Chapter 14 Relationship with other members of the healthcare team
There are seven principles in the Code of Ethics for Pharmacists and Pharmacy Technicians. These state that a pharmacist or pharmacy technician must:
All the above principles have to be adhered to by all pharmacists and technicians. However, to achieve these principles, pharmacists cannot work in isolation if they are to provide the best service to the public. Nowadays most pharmacists work as part of a team with other healthcare workers. If this team is to work efficiently to provide good pharmaceutical services to the public, then a good working relationship needs to be developed between all the members of the healthcare team. In many situations the pharmacist will be the manager/supervisor or responsible person for the team, as, for example, in a community pharmacy. In other situations the pharmacist may be part of a team but not responsible for the team, for example as a member of an ethics committee or team developing educational materials for use by ward staff in a hospital.
The relative position of the pharmacist in a team will determine the skills required to undertake an efficient role. If the pharmacist is the leader/manager/supervisor or responsible person for the team then the required essential skills will be leadership, managing/supervising and delegation. In order to delegate the pharmacist must be confident in the skills of the team and therefore may need to assess the training needs of the team members and organize any required training. Negotiating skills will also be needed but will be crucial if the pharmacist is part of, but not responsible for, a team. In such a situation the pharmacist must be a good teamworker.
Teamwork can be defined as the process whereby people work together cooperatively to deliver goals. The goals will vary depending on the type of team but it is essential that these goals are well defined. In any team it is important that each member knows the role they play and how they contribute to the goals. The introduction of standard operating procedures (SOPs; see Chs 7, 24, 43) has gone a long way in helping define each member’s role and responsibility as well as fulfilling UK clinical governance criteria.
The following skills and attributes would be desirable for successful teamwork:
The healthcare ‘team’ can be defined in a number of ways and will depend on the work environment of the pharmacist.
In community pharmacy the immediate team that the pharmacist works with on a day-to-day basis is made up of:
The terminology will vary depending on the individual company or business.
The community pharmacist will also be involved with external people, depending on their job role – the extended ‘team’:
This list is not exhaustive but gives an idea of the variety of people/professions the community pharmacist has to consider when providing expert patient care. They will interact on a daily basis when dealing with specific problems related to individual patients’ care, selection of drugs by the healthcare professional, dealing with drug interactions, etc.
In a hospital pharmacy the pharmacist will also interact with pharmacy technicians but will have a closer working relationship with the nurses and doctors directly involved in the patients’ care on a daily basis and with far more ease of contact than the community pharmacist has with the community GP. When dealing with the junior doctors and nursing staff in hospital the pharmacist will have a teaching/supportive role while assuming an advisory role on the use and side-effects of drugs when dealing with the more experienced consultants. Hospital pharmacists will also be in contact with other professionals with regard to discharging patients into the community, such as social workers, physiotherapists, occupational therapists, dentists and the local drug misuse team. Within the hospital environment the pharmacist may have to become involved with the various hospital committees, e.g. drug safety, ethics, general administration, formulary, etc. and interact with a range of professional as well as administrative roles. In addition, hospital pharmacists will be in contact with community pharmacists to ensure a seamless supply of medicines to those patients discharged from hospital on specialized drug regimens.
The changing role of the pharmacist as discussed in Chapter 1 has made it even more important that the pharmacist depends on their healthcare team to free up the time to allow them to deliver the various services required by the new pharmacy contracts. The pharmacist is moving further away from the traditional role of being ‘counters and pourers and stickers and lickers’ to advising patients and customers on their medicines, conducting medicine use reviews (MURs), promoting health advice, etc. (see Chs 5 and 47).
From 1 July 1996 it has been a professional requirement that each member of staff whose work in a pharmacy will regularly include the sale of medicines must have completed a course or be undertaking an accredited course relevant to their line of work. The Royal Pharmaceutical Society of Great Britain’s (RPSGB) requirement is that the courses should cover the knowledge and understanding associated with units 2.04 and 2.05 of the Scottish/National Vocational Qualification (S/NVQ) level 2 in Pharmacy Services. These are entitled ‘Assist in the sale of OTC medicines and provide information to customers on symptoms and products’ and ‘Assist in the supply of prescribed items (taking in a prescription and issuing prescribed items)’.
There is a requirement that the course should be completed within a 3-year time period and that the member of staff should be enrolled on such a course within 3 months of starting their role.
The following training programmes for medicines counter assistants/healthcare assistants have been accredited for the RPSGB by the College of Pharmacy Practice:
Medicines counter assistants/healthcare assistants will primarily be found in community pharmacy in residential areas and supermarkets. Their training usually takes the form of ‘workbook-led on-the-job learning’, meeting the above requirements for accreditation with the pharmacist acting as the tutor. This allows the relationship to develop and the pharmacist to realize the potential and limitations of these members of staff.
The training required is much more in-depth than for the medicines counter/healthcare assistant to reflect the variation in role and responsibilities. The job title will vary depending on the sector of pharmacy the person works in and indeed the company/business they work for – dispenser, dispensing assistant, pharmacy assistant, assistant technical officer, etc. Whatever their title or sector of pharmacy they are working in, what they all have in common is that they are working under the supervision of the pharmacist.
From 1 January 2005 there is the professional requirement that these dispensing/pharmacy assistants are competent in the areas in which they are working to a minimum standard which is equivalent to the new Pharmacy Services S/NVQ level 2 qualification or are undertaking such training.
This applies to staff working in the following areas:
To fulfil this requirement a training programme relevant to the job needs to be completed within a 3-year time period and the member of staff should be enrolled on such a course within 3 months of starting their role. If a member of staff has not undertaken such a course but they fulfil the requirements of the ‘grandparent clause’ and a declaration of competence has been sent by their supervising pharmacist to the RPSGB during the ‘grandparenting’ period, then the member of staff does not need to undertake further study to remain a dispensing/pharmacy assistant. (The ‘grandparent clause’ recognizes that existing staff may already have completed an appropriate course and/or have relevant experience.)
The dispensing/pharmacy assistant is a key member of the healthcare team as they free up the pharmacist from the assembly processes involved in the dispensing of prescriptions.
A pharmacy technician is someone who has undertaken a course that provides them with an S/NVQ Pharmacy Services level 3 qualification. The ‘pharmacy technician grandparent clause’ has allowed a number of other qualifications, formerly recognized as pharmacy technician qualifications, to be acceptable for registration purposes. Further details on these qualifications can be verified with the RPSGB.
Once qualified, the pharmacy technician may choose to join the register of technicians. This was a voluntary register opened by the RPSGB in January 2005 but registration is now a requirement for those wishing to use the title ‘pharmacy technician’ (this title is protected in law). By doing so they are bound by the Code of Ethics and must participate in continuing professional development – the same requirement as for pharmacists.
The pharmacy technician may work in hospitals, community pharmacy, health centres, primary care trusts, prisons and the armed forces and in the pharmaceutical industry. We will focus on community and hospital pharmacy.
Pharmacy technicians are required to make up the prescriptions issued by doctors. These are then checked by the pharmacist both for accuracy and to make sure that the dosage and treatment are safe for that patient, i.e. a clinical check.
The role of the technician involves:
As can be seen there is considerable overlap with the dispensing/pharmacy assistant role, but with additional responsibilities.
The pharmacy technician may choose to become an accuracy checking technician (ACT), which would require them to undertake a further period of study and development of a portfolio of evidence to demonstrate their competence in this area. The technician must have successfully checked 1000 items error free in a defined period of time (usually 4 weeks) while keeping a diary of all items checked and any errors made while checking or dispensing and completing any assignments required by the employer. They then have a final assessment which requires them to check the accuracy of a set amount of prescription items under timed conditions.
The checking technician plays an invaluable role. They will accuracy check the prescriptions once the pharmacist has clinically checked them. This has not only been shown to be more accurate than pharmacist checking but also, more importantly, it frees up the pharmacist to get on with the other new roles that are emerging, such as carrying out MURs in England, being involved in the electronic minor ailment scheme (eMAS) in Scotland, supplementary and independent prescribing, etc.
The work in the hospital pharmacy setting for a pharmacy technician has many similarities to that in the community sector. However, the work has greater variation due to the different areas for care within hospital. These include:
Hospital pharmacy has also had the role of the ACT in place for a number of years now and the criteria for this role are similar to those described above for the community role.
There are other people who can play an important role in the pharmacy team but they are not present in every pharmacy team at all times. These are pre-registration pharmacy trainees and also pharmacy undergraduates either taking part in a period of vocational placement or working on a part-time basis in the pharmacy setting.
Pre-registration pharmacy trainees will have completed 4 years of study at university and obtained an accredited degree in pharmacy. In order to become a pharmacist they are required to undertake a period of training, usually 1 year within a pharmacy setting, either community or hospital. Some may choose to enter industry and carry out a split placement between this sector and hospital but these only account for a small number of the graduates. At the end of the training period the graduate has a registration examination to undertake and pass before they can enter the pharmacy profession. During the training year the pre-registration pharmacy trainee becomes a valuable member of the team while turning their university knowledge into practical skills within the pharmacy. It is important that at this time the trainee has the end goal of pharmacist in mind and does not become absorbed into the day-to-day tasks of the job. The pre-registration pharmacy trainee is given guidance from their tutor throughout this period.
Pharmacy undergraduates join the pharmacy team at any time depending on the needs of the pharmacy setting. Some may work on a part-time basis at weekends, others for a period of time during the university breaks to gain experience in the different areas of pharmacy and decide where they will complete their pre-registration training.
The role of the pharmacist, both in the primary and secondary care setting, is changing. No longer can the pharmacist work in constant isolation: they must learn to become integrated members of both their immediate and extended teams, and so it is essential for the pharmacist to recognize that team leading, delegation, negotiation and teamworking are essential skills that they must possess.
There have been a lot of studies carried out to determine what it is exactly that makes good leaders. The majority of these studies lead to the conclusion that leadership is about the behaviour of the leader first and the skills that they possess second. It is about recognizing that people need to trust and respect you before they will listen and act on what you ask them to do.
In any one environment there can be a number of different teams working together, e.g. in the hospital setting or the community setting, and sometimes one particular team will outperform the others. Why is this?
In all cases it is attributable to the person leading the team and the fact that they possess such qualities as integrity, honesty, humility, courage, commitment, sincerity, passion, confidence, positivity, wisdom, determination, compassion and sensitivity. This makes their staff willing to go that ‘extra mile’ for them. Some people are naturally born with these behaviours already well developed but others, recognizing that these behaviours are important, can develop this side of their behaviours to achieve great leadership qualities.
A good leader will be able to use a number of different leadership styles depending on the situation they are faced with. Again some people have a dominant style of leadership, but to be truly great they need to look at all the other styles of leadership and develop these also.
As a pharmacist it is important to recognize that no matter what area of pharmacy you work in you will always be looked upon as the leader of that team, and it is crucial to know your own strengths and weaknesses and build on these. This is where continuing professional development (CPD) really comes into play. This is discussed in more detail in Chapter 10. CPD is the process whereby the pharmacist can effectively identify and plan what they need to address to develop their leadership qualities or indeed any area that will benefit their professional career.
The correct behaviour, especially towards your team, is the key to being an effective leader and the following are some tips towards being respected as a leader:
No pharmacist can do all the tasks themselves so it is essential that they recognize that many tasks need to be delegated to the other team members.
Good delegation will save you time, will develop your team and generally motivates all involved. It is not just a technique to free up time. Poor delegation will lead to frustration, demotivation among your team and failure of the task(s) involved so it is essential that delegation is effective.
When delegating tasks one should follow the SMARTER mnemonic. To ensure success on completion then all delegated tasks must be:
It is extremely important for the pharmacist to be able to delegate various tasks within the pharmacy to suitably trained persons because it is no longer cost-effective for the pharmacist to be carrying out tasks that others are more than qualified to complete. Thus this frees the pharmacist to get on with the job they were educated at university to do and leads to job satisfaction for all staff involved.
In order to get the members of the immediate and extended teams on board the pharmacist has to be aware of, and if necessary develop, their negotiation skills.
Negotiation is something that we do all the time in and out of the working environment and maybe do not realize it, e.g. deciding what to see at the cinema, where to go out to eat, where to go sightseeing on holiday, what shift someone should work and for how long, etc.
Negotiation is usually considered as a compromise between people to get what we want. To be really effective in the team environment the compromise should allow both parties to be satisfied with the eventual outcome. The only time you may want to consider the win–lose negotiation is if you do not need to have an ongoing working relationship with the other party. This is something that is going to be very unlikely in the pharmacy setting. If the pharmacist always negotiates to ‘win’ then the working relationship within the team will eventually break down and the working environment will suffer. Ultimately patient care deteriorates as no one works together.
Communication is the key link that will be used to negotiate and as such can be in a variety of ways – face to face, in writing, over the telephone, etc. (see Ch. 13). Body language is thus another area that the pharmacist may wish to develop as body language accounts for over 90% of a conversation.
For successful negotiation to occur the following should be considered:
Pharmacists in both the primary and secondary care sector are now required to work very closely together to deliver the government targets for access to health care, provision of services outside normal working hours in addition to the range of services and roles detailed in the new pharmacy contracts. As mentioned, pharmacists are dependent on the skills of their immediate teams to be able to fulfil these new roles and have to be able to demonstrate that they meet the clinical governance requirements. This requires a great deal of teamwork both within the immediate teams and the extended teams.
Pharmacists may work well in their immediate teams but if they are to embrace the changing role of pharmacy and health care then they need to extend their teamworking across a wide variety of healthcare professionals and embrace all the skills highlighted above.
It is essential that pharmacists start to maintain a formal record of all their contributions and interactions within the wide variety of teams to demonstrate their invaluable contribution to patient care.