TY - JOUR
AU - Whittlesea, Cate
AB - Abstract Objective Determine the effect of installing an original pack automated dispensing system (ADS) on staff experience of occupational stressors. Methods Pharmacy staff in a National Health Service hospital in Wales, UK, were administered an anonymous occupational stressor questionnaire pre- (n = 45) and post-automation (n = 32). Survey responses pre- and post-automation were compared using Mann–Whitney U test. Statistical significance was P ≤ 0.05. Four focus groups were conducted (two groups of accredited checking technicians (ACTs) (group 1: n = 4; group 2: n = 6), one group of pharmacists (n = 17), and one group of technicians (n = 4) post-automation to explore staff experiences of occupational stressors. Focus group transcripts were analysed according to framework analysis. Key findings Survey response rate pre-automation was 78% (n = 35) and 49% (n = 16) post-automation. Automation had a positive impact on staff experience of stress (P = 0.023), illogical workload allocation (P = 0.004) and work–life balance (P = 0.05). All focus-group participants reported that automation had created a spacious working environment. Pharmacists and ACTs reported that automation had enabled the expansion of their roles. Technicians felt like ‘production-line workers.’ Robot malfunction was a source of stress. Conclusion The findings suggest that automation had a positive impact on staff experience of stressors, improving working conditions and workload. Technicians reported that ADS devalued their skills. When installing ADS, pharmacy managers must consider the impact of automation on staff. Strategies to reduce stressors associated with automation include rotating staff activities and role expansions. automation, hospital pharmacy, job satisfaction, stress, working conditions Introduction Worldwide, demands on healthcare services have increased as a result of an aging population and a rise in the number of patients with chronic illnesses and multiple pathologies.[1–3] Consequently, healthcare staff are under increasing pressure to deliver efficient services to patients, whilst ensuring the quality and safety of patient care.[1,4,5] Human factors research suggests that occupational stressors reduce staff productivity and impair performance resulting in errors.[6] Occupational stressors are negative or noxious situations in work that induce an adaptive response in an employee resulting in mental, physical or behavioural changes which manifest at an individual, interpersonal and organisational level.[7] Le Blanc and colleagues categorise occupational stressors into four categories: job content (e.g. work overload/underload, complex work, monotonous work, excessive responsibility and conflicting/ambiguous demands), working conditions (e.g. poor working environment, noise, lighting, temperature and work posture), employment conditions (e.g. poor pay, lack of career prospects, contract of choice, job insecurity) and social relations at work (e.g. poor leadership and management, lack of social support, lack of participation in decision making and discrimination).[7] Symptoms of stress include anxiety, tension, irritability, gastrointestinal disorders, increased heart rate, loss of zeal and enthusiasm. These can be moderated by personal coping strategies and workplace and/or social support.[7] Original pack automated dispensing systems (ADS) have been heralded as a strategy for improving pharmacy working conditions.[3,8,9] These ADS are used in community and hospital pharmacy, automating the storage of medication, stock selection and product labelling.[10] Socio-technical theory proposes that an imbalance between technology and employee needs may lead to reduced efficiency, safety, quality, poor staff performance, low morale, reduced commitment, job dissatisfaction, absenteeism and high stress levels.[11,12] The impact of these original pack ADS on pharmacy staff experience of workplace stressors has not been investigated. Following the devolution of governing powers from the UK government to the Welsh Assembly Government, ADS were introduced into hospitals across Wales.[9] This programme of automation provided an opportunity to investigate the impact of automation on pharmacy staff experience of occupational stressors. This study aimed to determine the effect of installing an ADS on staff experiences of work, the psychological contract (i.e. contract of choice, content of contract, met expectations and reward equity), individual life outcomes (i.e. job satisfaction and work–life balance) and future plans (e.g. employability and organisational commitment). Methods Study design, setting and study participants A longitudinal case study[13] was undertaken at a UK district general National Health System hospital to explore the impact of installing an original pack ADS (Rowa Speedcase, ARX Ltd., St Albans, Hertfordshire, UK) on occupational stressors. Details of the participating hospital and pharmacy dispensing system, eligibility criteria for participation in the study and details of study participants are described by James and colleagues in another article in this issue of International Journal of Pharmacy Practice.[14] Data collection procedure Staff experiences of occupational stressors pre- and post-automation were determined using a quantitative (occupational stressor questionnaire) and qualitative (focus groups) strategy. Occupational stressor questionnaire An anonymous occupational stressor questionnaire was constructed based on the Pharmacy Workforce Behaviour Survey.[15] The questionnaire was developed using items from the Pharmacy Workforce Behaviour Survey relating to individual background characteristics, type of work, workload, stress, experiences of work, psychological contract and individual outcomes. Items from the Pharmacy Workforce Behaviour Survey relating to individual career orientation (early and current career anchors and commitment to continuing professional development) were excluded as they provided no indication of the occupational stressors influencing the behaviour of pharmacy staff. The developed questionnaire consisted of 124 items and included both closed and attitudinal questions. Closed questions were employed to ascertain demographic and employment data. Scales of attitudinal measures were used to determine a respondent's experience of stress, workload, job control, career and growth opportunities, contract of choice, content of contract, met expectations, reward equity, job satisfaction, work–life conflict, employability and organisational commitment. Responses to these attitudinal measures were obtained using a five‐point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The Cronbach's α for the majority of attitudinal items, determined by previous validation work,[15] were above the ideal minimum of 0.7 and none were below 0.6 (Table 1) indicating that the questions were reliable measures of the occupational stressor.[16] Table 1 Cronbach's α measurements for occupational stressor items and the median responses given by survey respondents pre- (n = 35) and post-automation (n = 16) Occupational stressor categories . Number of items . Cronbach's α . Pre-automation median response to survey items . Post-automation median responses to survey items . Mann–Whitney U test . P-value . Stress Job stress (e.g. I often feel under excessive stress at work) 3 0.84 4 3 175 0.023 Workload Work overload (e.g. I often have too much work to do in my job) 3 0.80 4 4 257 0.618 Logical allocation of workload (e.g. There is a logical process to workload allocation in this hospital pharmacy) 5 N/A 3 4 146.5 0.004 Fair allocation of workload (e.g. By and large, workloads are fairly allocated in this hospital pharmacy) 5 N/A 3 3 251 0.541 Experience of work Job control/autonomy (e.g. To what extent can you determine the methods and procedures you use in your work) 3 0.87 3 3 272 0.866 Career opportunities (e.g. I have the opportunity for further advancement in my career) 3 0.84 4 4 264.5 0.738 Growth opportunities (e.g. This job provides me with opportunity for self-improvement and development) 3 0.63 4 4 268 0.789 Psychological contract Contract of choice (e.g. My present employment contract suits me for the time being) 3 0.75 4 4 229 0.458 Content of contract (e.g. Fulfilment of promise to provide you with interesting job) 4 N/A 4 4 215 0.134 Met expectations (e.g. This job has lived up to the expectations that I had when I first started) 4 0.83 4 4 219.5 0.183 Reward equity (e.g. I am rewarded fairly considering the responsibilities that I have) 3 0.91 4 4 247.5 0.492 Individual outcomes Job satisfaction (e.g. Overall I am satisfied with my job) 5 0.89 4 4 257 0.516 Work–life conflict (e.g. My job or career keeps me from spending the amount of time I would like to spend with my family) 5 0.88 3 2 195 0.053 Employability (e.g. I am confident I could quickly get a similar job) 4 0.84 4 4 254 0.562 Organisational commitment (e.g. I feel myself to be part of my organisation) 6 0.89 4 4 184 0.061 Occupational stressor categories . Number of items . Cronbach's α . Pre-automation median response to survey items . Post-automation median responses to survey items . Mann–Whitney U test . P-value . Stress Job stress (e.g. I often feel under excessive stress at work) 3 0.84 4 3 175 0.023 Workload Work overload (e.g. I often have too much work to do in my job) 3 0.80 4 4 257 0.618 Logical allocation of workload (e.g. There is a logical process to workload allocation in this hospital pharmacy) 5 N/A 3 4 146.5 0.004 Fair allocation of workload (e.g. By and large, workloads are fairly allocated in this hospital pharmacy) 5 N/A 3 3 251 0.541 Experience of work Job control/autonomy (e.g. To what extent can you determine the methods and procedures you use in your work) 3 0.87 3 3 272 0.866 Career opportunities (e.g. I have the opportunity for further advancement in my career) 3 0.84 4 4 264.5 0.738 Growth opportunities (e.g. This job provides me with opportunity for self-improvement and development) 3 0.63 4 4 268 0.789 Psychological contract Contract of choice (e.g. My present employment contract suits me for the time being) 3 0.75 4 4 229 0.458 Content of contract (e.g. Fulfilment of promise to provide you with interesting job) 4 N/A 4 4 215 0.134 Met expectations (e.g. This job has lived up to the expectations that I had when I first started) 4 0.83 4 4 219.5 0.183 Reward equity (e.g. I am rewarded fairly considering the responsibilities that I have) 3 0.91 4 4 247.5 0.492 Individual outcomes Job satisfaction (e.g. Overall I am satisfied with my job) 5 0.89 4 4 257 0.516 Work–life conflict (e.g. My job or career keeps me from spending the amount of time I would like to spend with my family) 5 0.88 3 2 195 0.053 Employability (e.g. I am confident I could quickly get a similar job) 4 0.84 4 4 254 0.562 Organisational commitment (e.g. I feel myself to be part of my organisation) 6 0.89 4 4 184 0.061 Open in new tab Table 1 Cronbach's α measurements for occupational stressor items and the median responses given by survey respondents pre- (n = 35) and post-automation (n = 16) Occupational stressor categories . Number of items . Cronbach's α . Pre-automation median response to survey items . Post-automation median responses to survey items . Mann–Whitney U test . P-value . Stress Job stress (e.g. I often feel under excessive stress at work) 3 0.84 4 3 175 0.023 Workload Work overload (e.g. I often have too much work to do in my job) 3 0.80 4 4 257 0.618 Logical allocation of workload (e.g. There is a logical process to workload allocation in this hospital pharmacy) 5 N/A 3 4 146.5 0.004 Fair allocation of workload (e.g. By and large, workloads are fairly allocated in this hospital pharmacy) 5 N/A 3 3 251 0.541 Experience of work Job control/autonomy (e.g. To what extent can you determine the methods and procedures you use in your work) 3 0.87 3 3 272 0.866 Career opportunities (e.g. I have the opportunity for further advancement in my career) 3 0.84 4 4 264.5 0.738 Growth opportunities (e.g. This job provides me with opportunity for self-improvement and development) 3 0.63 4 4 268 0.789 Psychological contract Contract of choice (e.g. My present employment contract suits me for the time being) 3 0.75 4 4 229 0.458 Content of contract (e.g. Fulfilment of promise to provide you with interesting job) 4 N/A 4 4 215 0.134 Met expectations (e.g. This job has lived up to the expectations that I had when I first started) 4 0.83 4 4 219.5 0.183 Reward equity (e.g. I am rewarded fairly considering the responsibilities that I have) 3 0.91 4 4 247.5 0.492 Individual outcomes Job satisfaction (e.g. Overall I am satisfied with my job) 5 0.89 4 4 257 0.516 Work–life conflict (e.g. My job or career keeps me from spending the amount of time I would like to spend with my family) 5 0.88 3 2 195 0.053 Employability (e.g. I am confident I could quickly get a similar job) 4 0.84 4 4 254 0.562 Organisational commitment (e.g. I feel myself to be part of my organisation) 6 0.89 4 4 184 0.061 Occupational stressor categories . Number of items . Cronbach's α . Pre-automation median response to survey items . Post-automation median responses to survey items . Mann–Whitney U test . P-value . Stress Job stress (e.g. I often feel under excessive stress at work) 3 0.84 4 3 175 0.023 Workload Work overload (e.g. I often have too much work to do in my job) 3 0.80 4 4 257 0.618 Logical allocation of workload (e.g. There is a logical process to workload allocation in this hospital pharmacy) 5 N/A 3 4 146.5 0.004 Fair allocation of workload (e.g. By and large, workloads are fairly allocated in this hospital pharmacy) 5 N/A 3 3 251 0.541 Experience of work Job control/autonomy (e.g. To what extent can you determine the methods and procedures you use in your work) 3 0.87 3 3 272 0.866 Career opportunities (e.g. I have the opportunity for further advancement in my career) 3 0.84 4 4 264.5 0.738 Growth opportunities (e.g. This job provides me with opportunity for self-improvement and development) 3 0.63 4 4 268 0.789 Psychological contract Contract of choice (e.g. My present employment contract suits me for the time being) 3 0.75 4 4 229 0.458 Content of contract (e.g. Fulfilment of promise to provide you with interesting job) 4 N/A 4 4 215 0.134 Met expectations (e.g. This job has lived up to the expectations that I had when I first started) 4 0.83 4 4 219.5 0.183 Reward equity (e.g. I am rewarded fairly considering the responsibilities that I have) 3 0.91 4 4 247.5 0.492 Individual outcomes Job satisfaction (e.g. Overall I am satisfied with my job) 5 0.89 4 4 257 0.516 Work–life conflict (e.g. My job or career keeps me from spending the amount of time I would like to spend with my family) 5 0.88 3 2 195 0.053 Employability (e.g. I am confident I could quickly get a similar job) 4 0.84 4 4 254 0.562 Organisational commitment (e.g. I feel myself to be part of my organisation) 6 0.89 4 4 184 0.061 Open in new tab The questionnaire was distributed by hand to eligible members of staff both pre-automation (1 June 2007; n = 45) and post-automation (19 June 2009; n = 32) by the hospital-based academic researcher (KLJ). To maximise response rate, each participant received a personally addressed envelope containing a covering letter detailing the nature and purpose of the study, the questionnaire, a blank envelope and a stamped addressed envelope. The participants were given 14 days to complete and return the questionnaire. The ‘double envelope technique’ of returning questionnaires was adopted for this study. To return questionnaires, participants placed the completed questionnaire in the blank envelope. They then placed the blank envelope inside the stamped addressed envelope provided, which was coded with an unique number identifier corresponding to a member of staff. The questionnaires were returned by post to another researcher (CW) who used the code to identify and record the return of the questionnaire. The stamped addressed envelope was removed, leaving the blank envelope containing the questionnaire. After the deadline (pre-automation: 15 June 2007; post-automation: 3 July 2009), non-responders were sent a reminder letter and another copy of the questionnaire to be returned to the research team using the ‘double envelope technique’ (pre-automation: 18 June 2007; post-automation: 6 July 2009). Non-responders were given a further 14 days to return the reminder questionnaire (pre-automation: 2 July 2007; post-automation: 20 July 2009). Use of the ‘double envelope technique’ enabled follow-up of non-responders whilst maintaining the anonymity of questionnaire responses to the research team. Focus group Post-automation a letter was sent to eligible members of pharmacy staff (n = 32), together with an information leaflet and consent form, inviting them to take part in a focus group. In accordance with the Research Governance Framework, written informed consent was obtained from eligible staff wishing to participate in the focus groups.[17] Focus groups were undertaken post-automation (22 October 2009) to explore study participants’ views on the impact of automation on occupational stressors. Each focus group lasted approximately 1.5 h and consisted of participants from similar occupational backgrounds and seniority; i.e. a focus group comprised exclusively of all pharmacists or accredited checking technicians (ACTs). Using a specifically designed focus-group schedule, the moderator (KLJ) steered and prompted participants to discuss the impact of automation on workload, dispensing errors, job control/autonomy, job stress, job satisfaction, work–life conflict, contract fulfilment and opportunities to enhance career. Focussing exercises, consisting of anonymised results for the occupational stressor questionnaire distributed pre- and post-automation, were incorporated into the focus group with the aim of concentrating the groups’ attention and stimulating discussion.[18,19] With the participants’ permission, the focus groups were audio-recorded. An assistant moderator (CW) was present at each focus group to take notes and monitor the recording of the discussion. Research governance Ethical approval was granted for the study by North East Wales Research Ethics Committee [REC: 09/WNo03/12]. In addition, NHS Trust Research and Development approval was obtained and the researchers (KLJ and CW) held an honorary contract at the Trust. Data analysis Occupational stressor questionnaire A coding framework was developed for the questionnaire and the data were entered into SPSS version 16 software for analysis. The questionnaire response rate was determined and descriptive statistics were generated for respondent demographics. A χ2 test was used to compare the observed proportions of staff gender pre- and post-automation. An independent two sample t-test was used to compare the mean ages and mean contracted hours worked for respondents pre- and post-automation. The scales for each occupational stressor category were combined and the median responses were obtained to provide an overall indication of the respondents’ experience of each specific stressor category. For each occupational stressor category, the responses from respondents pre- and post-automation were compared using the Mann–Whitney U test as it allows comparison of two independent groups of data that have been measured on an ordinal scale (e.g. Likert scales) and is non-normally distributed. A P ≤ 0.05 was considered statistically significant. Focus group With the aid of the assistant moderator's notes, audio-recordings were transcribed verbatim. During transcription, the data were anonymised to maintain the confidentiality of study participants. The focus-group transcripts were imported into QSR Nivivo 8 and analysed according to the principles of framework analysis[20] using the themes in the pharmacy workforce behaviour questionnaire[15] (i.e. stress, workload, experience of work, psychological contract and individual outcomes) as the analytical framework. Results Details of occupational stressor questionnaire respondents Pre-automation, the occupational stressor questionnaire was administered to 45 members of staff at the hospital. Thirty-five questionnaires were returned giving a response rate of 78% pre-automation. Post-automation the occupational stressor questionnaire was administered to 32 members of staff of whom 31 had participated in the pre-automation stage of data collection; the exception being the pre-registration pharmacist. Sixteen questionnaires were returned giving a response rate of 49%. Table 2 summarises the background characteristics of the questionnaire respondents. There was no statistically significant difference between the individual background characteristics of survey respondents pre- and post-automation. Thirty-one members of staff completed the questionnaire both pre- and post-automation. However, the questionnaire responses were anonymous and comparison of responses pre- and post-automation for these 31 participants could not be undertaken. Table 2 Background characteristics of questionnaire respondents pre- (n = 35) and post-automation (n = 16) . Pre-automation (n = 35) . Post-automation (n = 16) . Mean age* ± standard deviation 36 ± 11.34 33 ± 2.62 Gender† Female: 31 (89%) Female: 13 (81%) Occupation‡ Pharmacist 14 (40%) 3 (18.8%) Accredited checking technician 7 (20%) 6 (37.5%) Technician 9 (25.7%) 5 (31.2%) Student technician 3 (8.6%) 1 (6.2%) Pre-registration pharmacy graduate 2 (5.7%) 1 (6.2%) Total 35 (100%) 16 (100%) . Pre-automation (n = 35) . Post-automation (n = 16) . Mean age* ± standard deviation 36 ± 11.34 33 ± 2.62 Gender† Female: 31 (89%) Female: 13 (81%) Occupation‡ Pharmacist 14 (40%) 3 (18.8%) Accredited checking technician 7 (20%) 6 (37.5%) Technician 9 (25.7%) 5 (31.2%) Student technician 3 (8.6%) 1 (6.2%) Pre-registration pharmacy graduate 2 (5.7%) 1 (6.2%) Total 35 (100%) 16 (100%) *t = 0.780, P = 0.439; †χ2 = 0.497, P = 0.481; ‡χ2 = 3.01, P = 0.556. Open in new tab Table 2 Background characteristics of questionnaire respondents pre- (n = 35) and post-automation (n = 16) . Pre-automation (n = 35) . Post-automation (n = 16) . Mean age* ± standard deviation 36 ± 11.34 33 ± 2.62 Gender† Female: 31 (89%) Female: 13 (81%) Occupation‡ Pharmacist 14 (40%) 3 (18.8%) Accredited checking technician 7 (20%) 6 (37.5%) Technician 9 (25.7%) 5 (31.2%) Student technician 3 (8.6%) 1 (6.2%) Pre-registration pharmacy graduate 2 (5.7%) 1 (6.2%) Total 35 (100%) 16 (100%) . Pre-automation (n = 35) . Post-automation (n = 16) . Mean age* ± standard deviation 36 ± 11.34 33 ± 2.62 Gender† Female: 31 (89%) Female: 13 (81%) Occupation‡ Pharmacist 14 (40%) 3 (18.8%) Accredited checking technician 7 (20%) 6 (37.5%) Technician 9 (25.7%) 5 (31.2%) Student technician 3 (8.6%) 1 (6.2%) Pre-registration pharmacy graduate 2 (5.7%) 1 (6.2%) Total 35 (100%) 16 (100%) *t = 0.780, P = 0.439; †χ2 = 0.497, P = 0.481; ‡χ2 = 3.01, P = 0.556. Open in new tab Pre-automation, 10 members of staff did not respond to the questionnaire (pharmacists: n = 2; technicians: n = 7, student technician: n = 1). Post-automation, 16 members of staff failed to respond to the questionnaire (pharmacists: n = 13; ACTs: n = 3). Further comparison of the baseline characteristics of questionnaire respondents and non-respondents was not possible. Details of focus-group participants Thirty-two members of staff were invited to take part in the focus group. Of these, 31 consented to participate in the focus groups giving a response rate of 97% with one person unavailable on the day the focus groups were scheduled. Participants were divided into four focus groups: one group of pharmacists (n = 17), two groups of ACTs (group 1: n = 4; group 2: n = 6) and one group of technicians (n = 4). The pre-registration pharmacist and the student technician that responded to the questionnaire post-automation had qualified by the time the focus groups were undertaken and were therefore included in the pharmacist and technician focus group. Staff experience of occupational stressors There was a significant difference between the median responses given by survey respondents pre‐ and post‐automation for staff experience of job stress (Table 1) with fewer staff reportedly experiencing stress post‐automation (12.5%, n = 2) compared to pre‐automation (34.3%, n = 12). This corresponded to the views of the focus‐group participants who reported overall experiencing less stress since the installation of the ADS (Box 1). Some staff did report experiencing stress when workload was high. Nevertheless, a little stress was considered a positive thing, causing staff to focus on their work (Box 1 ). Box 1 Staff experience of stress Pharmacist 4: “I‘d like to think it [automation] has reduced the feelings of stress. It's just as busy and we work just as hard but hopefully it doesn't feel quite as stressful.” (Focus group 3) ACT 3: “… A little bit of stress is good. It makes you work harder. If you're not stressed your mind is probably wondering” (Focus group 1) Working conditions Various working conditions were identified by the focus‐group participants as occupational stressors including the working environment, automation, staffing and sickness. Staff reported that the redesign of the dispensary and the installation of the ADS improved the working conditions by providing a spacious, organised and calmer environment for dispensing (Box 1). Nevertheless it was acknowledged that the design of the dispensary was far from ideal with pharmacy staff being distracted by outpatients and other healthcare staff in the waiting room and by poor lighting (Box 2). All focus‐group participants reported preferring the ADS compared to manual dispensing. The ADS was reported to facilitate the dispensing process by allowing staff to focus on the task, thereby reducing dispensing errors (Box 2). However, the ADS was also identified as a source of frustration breaking down and delaying the issue of medication (Box 2 ). Box 2 Impact of automation on stressful working conditions Working environment post-automation – spacious, calmer and organised Technician 4: “… the whole system that comes with the robot is so much safer, more organised.” (Focus group 4) Technician 3: “The atmosphere in there [dispensary – post-automation] is much calmer. I think even when it's busy, you know a lot of workload, it doesn't feel like chaos. Whereas in the old place [dispensary – pre-automation] it was just too small, too many people and if there was a lot of work it just felt chaotic. It felt more stressful.” (Focus group 4) Working environment post-automation – distraction and poor lighting ACT 10: “… We know the fact that where the door is all the outpatients can see you dispensing. It's not ideal.” ACT 5: “You don't want to be looked at when you're dispensing … and the staff come and hang over the desk until you get up from what you're doing.” (Focus group 2) ACT 7: “It's the lighting and things. There's not so much light. It's artificial light. It's not daylight. You had a little window [pre-automation]. It's more than what we're getting now.” (Focus group 2) Reduction in dispensing errors post-automation Technician 3: “It's easier to do a prescription. You can just do your labels, your items come out [of the robot], you attach your label. Generally it's [medicines] all in the robot and you don't have to locate things [medicines] … Whatever label you produce … the label and the item matches [post-automation]. Whereas before your label might not match your product or it might not match what's on your prescription so you had more chance of errors before [pre-automation].” (Focus group 4) ACT 3: “Robots are less likely to pick wrong items. You've a lot more time to go through your prescription [post-automation]. You focus on it.” (Focus group 1) Robot malfunction source of stress Pharmacist 11: “I have only one incident where I felt the situation went against us. I was waiting for the robot to kick out every single item of a drug that was out of date where in the old place I would have gone to the shelf and scooped them all up in about thirty seconds flat but it took about an hour …” Pharmacist 14: “When the robot breaks down it's almost impossible to get hold of certain items because you can't get access to it. It does increase the stress because it's a complete dead end.” (Focus group 3) Post-automation – inadequate staffing Technician 4: “Things have changed since the robot has come … We're supposed to be working as a departmental team aren't we? But you've got people calling you here there and everywhere and you turn around and you've got a student on one side and a pre-reg [sic] on the other. Help … Yes I think it is felt the robot warrants less staff in the dispensary and it's not the case … There's less of the skills like. We can still be chasing around for somebody to do clinical trials or inhaler counselling or turn to the counselling hatch. We're on a skeleton staff in the dispensary at times of the day when there are technicians up on the ward.” (Focus group 4) Negative impact of automation on teamwork ACT 7: “You prevent teamwork because you're individually stationed [post-automation]. Now there's less teamwork. Everybody gets on with what they're doing …” ACT 10: “There's a little group that go and stand at the end of the day. That wouldn't have happened before because you're all manic, all chipping in. So the teamwork was there more in the old department [pre-automation] because you had all this work to get through. Now at the end of the day you can have a lone period. Some are working and some aren't. That's when you feel there's no team.” (Focus group 2) Mental and physical demands Technician 4: “… When you're dispensing all day long the concentration levels go. You're tired, your eyes hurt, your back hurts you know. I find it physically very, very difficult …” Technician 2: “You get mentally tired. It's relentless.” Technician 1: “Illness is a difficult one now because we've got graphs in work showing us the percentage of how much time off we're having so that puts us under pressure to come to work if we're not feeling well.” Technician 3: “… If you come in and you're not right … you're not concentrating when you're not well and you are prone to so many mistakes and then you're relying on and putting extra pressure on the checker to pick up on your mistakes and that puts more pressure on you and makes you feel worse.” (Focus group 4) Automation was perceived to have had a negative effect on staffing within the pharmacy dispensary. The focus‐group participants reported that post‐automation there were fewer experienced staff in the dispensary, thereby increasing pressure on them (Box 2). Furthermore it was felt that the new dispensary layout reduced teamwork as pharmacy staff assumed insular working practices (Box 2). Although automation had improved working conditions and eased prescription processing, some technicians still felt that dispensing was physically and mentally demanding. Some technicians and ACTs also felt pressurised to work despite feeling unwell (Box 2). Workload There was no significant difference between the median responses given by survey respondents for experience of work overload pre‐ and post‐automation (Table 1). The focus‐group participants did report that the workload had increased post‐automation but the ADS had improved efficiency thereby enabling them to cope with the increased workload (Box 3 ). Box 3 Impact of automation on staff experiences of workload Work overload ACT 3: “Look at it like this we've taken on a lot more work [post-automation] so that we've had more services happening especially with technicians, medicines management, dispensing and more going on wards. Obviously, creates more work related back to the pharmacy which in the old system we wouldn't have been able to do that because we wouldn't have been able to cope … Feels like you're going to get it done a lot faster.” ACT 4: “Even though it's busier, you don't feel busier. It's not stressful.” (Focus group 1) Logical allocation of workload ACT 7: “You only have one prescription to dispense normally at a time [post-automation] …” ACT 10: “… Before there was no logic to it. Before [pre-automation] we had all those bags, you had no idea what was in the bags, as to how much work you could get rid of in half an hour. Could be one item per bag but could be ten items per bag. So I think you are a lot calmer …” ACT 7: “The process is made easier to actually allocate somebody [post-automation].” ACT 5: “To delegate people to the right work where the workload is.” (Focus group 2) Unfair allocation of workload Technician 3: “Like sometimes, if in the afternoon they have one ward top-up [check of medication available on ward] or two that have mini ward rounds that sort of thing. If someone who's doing one of those isn't here. Rather than just saying don't go up today because we haven't got anybody to do it, they'll ask you to do all three and obviously you're rushed because you've got to be back in the dispensary by four o'clock and sometimes fit in yourbreak so you're rushing.” (Focus group 4) There was a significant difference between the median responses given by questionnaire respondents pre‐ and post‐automation for logical allocation of workload (Table 1). The results indicate that less respondents perceived that there was no logical process to workload allocation post‐automation (6%, n = 1) compared to pre‐automation (29%, n = 10). This finding was supported by the focus‐group participants who reported that the redesign of the dispensing process in light of automation had resulted in a methodical system which allowed for easier allocation of staff to different tasks (Box 3). Nevertheless, there was no significant difference in staff experience of a fair workload allocation (Table 1). In the focus group, this finding was attributed to the expansion of pharmacy services with some staff feeling overburdened as they were scheduled on rotas for different activities and had to cover absent staff (Box 3). Experiences of work Staff reported having similar high levels of job control both pre‐ and post‐automation (Table 1). Nevertheless, the technicians did report that since the installation of the ADS they felt like production‐line workers rather than skilled dispensers ( Box 4). Contrary to this a pharmacist felt that automation had given staff control over their activities and opportunities to extend their role (Box 4). Box 4 Impact of automation on staff experiences of work Job control – post-automation production line Technician 2: “You feel more like you're on a production line rather than being a dispenser.” Technician 1: “I think I felt more like a dispenser before the robot because you put liquids and stuff … With the robot now it just brings you out five hundred millilitres whereas before we'd split down pack sizes and go and pour it. I felt more of a dispenser then than I do now.” (Focus group 4) Job control – job variation post-automation Pharmacist 4: “… Not control but in control of what we're doing and less stressful on a day to day basis. As we said before the opportunity to do more things. It's allowed people to get on and deal with greater roles so it may be the same things but it's on the wards. It's job variation.” (Focus group 2) Opportunities for career development – expansion of staff roles post-automation Pharmacist 10: “I think it's like you said, the extension of roles really. One has sort of affected the other. Because we've been able to improve the efficiency in the dispensary, releasing more people. So you know, they're being able to do like for instance the discharge checking, the discharge technicians. It gives them an extended role on the ward that we wouldn't have been able to do previously because we wouldn't have been able to release them from the dispensary. So they get more varied work which is more fulfilling. I think everybody would say that dispensing all day and every day is very boring.” (Focus group 3) Technician 4: “It has allowed us to develop, for example the discharge team and get most out on to the wards so particularly technician wise.” (Focus group 4) Opportunities for career development – lack of career progression ACT 6: “… Our progression is quite steady and things we've been trained to do whereas once you've reached a point like ACT 5 said, once you've done your checking and medicines management, that's the point it stops.” (Focus group 2) Automation had no significant effect on staff opportunities to enhance their career and professional development (Table 1). The focus‐group participants had varying opinions on the impact of automation on staff development. The pharmacists and some technicians felt that automation had enabled the expansion of technical staff roles to ward‐based dispensing as fewer staff were needed in the dispensary (Box 4). The ACTs held the opposite view and felt that staff could not progress beyond a certain level (Box 4). Psychological contract Automation had no significant effect on staff experiences of the psychological contract. Both pre‐ and post‐automation survey respondents agreed they had the contract of their choice, that their contract was fulfilled, the job met their expectations and they were rewarded fairly for their work (Table 1). The focus‐group participants were unmoved by these quantitative results presented during the discussions. A technician did query the honesty of the survey responses as she was aware that some staff did not have the contract of their choice (Box 5). Some ACTs reported that the ADS had not met their expectations ( Box 5). Box 5 Impact of automation on staff experiences of the psychological contract Staff not having the contract of choice Technician 3: “I don't think people have filled them in very honestly if that's the case. Job satisfaction and the contract of choice. I know there are a lot of people that would like to you know go part time or even increase their hours and they're not allowed and they are not happy about it.” (Focus group 4) Expectations not met by automation ACT 5: “Before we had the robot it [career development] was hindered. I suppose because we weren't able to do anything and I suppose when we had the robot we thought that, and we had been told really, and given ideas you know. It was suggested that the technicians would be out [on the wards]. So obviously that was what we were expecting and now the robot has come it hasn't really happened. Our roles haven't changed so yes it has hindered it.”(Focus group 2) Individual outcomes Both pre‐ and post‐automation, survey respondents reported that they were satisfied with their job (Table 1). There was a significant difference between the median responses given by respondents pre‐ and post‐automation for work–life conflict (Table 1). Post‐automation, none of the survey respondents indicated that their job had a negative effect on work–life balance. In contrast, pre‐automation 14% (n = 5) reported that their job affected their home life. The focus‐group participants reported that they were satisfied with their job due to the expansion of roles made possible through the release of staff from the dispensary as a result of automation (Box 6). Some staff did report that their extended roles did negatively affect their home life as they could not always get time off. One technician reported feeling exhausted after returning from work due to the tedium of using the ADS to dispense (Box 6). In contrast other staff reported that automation had improved their work–life balance by enabling them to finish work on time. Furthermore, the ADS enabled the on‐call pharmacists to dispense from home (Box 6). Box 6 Impact of automation on individual outcomes Improvement job satisfaction yet negative impact on work–life balance Technician 3: “It's nicer if you can do the rotas and I think that the robot is allowing us to do more because they can afford for us to be out. So that's nice like and the satisfaction of your job because you probably can do more but it means that it's not as easy to get time off, which can be frustrating because some people who have less rotas, they can have any day that they want off. And the more things that you do it doesn't get sorted for you and you have to sort it and if you can't, you can't have your day off and there is pressure if you do feel stressed. If you're full time and if you want to go part time it's very difficult.” (Focus group 4) Reduced job satisfaction post-automation Technician 4: “I don't feel like that I‘m the dispenser and I‘m just the labeller you know. The robot is doing the work really. I don't know it feels like a demotion and it's just the boredom factor. I'm a run around person and I just feel like, you know, energy creates energy and I get hung up. I feel exhausted whereas before I used to be looking for things to do at home. I wouldn't sit down but now I feel shattered all the time. It just makes you feel tired, the boredom.” (Focus group 4) Improvement in work–life balance post-automation ACT 7: “In general I don't think you stay late. You don't stay as late normally. You get out normally on time. The same time as everyone else whereas before [pre-automation] you would have a lot more work still left to do.” (Focus group 2) Pharmacist 13: “Robot allows us to dispense certain items out of hours without attending the hospital as well. Someone has access into the emergency cupboard. Certain items for wards can be sent directly to them.” (Focus group 3) Recruitment and retention of staff Pharmacist 7: “It's raised the profile of the pharmacy considerably …” Pharmacist 5: “It has raised our profile with training as well particularly with pre-reg [sic]. People perhaps you would think wouldn't come to us, say from further afield, come to look around our department, think it's state of the art. So I think we attract more people on that front.” Pharmacist 4: “Retention because no one wants to leave.”(Focus group 3) Automation had no significant impact on staff perceptions of their employability, with survey respondents agreeing that they could easily find another job (Table 1). However, both pre‐ and post‐automation survey respondents reported they were embedded and committed to the organisation (Table 1). The focus‐group participants did not comment on issues of employability and organisational commitment. However, it was felt that automation had raised the profile of the pharmacy department, facilitating the recruitment and retention of staff (Box 6). Discussion Main findings The study identified that automation improved overall staff experiences of occupational stress. The installation of the ADS and resultant redesign of the dispensary had improved working conditions, dispensing efficiency and management of workload. Study participants reported that automation had enabled the expansion of staff roles, improved work–life balance and the recruitment and retention of staff. However, automation was reported as a source of stress with robot malfunction causing frustration. Furthermore, technicians felt that automation devalued their skills as dispensers and ACTs had limited opportunities for career progression. Limitations This study is based on the experiences of pharmacy staff at one hospital, therefore the findings may not be generalisable to other hospitals or other types of ADS. The response rate for the occupational stressor questionnaire administered post-automation was low. This may be attributed to the high sickness absence because of swine flu. The questionnaire results may also be biased as fewer pharmacists completed the questionnaire post-automation. However, there was concurrence of findings between the questionnaire responses and the focus groups which included the staff that failed to respond to the questionnaire administered post-automation. The sample size was also small as only pharmacy staff who worked in the dispensary were eligible to participate in the study. Therefore it was not possible to control for confounding variables during the statistical analysis of questionnaire responses and the results may be biased; e.g. the extent of job control may be influenced by staff seniority. Although 31 members of staff completed the occupational stressor questionnaire on both occasions, it was not possible to compare their pre- and post-automation questionnaire responses due to the anonymity of the questionnaire data. The reliability of both questionnaire responses and focus group discussions may be questionable as the pharmacy staff may have been reluctant to share their opinions on the impact of the ADS on occupational stressors. Staff experience of occupational stressors This is the first study to investigate the impact of automation on pharmacy staff experience of occupational stressors. The study revealed that the installation of an ADS including the resultant redesign of the pharmacy dispensary had a significant positive impact on staff experience of job stress. This was attributed to changes in working conditions, workload, job control, career development and staff contracts. The focus-group participants indicated that automation had improved dispensary working conditions through the creation of a spacious and organised working environment. This finding was consistent with previous research where pharmacy staff reported, in a survey conducted pre- and post-automation, that there was far more space for dispensing and checking following the installation of an original pack ADS.[21] The focus-group participants also identified that the dispensary layout was problematic with pharmacy staff being distracted by patients and hospital staff in the waiting room. This supports the finding of McCann and colleagues who identified that open plan dispensaries, which allowed the public to view pharmacy staff working, increased pressure on staff to dispense quicker.[22] Another problem identified by a focus group participant was that lack of natural daylight in the dispensary. Buchanan and colleagues have previously identified that inadequate lighting significantly increased the rate of dispensing errors.[23] Similar to previous research, pharmacy staff preferred the ADS compared to manual dispensing.[21] The ADS was reported to have improved dispensing as staff no longer needed to search and retrieve medicines from shelves. Consequently, the focus-group participants perceived that automation had reduced the incidence of dispensing errors caused by the incorrect selection of medication. Currently it is a criminal offence under the UK Medicines Act 1968 to incorrectly label and dispense a medicine.[24] Dispensing errors are a major cause of distress and anxiety to pharmacy staff who fear criminal prosecution, litigation and disciplinary action.[25,26] Previous research has reported that automation reduces dispensing errors by 16% to 60% by significantly reducing drug selection errors.[27–29] Automation may reduce pharmacy staff anxiety related to dispensing errors. The ADS was identified as a source of stress. Consistent with previous research, robot malfunction, delays in the issue of medication from the robot coupled with the feeling that staff could retrieve medication quicker by manually picking from shelves was reported as a cause of frustration.[30] Automation was cited as reducing staffing levels in the dispensary, thereby increasing pressure on the remaining staff. The focus-group participants also reported that the dispensary and pharmacy layout prevented effective teamwork. McCann and colleagues noted that staff shortages and isolated working practices were a source of stress to pharmacists.[22] Furthermore staff shortages and poor teamwork have been identified as a cause of dispensing errors.[14] Automation had little impact on the physical and psychological well-being of staff with study participants reporting that dispensing remained physically and mentally draining. The UK Department of Health and National Patient Safety Agency have recognised the physical demands of dispensing and recommend the use of adjustable benches, pressure mats, appropriately positioned chairs and computer screens.[8,31] Research has reported that the pharmacy profession's requirement for perfection coupled with a heavy workload contributes to the physical and psychological manifestations of stress, including burnout.[32,33] Lahoz and Mason reported that more than 50% of pharmacists surveyed (n = 1261) in the USA experienced moderate to high levels of burnout.[33] In both nursing and medical research, burnout has been demonstrated to negatively affect patient care.[34–36] Pharmacist burnout has also been associated with staff absenteeism and increased job turnover, which may have an impact on staffing levels and staff performance.[32] The negative impact of workload on pharmacy staff was recognised by the Royal Pharmaceutical Society of Great Britain in 2009 when it launched its Workplace Pressures Campaign to address causes of stress in the workplace.[37] In an on-line survey, 70% of pharmacists reported that dispensing workload was a major cause of stress.[38] In this study, automation was found to have no significant impact on staff experience of work overload. The focus-group participants reported that since the installation of the ADS, workload had increased. This is consistent with the findings of Fitzpatrick and colleagues who reported that the number of items dispensed had increased by 19% post-automation.[27] Nevertheless, it was felt that automation had improved dispensing efficiency. This concurs with previous research which demonstrated that dispensary productivity at the department had improved from 9.20 items per person per hour pre-automation to 13.17 items per person per hour post-automation.[14] This study found that automation significantly improved the allocation of workload within the dispensary. This was attributed to the redesign of the pharmacy dispensary that was necessary to install the ADS and the resultant methodical workflow. The UK National Patient Safety Agency recognised that an illogical dispensary workflow can increase stress by causing confusion, fatigue, poor work processes and dispensing errors.[31] Automation did not have a negative effect on staff experience of job control. Some technicians did report that automation had devalued their skills as dispensers and reduced them to production-line workers. This contradicts previous research where pharmacy technicians at another hospital reported that automation had increased their technical skills.[30] This disparity may be attributed to differences in organisational and institutional factors between the different hospitals. Nevertheless, all survey respondents in this study reported having job control. It is possible that the negative effect of automation on staff dispensing skills had been mediated by opportunities for technicians/ACTs to enhance and develop their careers. Focus-group participants commented on the expansion of the ACT/technicians’ role to ward-based dispensing and discharge services which had been made possible post-automation. This is consistent with previous research in manufacturing, which identified that automation of tedious tasks coupled with increased staff involvement in key decision making tasks resulted in more rewarding and interesting jobs.[11] Pharmacy departments implementing ADS need to consider strategies for minimising the monotony of operating an ADS. Such strategies could include rotating staff activities within the dispensary; expanding pharmacist clinical roles through participation in clinics, ward rounds, independent prescribing; and extending technical roles to include medicines management, drug history and counselling services. The downside of role expansion was that some staff felt unfairly overburdened with work which also made it difficult to obtain time off. Automation was reported to significantly reduce work–life conflict with staff finishing work on time. Also the remote dispensing facility enabled on-call pharmacists to issue medication directly to the ward emergency cupboard without leaving home. The questionnaire responses would suggest that automation had no negative impact on job satisfaction, with survey respondents reporting that they were satisfied with their job post-automation. In addition, automation had no significant impact on contract of choice, contract fulfilment, reward equity and employability. A focus-group participant noted that she did not believe that the survey responses truly reflected staff experiences. It is accepted that matters relatingto contracts are sensitive; therefore staff may not divulge their true feelings for fear of repercussions. However, organisational commitment had improved post-automation, despite some staff feeling that automation had not yet met their expectations in terms of career progression. Automation also facilitated recruitment and retention as the robot had raised the pharmacy's profile. This is consistent with previous research in which pharmacy staff reported that automation makes pharmacy ‘more impressive.’[30] Conclusion Socio-technical research suggests that an imbalance between technology and the needs of employees could lead to decreased performance and job turnover.[39] In this study automation was found to reduce staff stress by improving working conditions, work–life balance and the management of workload. Post-automation pharmacy technicians did report feeling like workers on a ‘production line’ rather than skilled dispensers. This negative effect of automation on job control was mediated by new opportunities for pharmacy staff to expand and develop their role on the wards. Automation did introduce new stressors such as increased pressure due to fewer staff in the dispensary and the frustration caused by robot malfunction. Care must be taken when planning for automation and following the implementation of the ADS that occupational stressors are identified and rectified. Factors that should be considered include having designated staff to trouble-shoot and rectify robot malfunction; rotating staff activities; expanding technical and pharmacist roles by developing pharmaceutical services on the wards and in clinics. Disclosures Conflict of interest The author(s) declare(s) that they have no conflicts of interest to disclose. Funding This work was supported by the Welsh Assembly Government, Pharmacy Practice Development Scheme and the Pharmacy Practice Research Trust Galen award, UK. Acknowledgements This work was undertaken when KLJ was a post-doctoral researcher at King's College London. 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IJPP © 2012 Royal Pharmaceutical Society
TI - The impact of automation on pharmacy staff experience of workplace stressors
JF - International Journal of Pharmacy Practice
DO - 10.1111/j.2042-7174.2012.00231.x
DA - 2013-03-06
UR - https://www.deepdyve.com/lp/oxford-university-press/the-impact-of-automation-on-pharmacy-staff-experience-of-workplace-Lk6LXzb60C
SP - 105
EP - 116
VL - 21
IS - 2
DP - DeepDyve
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