Community pharmacists at transition to independent practice: isolated, unsupported and stressed

Esnath Magola* (MSc, MRPharmS)(esnat.magola@manchester.ac.uk)PhD studentCorresponding author

Sarah C Willis (MA (Econ), PhD) 1

(sarah.willis@manchester.ac.uk)Lecturer in Social Pharmacy

Ellen I Schafheutle (MSc, MRes, PhD, FFRPS, MRPharmS) 2

(ellen.schafheutle@manchester.ac.uk)Senior Lecturer in Law & Professionalism in PharmacyDirector, Centre for Pharmacy Workforce Studies

All:Centre for Pharmacy Workforce StudiesDivision of Pharmacy and OptometrySchool of Health SciencesFaculty of Biology, Medicine and HealthThe University of Manchester Oxford RoadManchester M13 9PT

*Author for correspondence:Tel: 0161 – 275 2421Fax: 0161 – 275 2416

Accepted version; can be cited as:

Magola E, Willis SC, Schafheutle EI. Community pharmacists at transition to independent practice: isolated, unsupported and stressed. Health & Social Care in the Community; DOI: 10.1111/hsc.12596

Keywords: Community pharmacist, transition to practice, stress in health professionals, newly-qualified, job strain, professional development

Community pharmacists at transition to independent practice:

isolated, unsupported and stressed

Abstract

While there is evidence from nursing and medicine that transition to independent practitioner is

challenging and has implications for patient care, there is little research exploring novice community

pharmacists’ (NCPs) transition. This study aimed to identify the challenges faced by NCPs at

transition to independent practitioner and perceptions of the relative importance of these

challenges. Nominal group discussions were held between November 2015 and April 2016, in North

West England, with purposively sampled NCPs, early career pharmacists, work-based pre-

registration tutors, and pharmacy support staff. In response to the question ‘What are the

challenges faced by NCPs at transition?’ participants individually wrote down and subsequently

called out, in round-robin fashion, then discussed, and broadly categorised challenges before ranking

them in order of importance. Discussions were audio-recorded with consent, transcribed and

analysed thematically. Twenty-five participants from independent, supermarket and small and large

multiple pharmacies took part in five nominal group discussions. Challenges experienced through

interacting with the workplace environment were identified as: (in order of importance) relationship

management; confidence; decision-making; being in charge and accountable; and adapting to the

workplace. With the exception of disagreement between pharmacists and pharmacy support staff

regarding whether adapting to the team was challenging for NCPs, all participants reported

challenges experienced through interacting with the workplace environment. Challenges were

described as inducing psychosocial stress, particularly because NCPs acquired immediate

professional accountability, worked in isolation from experienced peers, and faced job-related

pressures. Interpretation of the findings suggests that the Karasek job-demand-control-support

(JDCS) model of occupational stress provides valuable insight about transition for NCPs. NCPs’ jobs

are classified as high strain, where high workplace demands coupled with NCPs’ lack of control in

being able to meet demands, together with isolation and lack of support, result in transition being

characterised as causing iso-strain, where the workplace becomes a ‘noxious’ environment.

What is known about this topic

Medical and nursing literature states transition is challenging and has negative implications for

novices and patient care, however little research explores transition for novice community

pharmacists (NCPs)

NCPs’ workplace environments are associated with workload pressure, stress, a lack of support and

professional isolation

What this paper adds

Managing relationships was perceived to be most challenging; the other important challenges were

lacking confidence, decision-making, being in charge/accountable, and adapting to the workplace

The inability to manage relationships caused role conflict, role ambiguity and power struggles and

the burden of accountability made NCPs ‘risk averse’

Measures to support NCPs during transition should consider how to mitigate job strain, the potential

for job ’iso-strain’ and professional isolation

INTRODUCTION

The transition to independent practice marks a changeable period when newly registered (novice)

practitioners start becoming professionally accountable for patient care (Krautscheid, 2014;

Donaldson, 2001). This period, which can last up to three years, has been described extensively in

the nursing and medical literature as challenging and stressful (Sheehan et al., 2012; Tallentire et al.,

2011; Maxwell et al., 2011; Duchscher, 2009). Transition changes support needs, the ability to

control/influence, expectations and social structures for novice practitioners which may lead to

stress and job-strain as they adapt to their new roles (Meleis et al., 2000). Meleis’ transition theory

states that healthy transitions are characterised by healthy patterns of response [or reactions] to

change. These reactions include feeling connected, interacting, being situated, developing

confidence and coping with the new role (Meleis et al., 2000).

A detailed review (Magola et al., 2018) exploring transitions of novice nurses and doctors found that

they experienced challenges [or stressors] when they interacted with the workplace environment

and reacted to their new roles, as proposed by Meleis’ transition theory (Meleis et al., 2000). In this

review challenges associated with transition were categorised as personal, social or job-related

(Magola et al., 2018). Personal challenges described the novice’s response to their role

(psychological pressure, cognitive impairment, emotional or intellectual stress), social challenges

resulted from workplace relationships (interpersonal/inter-professional conflict, fitting in or

mismatched expectations) and job-related challenges resulted from role demands (shift patterns,

responsibility for complex patients, rotation, or time constraints). These challenges were perceived

to impact negatively on learning, personal and professional development, practitioner performance,

staff retention and importantly, the quality of patient care and patient safety (Wangensteen et al.,

2008; Kilminster et al., 2011; Goh and Watt, 2003; Satterfield and Becerra, 2010; Kelly, 1998).

Very little research exists about the transition experiences of novice community pharmacists (NCPs),

yet it is likely that they may experience similar transition challenges. Anecdotal and limited research

evidence suggests NCPs feel unprepared, undervalued, overworked and unsupported (Anon., 2009;

Eden et al., 2009; Ferguson et al., 2015). A recent longitudinal study on professional socialisation and

professionalism development, following a group of trainee pharmacists, indicated that NCPs faced

difficulties managing workloads, adjusting to workplaces, demonstrating affective skills and being

professionally accountable (Jee et al., 2017).

Under current training arrangements in Great Britain, novice pharmacists have relatively little

experiential learning compared with novice nurses and doctors; the majority of pharmacy graduates

have a work-based 12-month pre-registration training year following four years of mainly university-

based education. Upon registration, most pharmacists work in hospital or community settings

(Seston and Hassell, 2014). Whilst those in hospital settings work within wider teams that include

support staff, experienced pharmacists and other healthcare professionals, novices entering

community practice usually work as sole practitioners leading a small team of support staff (Jee et

al., 2016; Jee et al., 2017). Furthermore, while a dedicated tutor supports progression during the

pre-registration training year, no such support structure exists to ease transition to independent

practice for NCPs.

Besides professional isolation as sole pharmacists in the majority of community pharmacies, there

are further contextual differences from public sector (NHS) organisations into which novice nurses

and doctors transition. Community pharmacies are commercial retail settings which have been

associated with job-related stressors. They include workload pressure and role stress (Gaither et al.,

2008; Astles, 2011; Phipps and Ashcroft, 2011; Phipps et al., 2016), low job satisfaction (Ferguson et

al., 2011; McCann et al., 2009) and high mental workload (Family et al., 2015; Family et al., 2014).

Much of this is attributed to high workloads (Gidman, 2011), conflict between clinical and

commercial work demands, perceived low utilization of skills (Cox and Fitzpatrick, 1999; Seston et

al., 2009), poor organisational culture and isolation from other healthcare professionals (Gidman,

2011; Eden et al., 2009; Cooper et al., 2009; Seston et al., 2009; Elvey et al., 2015; Jacobs et al.,

2011; Jacobs et al., 2014).

Pharmacists are taking on increasingly clinical roles, with community pharmacy now providing acute

and long-term medicines management, alongside traditional pharmacy services such as dispensing

of medicines. Given this change to pharmacists’ role, together with increased work pressure and the

lack of formal support structures during the transition period, it is important to explore the

transition challenges NCPs experience as novice practitioners. This paper therefore presents findings

from a study addressing the research question, ‘What are the challenges faced by NCPs at transition

to practice?’ focussing specifically on those perceived to be most important.

METHODS

This study used the nominal group technique (NGT) to identify the challenges faced by NCPs as they

transition to independent practice, and to determine their relative importance, as perceived by

pharmacists and staff they work with (Clive, 2012; Foth et al., 2016). Developed by Delbecq, NGT is a

data collection technique that allows problem identification alongside solution generation. It allows

for all participants in a group discussion to have their voice heard through an initial stage where

responses to a research question are made on an individual basis, following which responses are

ranked in terms of their importance to question under investigation (Delbecq et al., 1971). As NGT is

more structured than traditional focus groups, it is better suited to the problem solving and

consensus building aim of the research question. This mixed methods technique combines the

benefits of social group dynamics with equal individual participant contribution (Clive, 2012). The

study was approved by the University of Manchester Ethics Committee 3 (ref.230915).

Participants

To achieve maximum variation, two variables (job role and workplace setting), were used to

purposively recruit participants from four populations: novice community pharmacists (NCPs)

[qualified up to 12 months]; early career pharmacists (ECPs) [qualified between 2-3 years] to provide

insight into recent experiences of transition; pre-registration tutors (PRTs) to provide views of those

who play a central role during pre-registration training and who research suggests are important to

some newly qualified pharmacists in terms of advice and support following registration(Jee, 2014;

Willis et al., 2011); and pharmacy support staff, as this group play a role in supporting NCPs’ learning

and may work as dispensers, pharmacy technicians, accuracy checking technicians (ACTs), and non-

pharmacist managers (often dispensers or pharmacy technicians) (Willis et al., 2011; Jee, 2014;

Bradley et al., 2016).

Recruitment

Targeted recruitment from independent (<5 branches), supermarket, small (5-100 branches),

medium (100-250 branches) and large multiple pharmacies (>250 branches) was used to recruit

participants working in a range of community pharmacy settings. From 241 pharmacies located

within a 6-mile radius of the research institution, 35 were identified as providers of pre-registration

training and confirmed (through enquiry) to have NCPs working there regularly: study invitations

were sent to these pharmacies in North West England. Those who expressed an interest in the study

were provided with an information sheet before consenting to take part. Snowball sampling was also

used. Participants were offered a £20 gift voucher for taking part.

NGT process

Nominal group discussions, lasting 90-150 minutes, were led by the first author, co-facilitated by one

of the co-authors, and conducted between November 2015 and April 2016. A five-step NGT process

was used(Foth et al., 2016). First, participants were presented with the research question ‘What are

the challenges faced by NCPs at transition to practice?’ and asked to individually write down

examples of challenges on sticky notes. In the second step, participants called out challenges in

round robin fashion; the sticky notes were then displayed on a flip chart. Participants were

encouraged to note down any additional ideas until no new challenges emerged. In step 3,

discussion was guided by the sticky notes identified as challenges on flip charts. After the discussion

the author and co-facilitator categorised the sticky notes into themes and presented this to the

participants for verification [through checking and agreement] in step 4. In the final step,

participants individually selected five challenges they considered most important and ranked them

in terms of importance. Discussions were digitally audio-recorded, with written consent, transcribed

verbatim and all flip charts and sticky notes were kept to support analysis.

Data analysis methods

Data analysis began during the nominal group discussions, where sticky notes were categorised into

broad themes capturing different types of challenges (in step 4, described above). Following this, in

step 5, participants were asked to select from all the challenges reported the five they perceived as

most important for NCPs. The authors then allocated a score of 5 to the challenge ranked as most

important, and 1 to 5th most important challenge. Based on the relative ranking from participants, a

total score was then calculated for each of the items to give a final rank from each group. Final

rankings from all groups were compared by the first author (EM). Where groups described

challenges differently, EM reviewed group discussions to standardise themes and reach a consensus

with co-authors.

Anonymised transcripts were analysed thematically using NVivo 10. Given that little was known

about the research topic, inductive thematic analysis was used to derive data-driven themes,

without use of pre-existing theory (Braun and Clarke, 2006). The author re-read the transcripts,

highlighting and coding keywords and phrases. Categorising similar statements and phrases, and

organizing them into themes allowed for an initial description of challenges. Comparisons of

categories were made during successive coding of transcripts and also compared to the initial

theming of challenges produced during the discussion, which had been verified by participants

(Sanders, 2014). The first author (EM) led data analysis. From early coding through to reaching final

interpretation EM met with her co-authors regularly to reach consensus in analysis and

interpretation.

RESULTS

Participants

Twenty-five participants took part in five nominal group discussions as detailed in Table 1.

Participants were comprised of seven novice community pharmacists (group 1), five pre-registration

tutors (group 2), four early career pharmacists (group 3), three pharmacy support staff (group 4) and

six pharmacy support staff (group 5). All support staff were female and had between 3 and 18 years’

experience of working in community pharmacy. Of the pharmacists taking part, half were female.

Pharmacist participants had been qualified for between 3 months and 18 years; pharmacists studied

at 7 different universities. Of these, eleven participants were transitioning pharmacists (i.e. up to

three years’ experience) and included five female participants. All discussions were held at the

authors’ institution, except for group 5, which took place in a private venue local to participants.

Quotes are used to illustrate findings, and 2–part identifier codes are used to identify the

participant’s role (i.e. NCP, or PSS(1) and PSS(2) for two pharmacy support staff groups), followed by

an individual ID number within the group (i.e. 1,2,3).

Findings

Challenges experienced by NCPs resulted from the novice interacting with their workplace

environment. Specifically, challenges were centred on the demands of the job, workplace

environment, and how the novice reacted to these stressors. Crucially, the absence of support

limited the extent to which NCPs could minimize the effects of work/role/job-related stressors and

how well they were able to cope with challenges.

Findings are presented of the challenges NGT participants identified as most important. These were

(in order of importance): relationship management; confidence; decision-making; being in charge

and accountable and adapting to the workplace. The only challenge identified by all five groups as

important was relationship management. The relative importance of challenges varied between the

groups; most dissonance was noted between pharmacist and pharmacy support staff perceptions of

whether adapting to the team was a challenge for NCPs (Figure 1). In addition, discussions suggested

a fear of appearing incompetent and being accountable made NCPs less willing to delegate to

support staff, seek their help or entrust important tasks to them. Support staff also felt that NCPs

lacked affective skills important for managing others, which contributed to tensions.

Relationship management

Transition to independent practitioner changed the role, responsibilities and relationships of NCPs

within organisational structures. Novices found themselves heading an ‘inverse hierarchy’, where

upon qualification NCPs [often the least experienced team member and typically in their early

twenties] commonly lead and managed a more experienced team of older colleagues.

“You have to lead the pharmacy team as the pharmacist, and [.…] that’s what I found quite difficult …

all of a sudden you’re in that position. It’s quite a learning curve.” NCP4

Pharmacy staff believed that NCPs were unsure how to assert their authority and threatened by

qualified support staff, especially when delegating responsibility for accuracy checking. Differences

in expectations also caused NCPs to clash with non-pharmacist managers. Analysis further suggests

that the lack of definition, clarity, and consistency about the limits of responsibilities and priorities of

team members, perpetuated power struggles within the team and contributed to role ambiguity.

“It’s a power struggle when you’ve got a manager that is a non-pharmacist that doesn’t understand

your professional liabilities..[…]...as a newly qualified, [you] just didn’t know where you stand. That

happens when the manager says, ‘Do this’, and, ‘Do that’. And the newly qualified, under pressure,

says, ‘Oh right, maybe I should do that, because that’s what the manager’s telling me’….” PRT5

Participants described a ‘wall’ or ‘divide’ between support staff and NCPs. Both pharmacists and

support staff partly attributed this ‘divide’ to NCPs lacking the skills and confidence to effectively

manage colleagues, whilst recognising their roles within the team. The inability to manage

relationships was a source of job-related stress, and perceived as detrimental to effective role

identity development, teamwork, and assimilation of the NCP into their team. As professionally-

isolated practitioners, NCPs reported needing support to manage relationships more effectively.

Confidence

Novices noted that they lacked professional confidence and the ability to stand their ground. They

struggled to influence colleagues, to exercise autonomy or authority to make decisions, as they had

no experience of autonomy as trainees (Jee et al., 2017).

“I’d found an error…… Ranitidine for a 10-week old baby, it was 15 times the amount you’d normally

have. The dispenser had dispensed it, so I said ‘This is wrong’; but then she questioned me for ages

and wouldn’t believe me when I said it was wrong.” NCP5

“Where dispensers know you’re newly qualified, sometimes they take advantage of that …. you

should be in charge of the pharmacy, but they think they’ve got an upper hand over you…..” NCP4

Support staff and tutors also thought NCPs lacked confidence, or were weak and vulnerable to

coercion by staff. To overcome this, tutors advocated that NCPs ‘appear confident’ and build

resilience. Despite this, NCPs’ perceived self-efficacy [belief in one’s ability to execute or achieve a

goal] was low. This was demonstrated by their struggle to delegate tasks, organise and manage

theirs and others’ workloads and make timely and effective decisions. Pharmacy support staff

reported NCPs’ approaches to tasks and response to stressful situations as a challenge:

“… they [NCPs] can be faced with a problem and they will go through absolutely every single option

and really deliberate over it, whereas I find more experienced pharmacists will be like…. ‘Well, what

does the patient need and how can I do that for them?’; whereas newly qualifieds will weigh up

‘What does this mean for the patient, what does this mean for me’, for every option - and it can take

a while sometimes.” PSS(2)3

The NCPs’ ability to manage workload and cope with role stress was also hampered by the lack of

available resources [adequate staff, time for reflection, consultation with experienced peers] that

may have helped mitigate the effects of the challenges. NCPs perceived exposing gaps in their

knowledge as a weakness, or lacked the insight to recognise the limitations of their capabilities.

Consequently, novices failed to seek support when needed, and often were unaware what support

was available to them.

“There was no clinical support in branch, so if you need to call someone when you have a dilemma,

who do you call? There are things available, but you just don't know that as a newly qualified.” ECP3

Furthermore, teams, employers and managers did not appear to recognise that learning was an

important part of the transition period and expected NCPs to know procedural aspects of pharmacy

practice.

“….they [NCPs] know everything about medicines but they don’t know the fundamental basis of how

a pharmacy runs….” PSS(2)1

“They [PSS] expect you to know everything. Of course, you've not worked in the shop, or you've been

there one day, and now, you're a manager, and they expect you to know everything, they expect you

to know right away……” ECP1

This pressure ‘to know’ may have limited the ability of NCPs to manage the team’s expectations and

prevented them from feeling safe and confident as a novice/learner. Consequently, NCPs lacked

confidence in asserting their right to support in the workplace.

Decision-making

Effective decision-making is a crucial professional skill for NCPs because as sole practitioners, they

hold ultimate responsibility and accountability for their own actions as well as those of their support

team (Byrne, 2013; Schon, 1988). To make effective decisions, NCPs had to clearly define problems,

consider multiple solutions, then identify and evaluate the most appropriate solution. Furthermore,

they had to apply knowledge, balance experience, awareness, critical thinking, and reflective

practice skills to resolve clinical, legal, or ethical issues appropriately. However when newly-

accountable, NCPs found applying professional judgement challenging.

“I wasn't actually so nervous about my clinical knowledge because I'd just passed the exam; I was

also very much involved with all the professional decision-making with my pre-reg tutor and the

other pharmacists. […] But yet, when I was on my own, I felt pressured by that. It's not so much the

clinical knowledge, it's about applying it to that situation.”….ECP4

Applying knowledge to new contexts and situations without [peer] support increased uncertainty in

decision-making, particularly when objective, balanced judgements were needed. The uncertainty

NCPs felt was caused by a lack of confidence, inexperience, the threat of professional liability,

decisions involving controlled drugs and unusual/ unfamiliar prescribing patterns.

“I found it difficult to balance when to let something go or not. And as a rule of thumb, I didn't let

anything go…. …..And it doesn't matter that you know that such and such interact, but if they've been

on it, especially for ten years, you've established it's probably safer to keep them on it, than to take

them off it. But no one could tell me that, until I'd learned it myself.” ECP4

Novices’ inexperience, combined with a need to make decisions quickly in a highly pressurised work

environment, was likely to increase mental workload and mental strain. NCPs also lacked the

reassurance and ‘sense-checking’ function previously provided by their pre-registration tutor.

Furthermore, as one pharmacist explained, being professionally isolated limited interaction with

professional peers and restricted opportunities for support, shared learning, and feedback:

“I think, generally, if you made a decision, I wouldn't know if you'd make the same decision as me.

That's never discussed, is it, when I [feel], ‘I don't know whether to let this go or not’, you've got no

idea whether other pharmacists would let it go.” ECP4

Being in charge and accountable

Full and immediate accountability for patient care was overwhelming for NCPs who had no prior

personal experience of sole professional responsibility. Prior to registration, NCPs had spent a year in

practice working alongside their pre-registration tutor, who they deferred to, and who took ultimate

responsibility. The stress caused by being fully accountable was further compounded by the fear of

making errors and the threat of litigation.

“So when there’s a query as a pre-reg, you know you’re not going to make the final decision. So when

you don’t know what to do, you know the pharmacist is still going to sort it out. In the back of your

head you think ‘It’s fine the pharmacist will sort it out!’ But then the first time it happened to me I

just switched off halfway through because I wasn’t sure. And then the patient comes back to you for

your decision and you realise that ‘I need to choose!’ So it’s after that moment when I realised it’s all

down to me. I need to make the final decision.” NCP1

NCPs’ reacted to being accountable by exercising caution and adhering strictly to regulations,

demonstrating a risk-averse approach to practice. This manifestation of the pressure/stress

associated with decision-making was noted in the NCP discussion when every participant reported

that they always placed regulations before patient needs, through fear of litigation.

“…...you go from being a non-decision-maker to a decision-maker, overnight I guess. It’s quite a

change in responsibility….the first few months are really hard.” NCP6

Transition was therefore heightened by the loss of the supportive designated pharmacist they had

had during pre-registration training and not replaced with another support structure.

“I think probably when you’re newly qualified […] it’s the fact that you’ve not got that safety net and

that any mistakes…any potential errors, you’ve realised that the patient’s health is in your hands

rather than someone else’s…” PRT1

As trainees, NCPs depended on others, yet after transition became registered accountable

pharmacists that others depended on, with little preparation on how to work in or manage a team

and indeed a pharmacy.

“The expectation to be an experienced pharmacist on day one…. I'm not even talking about the

clinical checking, we could clinically check a prescription… It's about running the whole show! I

haven't done this before, don't expect me to be able to do it to the same level as someone who's

been doing it for ten years.” ECP4

Adapting to the workplace

Adapting to the workplace and being accepted [professionally and personally] by the team was

made challenging by procedural inconsistencies between pharmacies and the hidden rules/social

norms of the workplace. NCPs learned that conforming to local norms facilitated adaptation and

acceptance. By contrast, support staff generally felt workplace ‘rules’ were necessary/helpful but

that perhaps NCPs did not ask often enough about ‘how things were done’. Support staff also

expressed a clear sense of ownership about their stores/customers, a sentiment they felt NCPs

lacked.

“I always say to my girls if ever I’m not there this is your store. You should always be able to say ‘This

is how we work here’, because these people [NCPs] will move on to another store and you’ll be left to

pick the pieces up from a complaint. So it’s [about] taking ownership.” PSS(1)1

As sole practitioners, NCPs reported many instances where support from their immediate team was

invaluable. Despite this, group discussions revealed a real disconnect in how pharmacists and

support staff viewed and understood each other’s roles:

“Some people come in and they are the pharmacist, so they think they’re the captain of the ship. The

ACT or the technician is the captain of the ship, they [pharmacist] just work alongside the captain.

But they don’t want to work alongside, they want to actually steer the ship. And it doesn’t work like

that.” PSS(1)1

This suggests NCPs experienced role ambiguity and role conflict in their transition to independent

practitioner. Pharmacists [and in particular NCPs] approached their roles very hierarchically,

focussing on their professional responsibilities and gaining colleagues’ respect. As a consequence,

NCPs perhaps failed to fully recognise/appreciate the capabilities of their support staff and trust

them. Experienced pharmacy staff who perceived they held valuable competencies not

acknowledged by NCPs, recognised that NCPs often lacked the speed, self-awareness, and

confidence of experienced pharmacists. Paradoxically, professional hierarchy or a lack of explicit

guidance for the role of the pharmacy team in easing the transition of NCPs, prevented both sides

from seeking/offering support, which impeded teamwork.

“I worked with a newly qualified locum a couple of weeks ago and it was just little things that they

were doing that I didn’t really understand…[…]…it’s quite hard for me to tell them sometimes. I do try

and subtly hint, but I feel like it’s not my place to [sic] say ‘This is what you need to do’.” PSS(1)3

Study limitations

The recommended group size of up to seven participants per group was not consistently achieved

[group size ranged from three to seven] hence a second discussion group for pharmacy support staff

was held (McMillan et al., 2014). The relatively small sample size and geographical location, may

limit transferability of the findings to NCPs in other community pharmacy settings. Moreover, whilst

some studies have found differences in the practice of employed vs. locum factors, the impact of

such factors or the influence of the workplace environment were beyond the scope of this study

(Seston et al., 2009; Shann and Hassell, 2006). Finally, male pharmacists were proportionally over-

represented amongst participants, (55%) compared with current pharmacist population (40% of

whom are male) (General Pharmaceutical Council, 2014).

DISCUSSION

Findings and implications

This paper is the first to explore transition to independent practitioner for NCPs and identify the

challenges perceived as most important by pharmacists and pharmacy support staff. The five most

important challenges faced by NCPs at transition were; managing relationships, confidence,

decision-making, being in charge and accountable, and adapting to the workplace.

NCPs experienced emotional stress, low self-esteem, and distress in response to professional

accountability, fear of making errors or not meeting expectations of others. In the context of a

highly-pressured work environment, these stressors diminished the psychological capacity of NCPs,

and resulted in them feeling overwhelmed. Added to this, validation and reassurance of their

capabilities was now lacking given the sudden loss of tutor support/supervision and the absence of

another support structure following registration.

Discussion about workplace relationships suggest the emergence of a perceived ‘divide’ between

pharmacists and their team, which is concerning. Given that this challenge was ranked highest, i.e.

most challenging at transition overall, findings suggest that a good organisational learning culture

and a healthy work environment are of critical importance to the novice practitioner. Kramer’s body

of evidence about the importance of healthy work environments for novice nurses supports this

(Kramer et al., 2013).

To understand the implications of findings from this study, Karasek’s job-demand-control-support

(JDCS) model proves valuable (Kristensen, 1995; Laschinger et al., 2001; Karasek, 2008). This focuses

on two aspects of the work environment: job demands and job control. ‘Job demands’ are stressors

or challenges, such as workload, responsibility, degree of concentration required, and role conflict.

‘Job control’ refers to the extent to which it is possible to control work activities. It has two

components: ‘skill discretion’ (variety in the workload and learning opportunities) and ‘decision

authority’ (ability to make decisions about a job, influence colleagues or company policy).

The challenges (‘job demands’) experienced at transition, can be mitigated by increased job control

(or decision latitude) and social support. Karasek’s JDCS model concludes that ‘active jobs’[classed as

high demand, high control] are the best jobs for psychological well-being. Jobs with low control and

high demand are known as high-strain jobs (Pelfrene et al., 2002). Strain refers specifically to the

negative impact or toll caused by high demand and low control nature of the job. Understanding job-

strain may help to explain why the context of the community pharmacy setting makes transition

particularly challenging for NCPs.

The relative levels of job demands and job control allow a job to be classified into one of four

categories, based on the level of strain it causes; high-strain jobs (high demand, low control), passive

jobs (low demand, low control), active jobs (high demand, high control) and low-strain jobs (high

control, low demand). Ideally, NCPs should have active jobs which promote and support personal

and professional development and learning. Study findings suggest that NCPs have high strain jobs

(caused by the challenges reported and NCPs’ inability to control their work and influence

colleagues), which are exacerbated by a lack of social support. Community pharmacists are

considered professionally-isolated practitioners: having a high-strain job may lead to iso-strain and a

‘noxious’ work environment. Workers in this environment experience the highest stressors and most

negative outcomes of work (Sargent and Terry, 2000; Pelfrene et al., 2002).

In the present study, ‘relationship management’ created stressors/job demands including

negotiating inverse hierarchy, workplace conflict and ‘power struggles’. Carrying out leadership

duties was challenging for many NCPs who reported lacking the interpersonal and social skills

required to effectively manage the power differentials with colleagues. Despite this, little formal

management training exists before registration to prepare novices for this aspect of their role.

Whether or not NCPs’ job titles were managerial, leadership duties were perceived to be an inherent

part of a novice community pharmacist’s role (Jacobs et al., 2014).

In contrast to nursing and medical novices who reported challenges from working within a

traditional hierarchy, NCPs experienced ‘inverse hierarchy’ (Brennan et al., 2010; Duchscher, 2001).

Despite being at the top of the inverse hierarchy, NCPs lacked experience and confidence and

remained highly dependent on their teams for support. To fit in and get support, NCPs had to

achieve a balance of being accepted [personally and professionally] by colleagues who were more

experienced but ranked lower in organizational and professional hierarchy. Negotiating the inverse

hierarchy was a complex challenge that increased NCPs’ job demands.

The level of job control was lowered by NCPs’ inexperience, their struggle to adapt to workplace

culture and the lack of clarity about their own roles and responsibilities, and those of their support

teams. This may have hindered professional socialisation and acceptance and have resulted in

increasing role ambiguity for NCPs, a phenomenon reported by novices in nursing and medicine

(Chang and Hancock, 2003; Tallentire et al., 2011). (Maxwell et al., 2011). Certainly, NCPs were

considered by other pharmacy staff to be too slow and meticulous, and as holding up the workflow

of the pharmacy by participants in our study. NCPs were further described as lacking skills in how to

delegate, act autonomously, manage workload, and cope effectively with stress, which limited the

control they had over work. In addition, novices lacked confidence, and felt pressured by staff ‘to

know’ what to do, which made it hard for them to gain respect, influence their teams, and was an

indication that decision authority was lacking, which reduces job control, and is consistent with high

strain jobs. To address this, and to support NCPs during transition, it might be worthwhile to allow

NCPs to be slower when they first enter practice – moreover, to conceptualise NCPs as learners.

NCPs’ application and clinical reasoning skills were not fully developed at the start of transition.

Evidence from nursing and medicine suggests novice practitioners struggle because they lack

experience of context-driven decision-making (Benner, 1982; Prince et al., 2004). Inexperience and a

lack of support limited the development of decision-making skills, reducing skill discretion (the

breadth of skills the novice has to complete a task), and therefore lowering job control.

The fact that the first day of independent practice coincides with the end of tutor support, without

another support structure taking its place, reduces the possibility of a seamless transition (Kumaran

and Carney, 2014). With no ready access to peers, NCPs face professional isolation while

experiencing a high job strain role. Unlike novice nurses and doctors, NCPs acquire full and

immediate accountability for patient care from day one of registered practice (Whitehead and

Holmes, 2011). From the start of transition, when they begin to make decisions, the additional

pressure of full, immediate accountability may increase psychological demands.

The combination of stressors and challenges faced by NCPs with the pressured, professionally-

isolated workplace environment, suggest NCPs may struggle to deliver safe, effective practice. The

challenges reported in this study suggest that NCPs need support to meet the recently revised

standards for pharmacy professionals set out by the regulatory body, (General Pharmaceutical

Council, 2017). Findings suggest that NCPs may struggle to demonstrate some of the nine standards,

in particular those related to using professional judgement and demonstrating leadership. As the

role of community pharmacists evolves to become more clinically demanding (through roles for

experienced pharmacies in urgent and intermediate care, and general practice, with some general

practice roles for novices), there is potential for job demands to increase further, making transition

increasingly challenging. Stressful transitions in medicine and nursing have shown negative

implications for patient safety, and based on findings from this study, it is possible that stressful

transitions of NCPs may have some implications for patient safety in community pharmacy.

Conclusion

This paper provides novel insights into the challenges associated with transition to independent

practitioner together with organisational issues such as workplace conflict and the pressures

associated with inverse hierarchy experienced by NCPs. Applying the JDCS model (Karasek, 2008) it

appears that as isolated practitioners in pressured environments, NCPs experience job ‘iso-strain’ as

a result of working in ‘noxious’ learning environments. The addition of a social support structure

from professional peers/colleagues may mitigate the effects of transition challenges and address

isostrain experienced during transition. If this were to happen, NCPs’ jobs could be transformed into

‘active’ jobs, where the level of support and other protective measures are sufficient to ensure

learning and development and limit strain of a challenging job (Jones and Bright, 2001).

Future research should explore how factors such as undergraduate programme, pre-registration

training experiences, locum or employee status, organisational culture and the workplace

environment influence the transition period. Research is needed too, to explore what types of

interventions could be developed and implemented to ease transition problems. Valuable contextual

insights into the role of the environment, the nature of the challenges and their effect on the novice

may be used to inform policy on foundation practice, education reform, and continuing fitness to

practise. Findings may inform recommendations for NCP training in affective, interpersonal and

leadership skills.

Acknowledgements

This work was supported by the 2015 Leverhulme Award from Pharmacy Research United Kingdom

(PRUK). PRUK provided financial support for conducting the research but had no involvement in the

study design, data collection, analysis or interpretation, writing of the report or in the decision to

submit the paper for publication. The findings and views stated in this paper are those of the

authors, and not those of PRUK.

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Figure 1 Group comparisons of the five challenges identified as most important by each discussion group.

NCPs ECPs PRTs PSS 1 PSS 2

Decision-making Decision-making Relationship management

Relationship management

Relationship management

Being in charge and accountable Low confidence Low confidence Adapting to the

workplaceAdapting to the

workplace

Lack of support Being in charge and accountable

Being in charge and accountable Low confidence Customer service

and patient care

Relationship management Relationship

management Decision-making Customer service and patient care Low confidence

Adapting to the workplace

Customer service and patient care

Workplace pressure

Workplace pressure

Workplace pressure

Least important

Most important

Table 1 Characteristics of interview participants

ID Gender Time in practice

Workplace setting Role

Group 1Novice community pharmacistsn=7

NCP1 M 3M Supermarket LocumNCP2 M 3M Large multiple LocumNCP3 M 3M Large multiple LocumNCP4 F 11M Large multiple EmployeeNCP5 M 3M Independent LocumNCP6 M 3M Small multiple EmployeeNCP7 F 3M Small multiple Employee

Group 2Pre-registration tutors n=5

PRT1 M 8Y Small multiple EmployeePRT2 M 4Y Large multiple EmployeePRT3 F 18Y Supermarket EmployeePRT4 F 4Y Small multiple EmployeePRT5 F 18Y Independent Locum

Group 3 Early career pharmacists n=4

ECP1 F 2Y Med multiple EmployeeECP2 F 2Y Large multiple EmployeeECP3 M 3Y Small multiple EmployeeECP4 F 2Y Large multiple Employee

Group 4Pharmacy support staff n=3

PSS(1)1 F 14Y Large multiple Employee -Non-pharmacist manager for 4 years

PSS(1)2 F 8Y Large multiple Employee - ACT for 4 years

PSS(1)3 F 3Y Large multiple EmployeeGroup 5Pharmacy support staff n=6

PSS(2)1 F 9Y Independent Employee

PSS(2)2 F 18Y Independent EmployeePSS(2)3 F 13Y Independent EmployeePSS(2)4 F 9Y Independent EmployeePSS(2)5 F 7Y Large multiple EmployeePSS(2)6 F 18Y Large multiple Employee - ACT for 6

years= –

Key Respondent roleNCP Novice community pharmacistECP Early career pharmacistPRT Pre-registration tutorPSS Pharmacy support staffACT accuracy checking technicianTime in practice

M = monthsY = years