Community pharmacy staff take flexible approach to SOPs, study finds

Community pharmacy staff members are often flexible with their adherence to standard operating procedures (SOPs), interviews with community pharmacy employees has revealed. 

Participants identified a number of reasons for not always following protocol, including an overload of procedures; belief that procedures were a ‘tick box exercise’; and concerns that particular procedures interfered with their professional judgement. 

The researchers, who published their findings in BMJ Open
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(online, 6 June 2016), interviewed 24 community pharmacy staff members in England and Wales, including 13 pharmacists and 11 dispensing technicians/assistants, regarding their view of procedures. 

The participants came from a range of pharmacy businesses, including independents (7), large pharmacy chains (9), medium and small-sized pharmacies (4), a supermarket, and locum staff who worked in a variety of pharmacy types. 

They were asked a number of questions including how they were made aware of procedures, how useful procedures were in helping them to do their job and whether they felt they were able to follow procedures at work. 

The authors identified three key themes that characterised why pharmacy staff members sometimes deviate from SOPs. Under the first, “dissemination and creation of standard operating procedures,” the researchers found that staff were required to follow a large number of procedures as part of their work, making full compliance impossible. 

The second theme, “compliance with procedures”, was influenced by a range of factors, including work demands; the behavioural norms within the pharmacy; staff shortages; pressure to hit targets; and poor communication. 

The third theme the researchers identified involved “procedural compliance versus using professional judgement”, whereby interviewees described tension between the standardisation of practice and pharmacists using their professional judgement. Some participants expressed fears that their employer would not support them if they worked outside procedures, even if they felt it was for the benefit of the patient. 

Although survey participants understood the need for procedures and agreed they were designed to guarantee patient safety, many drew a distinction between the ability of SOPs to signal the “ideal” way to work to preserve patient safety and the perception that procedures could often be restrictive and difficult to follow consistently. 

The authors, led by Christian Thomas, a PhD student at the University of Manchester, say their findings highlight the difference between “work-as-done” (as represented by actual practice at a given time or in a given location) and “work-as-imagined” (as represented by the formal procedures). 

Pharmacy dispensers, meanwhile, suggested that although following the guidance of pharmacists sometimes meant working outside of procedures, they didn’t always feel comfortable doing so but were reluctant to make their concerns heard. 

The researchers conclude that “future research should focus on exploring community pharmacy employees’ intentions and attitudes towards rule-breaking behaviour and the impact this may have on patient safety”. 

As well as supplying prescribed and non-prescription medication, community pharmacy employees offer advice on the management of minor ailments and the appropriate use of medicines, with pharmacists conducting medicines use reviews. Since 2005, pharmacies have been required to adopt SOPs for the storage, dispensing and supply of medicines, as well as for the provision of medical advice to patients. 

Sandra Gidley, chair of the English Pharmacy Board at the Royal Pharmaceutical Society, says the findings of the study rung “fairly true”, but has concerns about the study’s small size. 

She adds that she would like to see the emergence of simple, profession-wide SOPs that are evidence based and allowed some flexibility of practice, depending on patient preference. “Instead of directing staff where to place a [dispensing] label it would be much more useful if staff were encouraged to follow best practice according to the latest guidelines,” she says. 

Gidley, who is also a locum pharmacist, says there are inconsistencies in the way SOPs are applied in pharmacies. Some pharmacies do not follow the SOPs to the letter, but there is no disclaimer to that effect in the SOP folder, while others have excellent adherence, she explains. 

Gidley says SOPs are generally produced with good intentions but they do not always seem to be “sense checked”, adding that hard working pharmacists and their teams do the best job they can but adherence fails because of inadequate staff resources. 

“This usually does not put the patient at any greater risk but on the rare occasions mistakes are made the knee-jerk reaction of non-pharmacist bosses is to ask whether SOPs were followed,” she adds. 

“The answer may be ‘no’, but the reality is that the procedure followed may have fitted perfectly within the SOPs of another company – so it is little wonder that staff feel that the SOPs can be used as a disciplinary tool.”