SCIENCE AND PRACTICE

Journal of the American Pharmacists Association xxx (2021) 1e11

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RESEARCH
Perceptions of working conditions and safety concerns in
community pharmacy
Mercedes Clabaugh, Jenny L. Beal, Kimberly S. Illingworth Plake*

a r t i c l e i n f o a b s t r a c t

Article history: Background/Objective: Working conditions within community pharmacy can impact pharmacists
Received 31 March 2021 and their ability to provide safe patient care. The objective of this study was to determine phar-
Accepted 7 June 2021 macists’ perceptions of working conditions while controlling for respondent (years of experience,
degree, work status) and workplace variables (prescription volume, type of community setting).
Methods: This mixed-methods study used a cross-sectional survey to investigate community
pharmacists’ perceptions of company climate (at the store level, corporate level, as well as fear
of discipline), workflow issues, and career satisfaction. Items utilized a seven-point Likert-type
response format (1 ¼ strongly disagree to 7 ¼ strongly agree). Linear regression was used to
assess relationships between perceptions and years of experience, degree, work status, pre-
scription volume, and type of community setting. A free-response question captured per-
ceptions of safety concerns. An adapted version of the Agency for Healthcare Research and
Quality integrative model of health care working conditions on organizational climate and
safety was used as a framework for this analysis.
Results: Respondents working in national chains had significantly more fear of being disciplined
for following policies to promote safety and addressing patient safety concerns than respondents
in independent (P < 0.001) and grocery and big box stores (P < 0.001), when controlling for years of
experience in community pharmacy, degree, and prescription volume. Most participants (n ¼ 805,
96.9%) indicated organizational or company level factors were the most substantial threat to safety,
with work design and quality emphasis being the second most frequently mentioned hazards.
Conclusion: Company climate and workflow were perceived negatively in all community settings
but were perceived the most negatively by those working in chain pharmacies. A majority of phar-
macists feared being disciplined for addressing safety concerns with management, which may be
detrimental to patient safety. Further research on how to improve working conditions is warranted.
© 2021 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Background pharmacies and its impact on patient safety.1 Although pre-

In January 2020, Ellen Gabler reported on pharmacists’
perceptions of poor working conditions in chain community
Disclosure: The authors declare no relevant conflicts of interest or financial
relationships.
Previous presentation: Clabaugh M, Beal JL, Illingworth Plake KS. Percep-
tions of Working Conditions and Safety Concerns in Community Pharmacy.
American Pharmacists Association Annual Meeting 2021, Online, March 2021
[Podium Presentation].
* Correspondence: Kimberly S. Illingworth Plake, BSPharm, PhD, FAPhA,
Assistant Dean of Assessment and Learning; and Associate Professor of
Pharmacy Practice, College of Pharmacy, Purdue University, 575 W Stadium
Mall Ave., West Lafayette 47907, IN.
E-mail address: kplake@purdue.edu (K.S. Illingworth Plake).
ORCID
Jenny L. Beal: https://orcid.org/0000-0003-3997-8893
vious research has described pharmacists’ concerns with
working conditions in community settings,2 little is known
about the factors contributing to such conditions or their
impact on pharmacist and patient safety.
Concern over working conditions in community pharma-
cies is not new; in fact, a keynote presentation at the American
Pharmaceutical Association (now American Pharmacists As-
sociation) meeting in 1937 addressed many of the issues that
continue to occur today, such as long work hours.3 More
recently, in 2019, 75% of pharmacists working in chain phar-
macies reported high levels of stress regarding the amount of
work they are expected to complete, which is an increase from
60% in 2014.2,4 Further, 71% of community pharmacists
working in chain settings reported experiencing high levels of
stress due to inadequate staffing in 2019.2 In 2014, 67% of chain

https://doi.org/10.1016/j.japh.2021.06.011
1544-3191/© 2021 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE
M. Clabaugh et al. / Journal of the American Pharmacists Association xxx (2021) 1e11
Key Points
Background:
 Community pharmacists working in chain pharma-
cies report high levels of stress regarding the amount
of work they are expected to complete and staffing
levels.
 Pharmacists play a critical role in protecting patient
safety by ensuring medications dispensed or
administered to patients are appropriate, but they
may be unable to properly fulfill this role if working
conditions are not optimal.
Findings:
 Assesses community pharmacists’ perceptions of
working conditions and patient safety while control-
ling for respondent and workplace variables.
 Compares perceptions between different types of
community pharmacy settings (national chain, gro-
cery or big box store, and independent).
pharmacists also identified inadequate pharmacy technician
staffing as a stressor and 42% indicated stress related to lack of
pharmacist staffing.2,4 Frequent interruptions, lack of time to
complete tasks, and difficult interactions with patients have
also been cited as major contributors to work-related stress in
the community pharmacy setting.5
Employer support may also influence pharmacists’ per-
ceptions of working conditions. When comparing community
pharmacists by setting type, those working in chain settings
were less likely to report that their company looked out for the
good of their pharmacists.5 Moreover, chain community
pharmacists were more likely to believe supervisors were
unaware of existing work problems than their independent
counterparts.5
Working conditions in community pharmacies also affect
patient safety and outcomes. Factors positively influencing
safety include: the clear delineation of employee roles, the
ability of staff to perform roles and responsibilities adequately,
appropriate staffing, work-related pressure, and speed at
which pharmacists feel they need to complete tasks.6 Ac-
cording to the Agency for Healthcare Research and Quality
(AHRQ) community pharmacy survey, some important safety
culture factors in the community setting include discussing
mistakes, having proper training for staff, and being
adequately staffed.7 Pharmacists play a critical role in pro-
tecting patient safety by ensuring medications dispensed or
administered to patients are appropriate,8 but they may be
unable to properly fulfill this role if working conditions are not
optimal.
Objective
This study sought to examine community pharmacists’
perceptions of working conditions at the store and company
level and their perceived ability to address patient safety is-
sues without fear of being disciplined.
2
Methods
The data discussed in this paper are part of a larger study to
assess community pharmacists’ perceptions of their working
conditions, preferred solutions to improve working conditions,
and readiness to participate in influencing working conditions
through policy or change in work status.9 This paper will focus
on pharmacists’ perceptions of working conditions. This study
was determined to be exempt by the Purdue University Insti-
tutional Review Board.
Instrument
A Web-based Qualtrics survey (Provo, UT; https://www.
qualtrics.com/about/) assessed pharmacists’ perceptions of
company climate (13 questions), workflow issues (9 ques-
tions), and career satisfaction (3 questions) using a 7-point
Likert-type response format with agreement response an-
chors (1 ¼ strongly disagree and 7 ¼ strongly agree). Working
conditions were categorized as either having to do with
company climate (e.g., company policies promote a safe work
environment) or workflow issues (e.g., my pharmacy has staff
necessary to meet patient and customer safety). Pharmacists’
perceptions of company climate were assessed at both the
corporate/company level and store levels. Three items also
measured pharmacist job satisfaction. All working conditions
items were informed by previous literature,2,10,11 current
pharmacy organization goals,12,13 and concerns expressed in
Gabler’s New York Times article.1 Demographic characteristics,
including age, state where practice is located, terminal phar-
macy degree, type of community pharmacy (e.g., national
chain, grocery and big box store, independent, or other), cur-
rent work status, years of experience in the community
pharmacy setting, and average daily prescription volume, were
also collected. Current work status was collected to compare
those who were currently working and those who had left the
community pharmacy setting to control for biases that may
exist between these 2 groups of people. An open-ended
question was asked regarding the biggest safety concerns
with community pharmacy to collect any concerns that may
have not been captured in the quantitative portion of the
survey.
Sampling
To be eligible for participation, respondents had to be at
least 18 years of age, currently licensed as a pharmacist in the
United States, and either currently work in the community
pharmacy setting or have worked in community pharmacy
within the past 6 months. The survey was distributed via
anonymous posts on pharmacy-related Facebook pages and
through several state pharmacy association e-newsletters.
Facebook page coordinators were contacted about posting a
recruitment message outlining the purpose of the study and
the link to the survey. Nine state pharmacist associations and 2
pharmacy-related Facebook pages agreed to share the survey.
Data analysis
Exploratory and confirmatory factor analyses were used to
assess the appropriateness of using subscale scores for
 SCIENCE AND PRACTICE
Working conditions and safety in community pharmacy

analysis. Demographic data were analyzed using descriptive Table 1

statistics. Multiple linear regression was conducted to identify Demographics of study participants (N ¼ 1222)

relationships between perceptions of company climate, fear of Age n Year

discipline, workflow issues, and demographic characteristics. Mean (y) 1043 37.2
For all analyses, only respondents reporting working for a Range (y) 1043 24e69
national chain, grocery or big box store, or independent Years in pharmacy
pharmacy were included, due to the small sample size of re- Mean (y) 1061 12.6
Range (y) 1061 1e47
spondents reporting working at an “other” setting type. Lo-
n %a
gistic regression was used as a sensitivity analysis to test for Degree
robustness of findings where the data demonstrated a floor Bachelor of pharmacy 178 16.7
effect. An a priori alpha of 0.05 was used for all statistical tests Doctor of pharmacy 885 83.3
with Bonferroni corrections. Regionb
The AHRQ integrative model was utilized as the framework Northeast 191 18.1
Midwest 348 33.0
for coding qualitative responses.14 This model outlines orga-
South 406 38.5
nizational factors and their influence on working conditions in
West 110 10.4
health care.14 This model includes 3 domains: (1) core struc- Average # of prescriptions/weekday
tural domain, which includes leadership and organizational < 300 344 32.5
structural characteristics subdomains, (2) process domain, 300e499 381 36.0
which includes supervision, group behavior, work design, and > 500 333 31.5
quality emphasis subdomains, and (3) outcomes.14 The inte- Work status in community pharmacy
Current 1103 90.4
grative model was adapted to exclude the patient outcome
Past 6 mo 117 9.6
subdomain, since this study focused on pharmacists’ percep- Type of community settingc
tions on patient safety and did not assess patient outcomes National chain 674 63.4
directly. Responses were independently coded by 2 re- Grocery or big box store 281 26.4
searchers to themes within the adapted model. Differences in Independent 80 7.5
coding were then reconciled to achieve 100% agreement. Re- Otherd 28 2.6
sponses that did not fit into the integrative model were coded a
Calculated with a denominator equal to the number of responses to each
utilizing thematic content analysis and followed the same demographic item.
b
Based on the U.S. Bureau of the Census.
coding and reconciling procedure. c
Respondents were given the following options with examples: “National
Chain (Walgreens/Duane Reade, CVS, Rite Aid),” “Grocery/Big Box Store
Results (Kroger, Walmart, Costco…)”, “Independent”, or “Other.” If the participants
did not fit into one of the examples given, respondents self-defined which
setting type was most applicable.
Participants d
Other could include pharmacists in health system retail, outpatient, and
additional types of community pharmacy settings.
The total number of participants eligible for analysis was
1222, with representation from the District of Columbia and
significantly less negative perceptions of company climate
48 of 50 states (Table 1).
than those who had left within the past 6 months (P < 0.001).
Finally, perceptions of respondents working at stores with
Factor analysis moderate prescription volumes (300-499 prescriptions/d)
were less negative than those at higher volume ( 500 pre-
The subscales measuring company climate at the company scriptions/d) pharmacies (P ¼ 0.014).
and store levels, fear of discipline, and workflow issues, were When controlling for all other variables, respondents
supported by substantive evidence as well as exploratory working for independent pharmacies had significantly less
factor analysis. Findings from exploratory factor analysis sug- negative perceptions of company climate at the store level
gested removing one item from the subscale intended to than those working for national chains (P < 0.001) and grocery
measure company climate at the store level; this decision was or big box stores (P ¼ 0.001). Pharmacists responding to the
also supported by confirmatory factor analysis. After removing survey who worked at locations filling 500 or more pre-
this item, a good model fit was demonstrated for each subscale scriptions per day had significantly more negative perceptions
with a Comparative Fit Index > 0.95 and Root Mean Square of company climate than those filling 300 to 499 (P ¼ 0.011)
Error of Approximation < 0.065. prescriptions per day on average. Respondents who were still
working in the community pharmacy setting at the time of the
Company climate survey had significantly less negative perceptions than those
who had left within the past 6 months (P < 0.001).
Frequencies of responses to individual items are reported in The majority of respondents were afraid of being disci-
Table 2. When controlling for years of experience in the plined directly (65.2%) or indirectly (80.4%) for following
community setting, degree, and prescription volume, re- company policies designed to promote a safe work environ-
spondents working in an independent community pharmacy ment, such as taking breaks. Direct discipline was defined as
had significantly less negative perceptions of company climate receiving punishment for following the policy, and indirect
at the corporate level than respondents working for a national discipline was defined as being disciplined for the conse-
chain (P < 0.001) or grocery or big box store (P < 0.001). Those quence of following the policy (e.g., being disciplined for being
who currently practice in any community setting had behind on tasks due to taking a break). In addition,

3
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SCIENCE AND PRACTICE

Table 2
Pharmacist perceptions of community pharmacy working conditions

Item Total no. of responses Strongly Disagree Somewhat Neither Somewhat Agree Strongly
disagree disagree agree nor agree agree
disagree
Company climate Total n % n % n % n % n % n % n %
Corporate level
Policies promote a safe work environment 1218 435 35.7 274 22.5 173 14.2 40 3.3 159 13.1 93 7.6 44 3.6
Policies promote patient safety 1217 396 32.5 277 22.8 170 14.0 56 4.6 175 14.4 89 7.3 54 4.4
Policies promote employee well-being 1215 672 55.3 244 20.1 113 9.3 51 4.2 59 4.9 53 4.4 23 1.9

M. Clabaugh et al. / Journal of the American Pharmacists Association xxx (2021) 1e11
Policies support me in using my expertise to make 1219 215 17.6 206 16.9 166 13.6 93 7.6 245 20.1 215 17.6 79 6.5
professional judgments regarding patient care
Store level
Management promotes a safe work environment 1214 209 17.2 160 13.2 135 11.1 176 14.5 220 18.1 231 19.0 83 6.8
Management promotes patient safety 1206 199 16.5 172 14.3 133 11.0 203 16.8 191 15.8 213 17.7 95 7.9
Management promotes employee well-being 1201 262 21.8 182 15.2 142 11.8 172 14.3 190 15.8 183 15.2 70 5.8
Management support me in using my expertise to make 1202 142 11.8 120 10.0 103 8.6 152 12.6 228 19.0 297 24.7 160 13.3
professional judgments regarding patient care
Management encourages employees to follow 1211 54 4.5 40 3.3 33 2.7 83 6.9 143 11.8 492 40.6 366 30.2
corporate/company policies
Fear of discipline
I am able to follow corporate/company policies that 1213 415 34.2 219 18.1 140 11.5 111 9.2 103 8.5 154 12.7 71 5.9
promote a safe work environment without fear of
being disciplined directly
I am able to follow corporate/company policies that promote 1214 585 48.2 263 21.7 104 8.6 67 5.5 55 4.5 86 7.1 54 4.4
a safe work environment without fear of being
disciplined indirectly
I am able to address safety concerns with management 1207 340 28.2 239 19.8 135 11.2 117 9.7 137 11.4 172 14.3 67 5.6
without fear of being disciplined directly
I am able to address safety concerns with management 1207 387 32.1 274 22.7 136 11.3 99 8.2 114 9.4 137 11.4 60 5.0
without fear of being disciplined indirectly
Workflow issues
I have the time necessary to complete all tasks I am 1166 731 62.7 228 19.6 85 7.3 11 0.9 71 6.1 32 2.7 8 0.7
expected to complete
I have the time necessary to accurately verify prescriptions 1164 514 44.2 273 23.5 157 13.5 33 2.8 105 9.0 64 5.5 18 1.5
I have time to counsel patients so that they can safely 1160 584 50.3 253 21.8 138 11.9 30 2.6 82 7.1 55 4.7 18 1.6
use their medications
My pharmacy has the staff necessary to meet 1161 727 62.6 207 17.8 95 8.2 18 1.6 52 4.5 43 3.7 19 1.6
patient/customer safety
My pharmacy has the staff necessary to meet 1159 706 60.9 219 18.9 106 9.1 28 2.4 42 3.6 42 3.6 16 1.4
patient/customer satisfaction
My work environment allows me to focus on the 1160 642 55.3 239 20.6 130 11.2 39 3.4 71 6.1 31 2.7 8 0.7
task at hand
I am able to take breaks necessary to perform my job 1160 614 52.9 193 16.6 114 9.8 41 3.5 86 7.4 76 6.6 36 3.1
duties to the best of my ability
My work hours allow me to perform my job duties to 1161 488 42.0 230 19.8 133 11.5 89 7.7 103 8.9 89 7.7 29 2.5
the best of my ability
I often must work extra hours (unpaid) to complete tasks 1162 74 6.4 74 6.4 32 2.8 54 4.6 113 9.7 198 17.0 617 53.1

Working conditions and safety in community pharmacy
Figure 1. Perceptions of workflow issues, by setting type. Abbreviation used: rx, prescription.
respondents reported being afraid of being disciplined directly
(60.3%) or indirectly (68.2%) for discussing safety concerns
with management. Those pharmacists working in national
chain settings had more fear of being disciplined for following
policies to promote safety and addressing patient safety con-
cerns than respondents in independent (P < 0.001) and gro-
cery and big box settings (P < 0.001), when controlling for
years of experience in the community setting, terminal degree,
and prescription volume. Respondents working for grocery or
big box pharmacies were significantly more fearful of being
disciplined than those working at an independent pharmacy
(P < 0.001). Those who had left community pharmacy within
the past 6 months had more fear of discipline when compared
to those who currently worked in the community setting (P ¼
0.018) when controlling the same variables.
Workflow issues
Responses to individual items may be found in Figure 1.
Pharmacists working for independent pharmacies had signif-
icantly less negative perceptions of workflow issues than those
working for national chains (P < 0.001) and grocery or big box
stores (P < 0.001), when controlling for years of experience in
the community setting, terminal degree, and prescription
volume. Those working for a grocery or big box store also had
SCIENCE AND PRACTICE
significantly less negative perceptions of workflow issues than
those at national chains (P < 0.001) when controlling for the
same variables. Those who had left community pharmacy in
the past 6 months had significantly more negative perceptions
of workflow issues than those still currently in the community
setting (P ¼ 0.019) when controlling for the same variables.
Sensitivity analyses
Due to the floor effect present in the data related to per-
ceptions of company climate at the corporate level, fear of
discipline and perceptions of workflow issues, binary logistic
regression was used to assess the robustness of the findings
from the linear regression analyses.15 Similar results were
found for all comparisons, with one exception: for perceptions
of workflow issues, logistic regression did not detect any sta-
tistically significant differences between respondents
currently working in community pharmacy and those who
had left within the past 6 months.
Job Satisfaction
Only 27.9% (n ¼ 297) of respondents agreed that they were
satisfied with their current position. Only 36.9% (n ¼ 396) of
respondents agreed that they would still choose to be a
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SCIENCE AND PRACTICE
M. Clabaugh et al. / Journal of the American Pharmacists Association xxx (2021) 1e11

Table 3
Pharmacist identified safety concerns with community pharmacy (N ¼ 831)

Level, domain, definitiona Nb,c %d Example quotationse

Organizational 805 96.9
Supervision 51 6.1 “If I don’t do all this, I’ll have to stay 2 hours for free and get yelled at by my manager for clocking
Style out exactly on time. If I clock out on time and leave the work I get, I get yelled at for that. Once I got
Employee recognition yelled at for staying late to stop a major hospital from giving a pediatric patient in diabetic
ketoacidosis two different insulin scripts in completely different doses that would have put her in
hypoglycemia/coma.”
“Lots of don’t ask don’t tell attitude that promotes unethical and illegal behaviors and cannot be
reported due to fear of job loss.”
“No one seems to ever look at the drug interactions you catch or the things you are doing right.. it’s
only ever about what goes wrong. No one cares you tried to talk to a Dr back and forth all day. They
care about the bottom line.”
Work design 737 88.7 “Giving pharmacists a 30 minutes lunch break or 1 hour for pregnant moms to pump and eat can
Manageable workload make a huge impact positively in work conditions. Pregnant moms not able to sit or drink water
Resources/training working for more than 12 hours can cause a serious negatively health impact to which I am
Rewards concerned. When I was pregnant with my first child, I wasn’t able to eat or use the bathroom
Autonomy because I am constantly interrupted with immunizations. ie. influenza shots, doctor’s calls, patient
Employee Safety questions, telephones, technicians needing help, clerk not knowing what to do. The list goes on.
Having a chair in every pharmacy for pregnant moms will surely help the mom with her health and
making sure her health is taken care of. My biggest concern is making medications error from over
working and not taking breaks due to fear of falling behind. Even worse, losing a baby from
constantly standing and not able to use the bathroom which lead to UTI which in return does harm
to the baby and the mom. The work conditions in community pharmacy is very harsh and
dangerous to work in. We can not afford to make medications error and pharmacists need to eat.
We are not robots and I need to eat for my growing baby.”
“They use being “salaried exempt” as a way to get free work done from the pharmacists. We are
expected to go to work meetings and be on conference calls on our days off unpaid. We are made to
rush and do the job of a pharmacist and tech to keep the pharmacy afloat from understaffing. The
open environment, being constantly distracted from patients interrupting us (open floor plan), and
the phones ringing off the hook with not enough bodies to answer the phone leads to a truly
stressful environment that makes it difficult to safely multi-task. More mistakes are being made.”
“Not enough help! Quality help! Takes a long time to train someone and then they leave for better
pay and less stress”
“We can’t staff adequately because we can’t get paid adequately.”
“Corporate not backing pharmacist professional judgement when we decide not to fill a
prescription and encouraging us to fill it anyway just for patient satisfaction.”
Group behavior 47 5.6 “My position in a grocery store pharmacy has me working all phases of production and then I still
Collaboration have to ring out the customer and all of their groceries. I’m not above it, I simply don’t have the
Consensus time.”
“It is absurd that healthcare management would expect the pharmacist to drop whatever he is
doing to run the register or drive-thru so that a customer would not have to wait several minutes.”
Quality emphasis 361 43.4 “I am terrified every day when I leave work that I’ve made a mistake that could potentially harm a
Patient centeredness patient. It is such an unsafe environment for patients and pharmacists.”
Patient safety
Innovation
Outcome measurement
Evidence-based practice
“Something has to give and when it does, the patients pay the price with prescription errors. It’s not
fair to the patients. They deserve a pharmacist who can give their prescriptions the adequate
attention needed.”
“Making a fatal mistake when verifying prescriptions. I do not even have time to truly verify
prescriptions, instead I scan the prescription and hope for the best. In order to keep up I have to
verify at least 5-7 prescriptions a minute leaving no time to determine if the dose is appropriate, if
there any drug interactions or errors.”
“Everything is based on company profits (i.e., scripts to budget, tech hours to budget, pharmacist
hours to budget) instead of patient safety.”
“Would love to do med recs/mtms with my patients but I have absolutely no time for such things
because metrics are watched so closely”
“Pharmacies used to be able to afford safety features and automation but even that can no longer be
afforded”
Leadership 99 11.9 “Corporate puts too much emphasis on scripts filled by certain times and just getting refills in the
Values system and discipline pharmacists who don't meet the criteria.”
Strategy/style
“If I get a complaint I could be written up even if I had a valid reason that they had to wait I am
always in the wrong and must call to apologize even if they were wrong the patient is never wrong
and my professional judgment on not filling or refusing a patient is constantly being questioned
and must be defended against a patient who doesn’t know anything about my job or the logistics of
pharmacy billing dispensing and law.”

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 SCIENCE AND PRACTICE
Working conditions and safety in community pharmacy

Table 3 (continued )

Level, domain, definitiona Nb,c %d Example quotationse

Organizational structural 28 3.4 “My boss isnt even a pharmacist! Tells me to fill opiates as cash to keep complaints down...this
characteristics increases the opiate crisis and diminishes my personal values.”
Communication processes
Governance
Information technology
“Constant emails, texts, calls and visits from pharmacy DM regardless of how hard you work”
“Our volume is such that staff want to cut corners to save time (like staging prescriptions).”
Extra-organizational 117 14.1
Expectations 63 7.6 “but most of the pressure I feel comes from the patient.
Expectations from patients, People do not understand what is involved in the filling/verifying process and think all we do is slap
other providers, and a label on it. They don’t understand why it takes so long. This then affects my corporate patient
company satisfaction score.”
“Corporate pharmacy has over simplified and belittled pharmacists jobs to the point that the
patient (they prefer “customer”) has come to expect instant service. The general public needs to be
educated on the complexity and seriousness of this job. READ CAREFULLY. TWICE. We are being
swept away from a thought-provoking task of providing medicine to an individual to an over-
mechanized and automated rubber stamp/conveyor belt assembly line “I’ve been waiting two
minutes...isn’t it done yet?” world. Re-educating the public is the second greatest concern.”
Reimbursement 52 6.3 “PBMs will be the downfall of pharmacy. Customers are having choice removed from them due to
PBMs. Patients can no longer use the pharmacy of their choice and are having to to chains that are
more understaffed than mine with staff that they don’t trust. Some are choosing to spend more
money to stay at a preferred location.”
“Everything is about money and not about health or wellness. This leads to the company trying to
make a profit at any cost. With decreased reimbursement from insurance and PBM companies, the
pharmacies solution is to cost control which leads to less hours allotted to the stores and cut payroll
with increased pressure to perform more mentally demanding clinical tasks while juggling
increased dispensing amounts per pharmacist. This leads to mistakes and ultimately the patient’s
suffer. Patients dont understand this shift to clinical work in a community setting which leads to
confusion and anger on both sides.”
Abbreviation used: UTI, urinary tract infection.
a
Domains from the adapted integrative model of organizational climate and safety (see also Figure 2).
b
Respondents may indicate more than one level, thus level sums will not equal N ¼ 831.
c
Respondents may indicate more than one domain, thus domain sums will not equal N ¼ 831.
d
Percent is calculated with total number of participants who answered the question as the denominator (N ¼ 831).
e
All spelling and grammatical errors are directly from participants’ written responses.

pharmacist if they could do it over again, even though 97.2% Leadership

(n ¼ 1043) agreed they would enjoy being a pharmacist if
they could practice in an ideal setting.
Qualitative analysis
Respondents identified safety concerns at both organiza-
tional and extra-organizational levels (Table 3). Responses
(n ¼ 831 qualitative responses, 68% of all study respondents)
were mapped to 6 of the subdomains from the integrative
model.14 The adapted model can be found in Figure 2. The
safety concerns identified by pharmacists included organi-
zational core structural domains (1) leadership and (2)
organizational structure, and process domains (1) work
design, (2) quality emphasis, (3) supervision, and (4) group
behavior. Two additional themes emerged that did not fit
within the adapted integrative model. These themes were
extra-organizational in nature and included: (1) expectations
and 2) reimbursement. Responses that were coded into the
expectations domain included comments regarding expec-
tations of health care providers external to the pharmacy, as
well as patients. Reimbursement encompassed responses
that discussed pharmacy benefit managers (PBMs), the
regulation of PBMs, the inability to bill as a provider, and
other forms of reimbursement issues classified as extra-
organizational in nature.
Pharmacists surveyed suggested corporate management
styles endanger patient safety. Despite many respondents
indicating that volume and pace of work were unsafe,
addressing issues with leadership was not viewed as an option
due to fear of job loss. Respondents also perceived that
corporate management did not display values that aligned
with patient care and safety, but rather aligned with financial
growth and productivity.
Organizational structure
Respondents felt supervisors who were pharmacists have a
better understanding of pharmacy processes, law, and clinical
decision-making. Dated technology and overriding patient
protection systems were information technology factors that
concerned participants. Many respondents reported commu-
nication from corporate management was delivered via con-
ference calls which took place during time off, for which they
were unpaid, or during working hours, which required
multitasking.
Work design
Participants felt workload was too demanding with too
many prescriptions and other tasks to be completed by the

7
SCIENCE AND PRACTICE
M. Clabaugh et al. / Journal of the American Pharmacists Association xxx (2021) 1e11
Figure 2. Adapted integrative model of organizational climate and safety in community pharmacies.
pharmacist. Respondents also indicated they did not have
adequate time or staffing to complete all assigned tasks. Many
respondents believed technician training was necessary, since
they felt few skilled technicians were available in the com-
munity setting. Many also identified long working hours,
verbal abuse from patients, constant pressure to perform at an
unachievable level, and a lack of breaks as negatively
impacting employee safety.
Quality emphasis
Some participants believed metrics, or outcome measure-
ments, measured sales rather than provision of quality patient
care, which deterred respondents from providing meaningful
direct patient care. Respondents felt the speed of filling pre-
scriptions was more important to management than coun-
seling and evaluating the appropriateness of medication use
(e.g., drug-drug and drug-disease interactions). Many shared
that they worry potentially harmful mistakes may have been
made due to working conditions. Others indicated that the
lack of transparency and medication error reporting puts pa-
tient safety at risk.
Supervision
Participants felt they are not recognized by their supervi-
sors for quality work that they do, but rather only noticed
when they fall short of expectations. Many felt issues they
bring to their supervisor’s attention are never addressed.
Group behavior
Many respondents reported spending a large portion of
their time completing nonpharmacist activities such as
running the register, answering calls that could be addressed
by technicians, assisting patients in the drive-thru, and
8
completing the entire prescription filling process on their own
on top of pharmacist duties.
Expectations
Expectations from both the public and other health care
providers were identified as causing safety concerns. Re-
spondents felt the public did not have reasonable expectations
regarding prescription filling and pharmacy services. Many felt
patients believe pharmacy processes should be similar to how
fast food restaurants operate. Others indicated that health care
providers had unrealistic expectations of pharmacist avail-
ability, such as their availability to take prescriptions over the
phone at any time.
Reimbursement
PBMs were identified as causing safety concerns in the
community pharmacy setting due to their ability to reduce
reimbursement. Many respondents blamed the inability to
maintain adequate staffing levels, have pharmacist overlap,
and other budget cuts on PBMs.
Discussion
The AHRQ integrative model, which is intended to measure
organizational climate in health care, was adapted to fit the
needs of this study.14 Our findings suggest the integrative
model, with some minor adaptations, is appropriate for use in
the community pharmacy setting with responses mapped to
all subdomains. This also demonstrates that this model may be
transferable to more health care settings beyond the hospital
setting. In addition to the domains in the AHRQ integrative
model, our research revealed an additional domain that
affected patient and employee safety concerns: extra-
organizational factors. This domain included subdomains of

Working conditions and safety in community pharmacy
reimbursement and expectations. Reimbursement rates for
dispensing medications are declining, in part due to PBMs.16,17
Although PBMs are an extra-organizational factor, this reduc-
tion in pharmacy income has organizational level impacts.
With pharmacists in most states unable to bill for patient care
services beyond product dispensing and the reimbursement
for dispensing medications declining, companies may be
forced to continue to increase the number of prescriptions
filled or close pharmacies altogether.18,19
Expectations were another response that was classified as
extra-organizational. Factors outside of their organization,
including reimbursement and unclear or unrealistic expecta-
tions, could be contributing to perceived work stress among
community pharmacists. Although research on patient or
other health care provider expectations of pharmacists is
limited, a survey conducted by Smith et al.20 assessed physi-
cian expectations of community pharmacists. Most physicians
expected pharmacists to educate patients about prescriptions
and to have refills completed on time.20 By suggesting that
patients’ medications will be ready on arrival at the pharmacy,
physicians create unrealistic expectations of pharmacists for
patients, which can negatively impact pharmacists’ working
conditions. However, fewer physicians expected community
pharmacists to play a role in clinical patient care (e.g., moni-
toring patient’s therapy etc).20
Overall, community pharmacists had negative perceptions
of their working conditions, with pharmacists working for
chain pharmacies reporting significantly more negative per-
ceptions than pharmacists in all other community settings.
These findings reaffirm findings from the most recent National
Pharmacist Workforce Survey.2 Despite assurances of positive
employee perceptions of a “culture of patient safety” from
corporate chain pharmacies in Consumer Value Store's()
response to Gabler’s articles,21 the majority of pharmacists in
this study (69.3% of all respondents, 80.6% of respondents in
chain pharmacies) somewhat disagreed to strongly disagreed
that corporate or company policies support patient safety.
How management within pharmacies handle errors or report
errors was also a common concern among survey respondents.
This is a serious concern, given that one of community phar-
macists’ primary goals is to protect patients from adverse drug
events. Most pharmacists surveyed feared being disciplined
directly or indirectly for addressing safety concerns with
management. As recommended in To Err is Human, the best
practice is to not threaten health professionals with conse-
quences when reporting errors or concerns, or else they may
be disincentivized to address safety concerns.22 A decrease in
willingness to address safety concerns could be detrimental to
patient care. Fear of being disciplined was also statistically
significantly associated with having left community pharmacy
within the past 6 months; therefore, fear of being disciplined
may be a driver of pharmacist turnover.
Some respondents feared losing their jobs if they brought
up concerns about working conditions. Pharmacists surveyed
indicated that the decrease in workplace demand of pharma-
cists23 exacerbated the situation by enabling leadership to
discipline or terminate employment of pharmacists. The in-
crease in the number of pharmacy schools in recent years24
has, in part, led to a supply which has outpaced the demand
for pharmacists in the United States and is predicted to
continue through 2025.25 With the community pharmacy job
SCIENCE AND PRACTICE
market saturated in many regions, employers may be less
motivated to improve working conditions or address concerns
over patient safety due to the ready supply of pharmacists
seeking a job.25
Organizational structural characteristics, the second core
structural subdomain, include governance at the corporate or
company level. Organizational structural characteristics can
differ widely between national chain, grocery or big box, and
independent pharmacy settings. Pharmacists practicing in
independent pharmacies reported poor working conditions,
but less negative perceptions than those working in other
community settings. Although independent pharmacies tend
to have lower prescription volumes, the difference in percep-
tions persisted even when controlling for other variables. In-
dependent pharmacies are often owned and operated by
pharmacists, while national chains and grocery or big box
pharmacies are often managed by nonpharmacists.26 As a
result, managers and pharmacists may have different expec-
tations for the primary role of community pharmacies;
viewing community pharmacies solely as a business rather
than a place for health care provision may impact company
climate and working conditions. Respondents suggested
managers’ lack of pharmacy background contributed to safety
concerns within the community setting, further supporting
the theory that pharmacist supervisors influence working
conditions.
The most commonly occurring and most pressing issues
contributing to poor working conditions and safety concerns
were within the process domain, including those related to
prescription volume, interruptions and distractions, multi-
tasking, and level of responsibilities. Previous research found
pharmacists were interrupted anywhere from 3 to 7 times in
just one hour of working with 43% of overall interruptions
coming from patients and 25% from technicians.27 These
frequent interruptions in the verification process could cause
medication errors to occur by shifting the pharmacist's focus.
Research analyzing errors reported to the New Hampshire
Board of Pharmacy found that 51% of errors occurred during
the pharmacist verification step.28 These findings further
suggest that minimizing distractions to the pharmacist is
crucial for patient safety. In addition to workload, respondents
indicated that the physical layout of the pharmacy made them
vulnerable to distractions from technicians and patients as
well as jeopardized their own safety by exposing them to
potential pharmacy robberies.
Another issue frequently identified by respondents in the
process domain was quality emphasis. Many participants felt
outcome measurements, or metrics, are not patient-oriented.
Instead, many likened the metrics to encouraging pharma-
cists to fill as many prescriptions as fast as possible rather than
emphasizing accuracy and therapeutic appropriateness.
Recent efforts have been made to create and standardize
performance-based measures in the community pharmacy
setting. With input from existing Centers for Medicare and
Medicaid Services programs, Congress, and pharmacy pro-
viders, the Pharmacy Quality Alliance has developed measures
to focus on quality of patient care rather than quantity or
speed.29
Despite the majority of surveyed pharmacists (72.1%) not
being satisfied with their current position, the majority (97.2%)
would enjoy being a pharmacist if they could practice in an
9
SCIENCE AND PRACTICE
M. Clabaugh et al. / Journal of the American Pharmacists Association xxx (2021) 1e11
ideal setting. This suggests that community pharmacists’ poor
perceptions are largely due to working conditions rather than
the profession itself. Conditions in community pharmacy may
foster “role conflict,” in which pharmacists as health care
providers desire to provide the best possible care to their pa-
tients; however, the organization in which they work for as-
serts pressure to perform tasks as quickly as possible.30
Attempting to balance discordant priorities eventually leads
to decreased patient care and reduced overall job satisfac-
tion.30 This could be particularly important to companies, as
research examining physician and patient satisfaction indicate
patients build better relationships with physicians who pa-
tients believe are satisfied with their job.30 Translating these
findings into the community pharmacy setting, where the
pharmacist is the health care provider, would suggest that
increased work satisfaction would directly increase patient
satisfaction, a goal that many company metrics set standards
to meet. Role conflict and reduced job satisfaction could also
lead to burnout experienced by community pharmacists.31
Recent literature has indicated over 70% of pharmacists in
the community pharmacy setting have experienced burnout.31
Future research should be conducted to examine associations
between burnout and working conditions. Improving working
conditions can benefit pharmacists, patients, and pharmacy
owners. There is hope for pharmacists working in the com-
munity setting: those who have left community pharmacy in
the past 6 months report being significantly more satisfied
with their new position than those still practicing in the
community setting at the time of completing the survey.
A limitation of this study is the use of a convenience sam-
ple; however, the sample of survey respondents is fairly
representative of community pharmacists practicing in the
United States, which supports the generalizability of the re-
sults to the greater community pharmacist population.25
Another limitation to this study is that little is known about
individuals who did not complete the survey, and therefore
potential nonresponse bias cannot be assessed. A major
strength of this study is the large sample size. Further research
is warranted into what solutions may address working con-
ditions in community pharmacies.
Conclusion
Pharmacists practicing in the community setting have
negative perceptions of the company climate and working
conditions and feel these issues may negatively impact patient
safety. Company climate and workflow were perceived nega-
tively in all community settings but were perceived the most
negatively by those working in chain pharmacies. The adapted
integrative model helped to identify contributing factors at the
core structural and process domains, while factors at the
extra-organizational level were revealed through the qualita-
tive portion of this study. Work design and quality emphasis
were the largest safety concerns indicated by pharmacists on
the organizational level while extra-organizational factors of
expectations and reimbursement were also identified.
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Mercedes Clabaugh, PharmD, Graduate Student, College of Pharmacy, Purdue
University, West Lafayette, IN
Jenny L. Beal, PharmD, PhD, Postdoctoral Fellow, College of Pharmacy, Purdue
University, West Lafayette, IN
Kimberly S. Illingworth Plake, BSPharm, PhD, FAPhA, Assistant Dean of
Assessment and Learning; and Associate Professor of Pharmacy Practice, College
of Pharmacy, Purdue University, West Lafayette, IN
11