Exploration of professional and working conditions among community pharmacists in Gipuzkoa

INTRODUCTION

In the Autonomous Community of Euskadi, the provision and distribution of community pharmacies is governed by the 1994 Basque Pharmaceutical Organisation Act [Ley 11/1994 de Ordenación Farmacéutica de la Comunidad Autónoma de Euskadi (CAE)] (1). Decree 129/1997 on the provision of human resources (2) regulates the presence of the pharmacy owner and the provision of the necessary human resources in the Basque region. Decree 188/1997 on business hours (3), regulates, inter alia, the minimum opening hours of pharmacies (9 am – 1 pm and 17pm – 19pm) and the voluntary opening hours described in Table 1. Options include voluntary continuous 9 am – 10 pm opening from Monday to Friday (13 hours); Saturday mornings, 9 am – 1.30 pm; Saturdays, 9 am – 10 pm; Sundays and public holidays, 9 am – 10 pm or 24h opening. This decree also regulates the coordinated system for providing duty pharmacy services in the different time slots.

 

Table 1 Distribution of Community Pharmacies (CPs) by opening hours and location in Gipuzkoa (n,%). (Data obtained from the Pharmacist Association database)

A total of 1405 people work in community pharmacies in Gipuzkoa. Of these, 950 are pharmacists (313 owner pharmacists (OPs) and 637 associate pharmacists (APs)) and 455 are pharmacy technicians and assistants.

In November 2022, the Gipuzkoa Association of Non-owner Pharmacists [Asociación de Farmacéuticos sin oficina de farmacia] launched a campaign, as a result of which twenty associate pharmacists sent letters to the Official Pharmacists’ Association of Gipuzkoa (COFG) describing their work-life balance issues. Around the same time, the COFG had also been hearing from pharmacy owners about the difficulties they were facing in finding associate pharmacists available to work in their community pharmacies. The governing board of the association decided to address the problem and agreed to begin a process of reflection on working conditions in community pharmacies.

Primary aim

Explore the professional and employment situation of community pharmacists in Gipuzkoa.

Specific goals

• To assess the opinion of community pharmacists in Gipuzkoa on their job satisfaction and work-life balance.
• To analyse the reasons leading members in Gipuzkoa to cancel their association membership in the last 3 years.

MATERIAL AND METHOD

Discussion group of owner pharmacists and associate pharmacists

To address the primary aim, a discussion group was held in March 2023 at the COFG facilities, attended by OPs, APs and senior staff from the association. The COFG staff made a purposive selection of participants, who included 5 APs and 5 OPs considered active and participatory. The meeting was chaired by the president of the association. A member of the board of governors and the technical director also attended. The participants gave consent for the meeting to be recorded in its entirety for subsequent transcription and analysis. The attendees were assured that full confidentiality would be respected at all times.

The meeting was conducted using a previously prepared script, which explored OPs’ difficulties in recruiting APs and the APs’ perception of their work-life balance and job satisfaction (See Appendix 1).

The data were collected, transcribed and subsequently analysed following the fundamental principles for discussion groups (4) and Braun and Clarke’s thematic analysis method (5,6).

Survey of job satisfaction and work-life balance

In May 2023, the COFG sent out an ad-hoc online questionnaire ( See Appendix 2) to the 950 pharmacists working in community pharmacies. It contained 4 closed questions for OPs and 9 closed questions for APs on job satisfaction, work-life balance, pharmacy schedules and (in the case of APs) working hours. The survey also included a common open field where APs and OPs could add their own observations.

The quantitative variables were statistically analysed using IBM’s SPSS 26 program. Statistical significance was set at p<0.05. The results of the continuous variables were expressed as mean ±SD and/or median (interquartile range). The groups were compared using the one-way Anova test and Student’s t-test for independent samples.

The observations field was qualitatively analysed using the thematic analysis method (5,6).

Reasons for cancelling association membership

In June 2023, pharmacists who had cancelled their membership in the previous 3 years (May 2020 - May 2023) were contacted and asked for their reasons for deregistering. The answers were all compiled in a database in MS Excel. For statistical purposes, the answers were divided into three groups: (i) change in professional field, (ii) same professional field in different province and (iii) change in employment status (sick leave, extended leave of absence, etc.).

The variables were quantified and expressed as percentages.

RESULTS

1. Discussion group of owner pharmacists and associate pharmacists

Before the discussion group proper began, several APs complained that the COFG had only responded to their professional issues when the OPs started having difficulty recruiting pharmacists to work in their CPs.

The problem was defined as multifactorial and was grouped into 4 major themes: (i) working hours, (ii) working conditions, (iii) work-life balance and (iv) professional development.

Working hours

The participants felt that they worked long hours compared to other professionals with similar qualifications. Furthermore, they felt that their working day was poorly distributed. In particular, they mentioned the superfluous free hours at midday in CPs with split business hours and the fact that Saturdays and Sundays were considered as ordinary working hours, in cases where this is covered by the collective labour agreementa.

‘The hours for associate pharmacists, who generally work split days and, in most cases, Saturday mornings, are frankly inhuman.’

‘I spend from eight-thirty in the morning to eight-thirty in the evening dependent on the pharmacy, with three-and-a-quarter hours off in the middle of the day. Its utterly inhuman.’

‘…for me, an hour on Sunday counts for the same as an hour on a Tuesday…’

Working conditions

As for other working conditions, participants particularly mentioned difficulty in choosing holidays, failure to distinguish between the functions of the associate pharmacist and those of the technicians and assistants, and insufficient recognition of seniority. They also reported that in many cases the terms of the collective agreement with regard to the timeb they are supposed to have for training during working hours were not being respected. They partly blame the small business structure of community pharmacies for the failure to ‘think collectively’, which makes it difficult to claim certain rights. In some cases, the issue of ‘demand possibilism’ [limits to what can be demanded] was raised; this refers to the fact that there are indeed aspects that should be championed, but because the CP is a small organisation, the AP has few options to do so.

‘…that I can retire in Pharmacy XX in 35 years’ time and I’m going to be paid the same as I am from next year on….’

‘… but, sorry, I just want to say something about the hours; 20 work hours are earmarked for training. I mean, that is stipulated in the collective agreement.’

Work-life balance

Most of the APs in the group reported difficulty in balancing their work and their home life. This is one of the chief factors leading them to feel that they need to give up their career.

‘I think there are two major issues. One, obviously, is work-life balance; the other is the problem of the hours, especially in pharmacies that close in the middle of the day’;

‘…there’s no work-life balance, you don’t have aspirations and you don’t have any sense that your life is getting better. (…) What can I do? Should I leave? (…) But when you like your career and your work, it’s very sad that you have to leave...’

However, there are also some OPs who report having an even worse work-life balance than their APs.

‘So, in my case, I have three people working part-time. For me, that’s a drag; in the end, of course, I’m the one who does most work, the one who has no work-life balance.’

Professional development

The lack of time for training, the perception that some OPs have of the need for AP training, and the lack of a real professional practice of care, generates a certain amount of frustration among APs.

‘I don’t think any real value is given to the fact that you are more qualified than someone else.’

‘I have been working in the same place for 15 years, doing exactly the same thing. It doesn’t matter what I study; it doesn’t matter how much or how little I study (...). I’m still going to get paid the same and get the same recognition. I think that is frustrating.’

There were frequent references to the need to ‘humanise’ the relationship between the OPs and the APs. APs would like their work to be valued by the OP through small details, such as an afternoon off, some flexibility in scheduling, etc.

‘That human consideration... Say, for example, my father has had an operation, and the pharmacy owner knows and says, ‘you can take a couple of days off, no worries’. I mean, it’s not a question of money; it’s just a question of showing some concern for me.’

A number of proposals were also made for tackling these demands:

• Humanise the relationship between the OPs and the APs; avoid paternalism.
• Amend the Decree on Opening Hours.
• Change the times of training courses.
• Compliance with all the terms of the collective agreement.

2. Satisfaction and work-life balance survey

2.1. Quantitative analysis

The survey was answered by a total of 383 community pharmacists (40.3% response rate), of whom 282 (73.6%) were APs and 101 (26.4%) were OPs.

A total of 257 of the pharmacists (67.1%) work in pharmacies with regular business hours from Monday to Friday, as compared to 91 (23.8%) who work in establishments that open on a voluntary continuous 13-hour basis. Only 52 of the pharmacists (13.2%) work in CPs that are not open on Saturday mornings. Table 2 shows the type and distribution of working hours and working day among pharmacists answering the survey.

 

Table 2 Opening hours of community pharmacies and working days of pharmacists who filled out the questionnaire

 

Table 3 Job satisfaction of pharmacists completing the questionnaire (on a scale from 1 (very dissatisfied) to 5 (very
satisfied)

Table 3 shows the perception of job satisfaction and work-life balance among APs and OPs, on a scale from 1 (very dissatisfied) to 5 (very satisfied). Job satisfaction among pharmacists stands at 3.30 (±1.17), with significantly higher satisfaction among OPs than APs (3.91±1.00 vs. 3.08±1.15; p<0.001). Similarly, the overall score for work-life balance was 2.45 (±1.28), i.e., between ‘neutral’ and ‘dissatisfied’. Again it is higher among OPs than APs (2.89±1.29 vs. 2.29±1.28; p<0.001).

When analysing the data by CP hours, job satisfaction is significantly lower among APs than OPs in all timetables (p<0.05), except in the 13-hour schedule from Monday to Friday and Saturday mornings where no differences are observed (p>0.05).

The score for work-life balance tends to break down according to the business hours of the pharmacy. The AP group reported better work-life balance in pharmacies open continuously 13 hours from Monday to Friday and in those with 13-hour opening from Monday to Friday plus Saturday mornings than in CPs with split hours from Monday to Friday and open on Saturday mornings (2.72±1.21 and 2.55±1.42 vs 1.96±1.04; p<0.007). APs gave lower scores for work-life balance than OPs (p<0.05) in all types of CP opening hours, except those open 13 hours from Monday to Friday and on Saturday mornings, where there was no differences between the two groups (p>0.05).

No significant differences were observed by type of employment contract (part-time vs. full-time) in either job satisfaction or work-life balance (p>0.05).

Analysing the data by working day, no significant differences were observed for job satisfaction (p>0.05). However, work-life balance scored significantly better (p<0.001) in the morning shift (3.07±1.44), in the night shift (2.70±1.05) and in alternate shifts (mornings/afternoons) (2.70±1.40), than in the split shift (1.94±1.16), which is the worst-rated shift.

2.2. Qualitative analysis (observations field)

Of the 383 pharmacists who answered the survey, 173 (45.2%) entered a remark in the open ‘observations’ field; Of these, 137 were APs (79.2%) and 36 OPs (20.8%). The comments received were grouped into the following topics: (i) working conditions, (ii) pharmacy business hours, (iii) professional development and recognition, and (iv) role of the COFG.

Working conditions

One of the issues most often mentioned by APs was the large number of hours required under the collective agreement. Some said that it increases over the years, that it is not comparable to other health professions and that it is poorly distributed because most pharmacies operate a split schedule (closing in the middle of the day). These hours are considered to be the main obstacle to balancing work and family life. Possible solutions suggested to improve the situation include shorter working hours and night shifts. Indeed, insufficient work-life balance is one of the greatest problems perceived and repeated by both APs and OPs.

‘The collective agreement requires too many hours per week. It should be closer to 35 hours per week.’

‘Almost 200 hours more than nurses or doctors have in their agreement... and 100 hours more than nursing home staff, dentists and physiotherapists.’

‘With the business hours of pharmacies, there is no work-life balance. The only solution is a reduction in working hours’

APs also said that their salaries were insufficient, do not take into account their seniority and do not recognise their professionalism or training.

‘Improve the salary and the social benefits; our job has a high degree of responsibility and it is not well paid.’

‘The issue of salary, no seniority for 12 years, no supplement, no bonus for experience/courses/training (loads of hours) that some of us have done.’

Some criticised the fact that APs’ rights under the collective agreement are sometimes not recognised. These rights include the 20 hours of training per year during working hours; annual medical check-ups; work uniform (gowns and footwear), and the fact that duty hours and overtime are not paid at the agreed rate.

‘Plus we work overtime at weekends that is not paid for and there are always problems with taking hours off in lieu. There are no medical check-ups. Gowns and clogs are not provided.’

‘Duty hours on Saturday afternoons, Sundays and public holidays should be paid for’

Opening hours of community pharmacies

Another of the issues most often reflected in the comments, and mentioned as a possible solution for improving the work-life balance, is that of adapting the opening hours of the pharmacy to the wider context. Both APs and OPs propose that the decree regulating the opening hours of pharmacies be amended.

‘Change in the regulations governing the opening hours of pharmacies with respect to other autonomous communities.’

‘If business hours were not restricted, we could have a better work/life balance; and that goes not only for the employees, but for me as the proprietor too.’

Professional development and recognition

The APs say they do not receive the professional recognition they are owed. Moreover, the training they have received over their career is not reflected in their day-to-day work, making them feel undervalued. They say they feel demotivated by the lack of professional development.

‘Given all we have studied, we feel undervalued; it is not reflected in our everyday work.’

‘We have studied a difficult career, and we are not valued at all. We have a certain degree of responsibility and there is no appreciation for that at all.’

Role of COFG

As regards the COFG’s role in the current problems, some pharmacists welcome the initiative, while others call for greater involvement.

Finally, some pharmacists, in their personal assessments, said that they regretted their career choice, because of the frustration and disappointment they feel over their professional and work situation:

‘I’m not brave enough, but I would give up pharmacy for any other job.’

‘Regret about my choice of career; it is too late for me to put it right.’

‘I am very frustrated and disappointed with my career.’

‘It is all demotivating. It gets to the point where you want to give up and have nothing more to do with this stale, obsolete sector.’

In addition to these demands, the following proposals were posited to tackle them:

• Amend the Decree on Opening Hours.
• Review of working conditions to bring them into line with other healthcare professions.
• Full compliance with the Collective Labour Agreement.
• Introducing work/life balance measures.
• Valuing the responsibilities of the different profiles in professional practice

3. Reasons for cancelling membership

Of the 135 members who cancelled their membership during the period under study (May 2020 - May 2023), 95 answered (70.4% response rate). Of these, 70.5% (n=67) said they had left due to a change in career; 17.9% are still working in a community pharmacy in another province and 11.6% have altered their employment status (sick leave, retirement, etc.) (Table 4).

 

Table 4 Distribution of reasons for discontinuing membership (n=95)

Of the former members who no longer work in CPs, 26.3% have taken employment in secondary education or vocational education in different disciplines; 15.8% have gone on to practise in the pharmaceutical industry and 12.6% have moved to hospital pharmacy (including pharmacists who are preparing to sit their pharmacy residency (PR) exam and those who have already obtained a position).

DISCUSSION

This is the first study in Spain to address the professional and working conditions of community pharmacists. It is an issue of great practical importance for the future of community pharmacies, since many in the sector, particularly associate pharmacists, feel discontented and frustrated with their working situation, due to the working hours and consequent lack of a work/life balance. The purpose of the study is to make a diagnosis of the situation that will enable further work on this highly complex and sensitive subject. It goes hand in hand with a shortage of APs to fill the positions that are needed to guarantee the current provision of pharmaceutical services and the care services to be added in the near future. This problem is also becoming increasingly evident in a number of countries (7).

The discontent felt stems from the difficulties that pharmacists (primarily APs, but also some OPs) encounter in reconciling their work and home life. This is especially true of those who have split working hours (with a break in the middle of the day) from Monday to Friday and who also, in many cases, work on Saturday mornings. It is worth noting that the working day and the way it is distributed are the principal factors conditioning work-life balance, not only in the field of the community pharmacy, but in all areas of employment. This has been described in a study by InfoJobs showing that only 14.4% of the Spanish working population enjoyed continuous working schedules, even though 76.3% would like to (8).

It should also be remembered that the CP is a health facility with a public service mission. As such, its functions, minimum opening hours and duty schedules, human resources, etc. are all highly regulated by state and regional legislation. Therefore, any action aimed at improving the issues discussed here should take an overall perspective, with a thorough analysis of the regulations and their social impact.

It is also important to note that the COFG has been observing a shift among its members away from community pharmacy and towards other areas (such as education, industry, government, etc.). This trend is also reflected in our analysis of the number of cancelled memberships over the last 3 years. This movement is not exclusive to Gipuzkoa, as can be seen in the article analysing the reasons for pharmacy graduates leaving the profession (9), which points the finger particularly at limitations on professional development and a failure to make use of the pharmacist’s skills, partly due to the lack of healthcare provision in CPs. This lack of professional recognition is also discussed in a report published by the FIP (10). Some authors have described how the introduction of professional care services might help reduce professional frustration and foster professional development among pharmacists (11).

For its part, although employment actions lie outside the COFG’s remit, the association nonetheless seeks to bring greater visibility and awareness of this thorny issue and make it easier to tackle, given that it impacts the professional performance of community pharmacists and the management of CPs. For the time being, a roadmap with a number of different actions has been designed. These include proposing that the Council of Pharmacists of the Basque Country organise a monographic meeting on business hours and aspects related to the pharmacist’s work-life balance, in order to evaluate, among other issues, a possible amendment to the decree on opening hours (Decree 188/1997); working with professional groups to try to find alternatives that would improve working conditions, measures for work/life balance and exercise of the APs’ entitlements under the collective agreement. The COFG has been working to make further progress in the provision of professional pharmaceutical care services (PCSs) in community pharmacies (12-16) and highlighting the different roles and responsibilities of the people who make up the pharmacy teams. Together, these actions will lead to greater recognition and professional development.

It would be useful now to propose a general reflection and discussion at a national level, involving both the collegiate organisation and professional and trade union organisations. This would enable an in-depth analysis of the model (access to ownership, schedules, professional development, career, implementation of reimbursed PCSs, pharmacy remuneration systems, etc.). General strategies should also be set out for improving the work situation and job satisfaction of the collective as a whole.

ACKNOWLEDGEMENTS

Our thanks to the community pharmacists who participated in the discussion group, those who replied to the questionnaire and those who answered our query on their cancellation of membership.

REFERENCES

1. Law 11/1994, of June 17, 1994, on Pharmaceutical Regulation of the Autonomous Community of the Basque Country. In Spanish [Ley 11/1994, de 17 de junio, de Ordenación Farmacéutica de la Comunidad Autónoma del País Vasco]. Boletín Oficial del País Vasco nº 135 (15/07/1994). Available at: https://www.boe.es/diario_boe/txt.php?id=BOE-A-2012-1682

2. Decree 129/1997, of June 3, 1997, on the provision of human resources for pharmacy offices. In Spanish [Decreto 129/1997, de 3 de junio, sobre dotación de medios humanos de las oficinas de farmacia]. Boletín Oficial del País Vasco nº 115 (18/06/1997). Available at: https://www.legegunea.euskadi.eus/eli/es-pv/d/1997/06/03/129/dof/spa/html/webleg00-contfich/es/

3. Decree 188/1997, of July 29, 1997, which determines the opening hours for pharmacies. In Spanish [Decreto 188/1997, de 29 de julio, por el que se determina el horario de atención al público de las oficinas de farmacia]. Boletín Oficial del País Vasco nº 155 (18/08/1997). Available at: https://www.legegunea.euskadi.eus/eli/es-pv/d/1997/07/29/188/dof/spa/html/webleg00-contfich/es/

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5. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3(2): 77–101. doi:10.1191/ 1478088706qp063oa

6. Michelle E. Kiger & Lara Varpio (2020) Thematic analysis of qualitative data: AMEE Guide No. 131, Medical Teacher, 42:8, 846-854. doi:10.1080/0142159X.2020.1755030

7. Connely D. Special report: the community pharmacy workforce crisis. The Pharmaceutical Journal, PJ.2023; 311(7976). doi:10.1211/PJ.2023.1.194422

8. Estudio de InfoJobs sobre el horario laboral en España; 2019. Accessed 2023 Jun 23. Available at: https://nosotros.infojobs.net/prensa/notas-prensa/solo-el-14-de-la-poblacion-activa-cuenta-con-horario-laboral-continuado-europeo

9. Aspden TJ, Silwal PR, Marowa M, Ponton R. Why do pharmacists leave the profession? A mixed-method exploratory study. Pharm Pract (Granada). 2021 Apr-Jun;19(2):2332. doi:10.18549/PharmPract.2021.2.2332

10. International Pharmaceutical federation. Pharmacist Ethics and Professional Autonomy: Imperatives for Keeping Pharmacy Aligned with the Public Interest: reference document. [Internet] Accessed 2023 Jun 23. Available at: https://www.fip.org/file/1368

11. Aspden TJ, Marowa M, Ponton R, Scahill S. Why are we still waiting? Views of future-focused policy and the direction of the profession from dissatisfied recent pharmacy graduates. J Health Organ Manag 2021;35(6):744-762. doi:10.1108/JHOM-04-2020-0162

12. Malet-Larrea A, Goyenechea E, Garcia-Cardenas V, Calvo B, Arteche JM, Aranegui P, et al. The impact of a medication review with follow-up service on hospital admissions in aged polypharmacy patients. Br J Clin Pharmacol. 2016; 82(3):831-8. doi:10.1111/bcp.13012

13. Oñatibia-Astibia A, Malet-Larrea A, Larrañaga B, Gastelurrutia MÁ, Calvo B, Ramírez D, Cantero I, Garay Á, Goyenechea E. Tailored interventions by community pharmacists and general practitioners improve adherence to statins in a Spanish randomized controlled trial. Health Serv Res. 2019;54(3):658-668. doi:10.1111/1475-6773.13152

14. Rodríguez-Castejón J, Aizpurua-Arruti X, Isla A, Malet-Larrea A, Calvo B, Martiarena A, Solinís M, Domingo-Echaburu S, Gastelurrutia M, Goyenechea E, Del A. Nuevo servicio de seguridad y uso de medicamentos sujetos a seguimiento adicional (SSUM) en farmacia comunitaria: resultados iniciales. Farm Comunitarios. 2020 Nov 05;12(Supl 2. Congreso SEFAC 2020):66. Available at: https://www.farmaceuticoscomunitarios.org/es/journal-article/nuevo-servicio-seguridad-uso-medicamentos-sujetos-seguimiento-adicional-ssum

15. Oñatibia-Astibia A, Malet-Larrea A, Mendizabal A, Valverde E, Larrañaga B, Gastelurrutia MÁ, Ezcurra M, Arbillaga L, Calvo B, Goyenechea E. The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach. Aten Primaria. 2021;53(1):43-50. doi:10.1016/j.aprim.2020.04.008

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Appendix 1. Meeting script used in the discussion group between pharmacists owners and associate pharmacists

 

Appendix 2. Satisfaction and work-life balance survey