparation, storage, distribution, and control of all drugs throughout the hospital”.
Nursing kept their kitchen and break area clean. They would never leave outdated milk and other food items strewn amongst the shelves.
Nursing kept their desk area organized. The charts were put in the appropriate slots, and the forms were placed in the proper bins and drawers.
Nursing kept their utility room nice and tidy. The equipment was stored in labeled cabinets.
So why didn’t nursing clean and organize their medication rooms? Because “the pharmacy was responsible for the procurement, preparation, storage, distribution, and control of all drugs throughout the hospital.”
I understood the logic of this rule. I knew why it was put in place. I also felt that the nurses should have been responsible for keeping their own areas clean and organized.
There were some people who saw my point of view. But they weren’t willing to support me and thereby ignore the rule.
So the pharmacy was responsible for dealing with mess in medication rooms on the nursing units.
Doing More With Less
I was a hospital pharmacy manager. I never worked in a chain store or supermarket pharmacy. But I knew many people who did.
My college roommate was a pharmacist for a supermarket pharmacy. His pharmacy was a loss leader for the store. It was only responsible for 2% of the entire store’s gross profit.
Whenever a customer came to the pharmacy counter to drop off a prescription, my roommate (the pharmacist) would tell them to come back in an hour. Then, the customer would go and buy over a hundred dollars worth of groceries. The customer would eventually return to the pharmacy. Then, they would get a dollar off their prescription. They would be happy.
Most of the time, my roommate worked in the pharmacy by himself. He rarely had a pharmacy technician helping him. This was because his numbers didn’t justify having a pharmacy technician.
However, I wouldn’t say it was slow. I watched him for twenty minutes one day. This is what I noticed:
- He was constantly on his feet. He never sat down.
- He waited on every customer, writing their name, date of birth, and address on each prescription he received.
- He entered the information into the computer records and generated a prescription label.
- He counted the tablets, poured the liquid, or prepared the final product.
- He labeled the product, bagged the medications, and priced the prescription.
- He repeated this process for multiple prescriptions.
- He brought the prescription(s) to the register and charged the customer.
But that wasn’t everything. Interspersed in this process, he answered the phones, spoke with doctors and office staff people, dealt with the patient’s insurance companies, and answered customers' questions.
He never closed for meals— in fact he grabbed food when he could while he was working. He never got any breaks. And as for using the bathroom— well that was a challenge.
As a pharmacist, my roommate worked between 50-60 hours per week. And many times, he worked several twelve hour days in a row.
So why did he put up with this? For two reasons:
- Money. Many chain stores and supermarkets paid extremely well. In fact, as I previously stated, my roommate made more as a supermarket pharmacist than I made as a pharmacy manager. Thus, if my roommate quit because of these extreme working conditions, he would definitely be taking a pay cut if he worked another job. What’s more, the supermarket pharmacy’s salary would definitely entice another pharmacist to work there.
- Because pharmacy allowed this to happen. The profession of pharmacy has allowed these things to become the norm. We’ve allowed stores and states to dictate these harsh procedures (no breaks, no help, and long hours) and accept them as standard practices.
Sometimes rules and regulations were enacted to address these unfair conditions. Yet, quite often, the pharmacy profession is burdened with additional tasks, that somehow have become the pharmacists’ job.
Absorbing Additional Work
Every year I got my flu shot. I went to the same pharmacy each time. I never made an appointment. I just walked in when it was convenient for me.
I usually went first thing on a Saturday morning. Each time the same pharmacist was there. She was there by herself in the prescription department. She had no pharmacy tech to help her fill prescriptions, answer the phones, or wait on the customers.
I didn’t know how many prescriptions she needed to fill in order to justify having a pharmacy technician. But she looked pretty busy to me.
I did not need a prescription in order to get my flu shot. However, there is a procedure that this pharmacist had to follow:
- She brought up my patient profile in her computer using my name, address, and date of birth.
- She checked my patient profile for allergies and any possible interactions.
- She entered the type of flu shot that she would be administering in the computer.
- She generated a prescription label and labeled the individual vaccine’s syringe.
- She produced paperwork for me to read and sign.
- She had to leave the prescription department in order to administer the shot.
- She completed the transaction by charging my insurance company.
As stated, during the time that she was physically administering the vaccine, she was NOT in the prescription department. At that time, the phone was ringing and going unanswered, other customers were waiting, and her work was piling up.
I was well aware that administering vaccines was a money making service for the pharmacy. I also knew that offering vaccines to customers was a convenience, since many people can’t get to their doctor’s office. I also knew that many pharmacies have added staffed medical clinics (within the store) that provided vaccines as well as other services.
But this one didn’t. Now according to their website, this retail chain pharmacy provided immunizations against the following: measles, mumps, rubella, flu, diphtheria, chickenpox, hepatitis A&B, haemophilus, HPV, Japanese encephalitis, meningitis, pneumonia, polio, shingles, tetanus, typhoid, whooping cough, and yellow fever. In addition, the website stated that their pharmacists were specially trained certified immunizers, and would administer the immunizations.
So my questions are… What corporate board officer decided that their pharmacists should be the ones to undertake this monumental task of administering these vaccines? Especially with no additional help nor any consideration of how these increased tasks would affect the pharmacists’ workload.
And why pharmacists working for this pharmacy chain would have agreed to perform these extra jobs, given the fact that their current assignments were already pushing the limits?
Performing Future Tasks
I was watching the news a few weeks ago. The TV anchorman announced that the CDC would permit two major retail pharmacy chains to start administering COVID vaccines in their facilities. This would benefit the public by allowing people to get vaccines close to their home at their local pharmacy.
I cringed when I heard this report.
I could only imagine what would happen. Thousands of people would be lining up at their neighborhood pharmacy. And the poor pharmacist would have to take on the chore of administering COVID vaccines in addition to all their other responsibilities,
In all fairness, this has not happened. Many of the pharmacies hired additional staff to check people in, complete temperature and other pretesting, and administer the vaccines. Some even used the in-house clinic personnel, so that the pharmacy or pharmacists were not even involved.
Recently, I saw a television news report about several pharmacists who worked in a chain drug store. They stated that their tasks in the pharmacy were leading to stressful lives because they were overworked and understaffed. They worked 12-15 hours days, with no breaks, and sporadic meal breaks. Even bathroom visits were a challenge.
The pharmacists worried about making a mistake since it could severely impact someone’s health.
The report then went on to say that due to COVID vaccines, the pharmacist’s responsibilities and workload would only increase.
I tend to agree. From what I’ve heard, even though people have gotten their vaccines, COVID will not be a one-shot (or two-shot, pardon the pun) deal. People will probably require a yearly booster much like the flu.
Will these chain store pharmacies continue to have an abundance of people to administer COVID booster vaccines? Or will the administration of COVID vaccines and boosters be absorbed into the pharmacists’ already excessive workload?
Only time will tell.
Daniel Shifrin, R.P., M.S. is a recently retired pharmacist who enjoys sharing his insights about hospital pharmacy. He is proud to own one of the largest collections of Pharmacy Stamp First Day Covers.