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Abstract

This study sought to describe the impact of the COVID-19 pandemic on community pharmacy practice and its workforce. Interviews were conducted with 18 key informants from pharmacy associations and community pharmacists representing chain and independent pharmacy organizations across the United States from January to May 2022. Interview notes were analyzed using a rapid content analysis approach. Four themes resulted: (a) patient care at community pharmacies focused on fulfilling COVID-19 response needs; (b) pharmacists’ history as immunizers and scope of practice expansions facilitated COVID-19 response efforts; (c) workforce supply shortages impeded COVID-19 response efforts and contributed to burnout; and (d) maintaining community pharmacy workforce’s readiness will be critical to future emergency preparedness and response efforts. Formalizing scope of practice expansion policies and reimbursement pathways deployed during the COVID-19 pandemic could facilitate the community pharmacy workforce’s ability to address ongoing public health needs and respond to future public health emergencies.

Keywords

COVID-19 emergency preparedness and response public health community pharmacy workforce

Introduction

Community pharmacies, or pharmacy locations open to the public for medication dispensing and patient care, are among the most accessible health care sites in the United States. There are over 60,000 community pharmacies nationwide, many of which are open beyond traditional business hours, including evenings and weekends (Qato et al., 2017). Approximately 89% of the overall U.S. population lives within 5 miles of a community pharmacy (Berenbrok et al., 2022). Furthermore, patients visit a community pharmacy more frequently than their primary care providers. Berenbrok and colleagues found the median number of visits to community pharmacies annually among Medicare beneficiaries was significantly higher than encounters with primary care physicians (13 vs. 7) (Berenbrok et al., 2020).

The services patients can access at community pharmacies have expanded beyond medication dispensing. Community pharmacists offer a spectrum of services including medication optimization, chronic and acute care management, wellness and prevention, and patient education (Bacci et al., 2019; Goode et al., 2019). Medication optimization services, such as medication synchronization and other adherence programs, help patients manage their medication therapy. Community pharmacists support chronic care management as collaborative members of the health care team for conditions such as diabetes, hypertension, cholesterol, and asthma. Point-of-care testing offers patients an accessible option for acute care needs. Wellness and prevention services, such as immunizations, are also offered.

However, community pharmacies face several barriers that have impeded patients’ ability to universally access these services. There are differences in the patient care services pharmacists can provide due to variation in state scope of practice policies (Goode et al., 2019; Pollack et al., 2020). For example, pharmacists’ ability to initiate, modify, or discontinue drug therapy; order and administer vaccines or other medications; order and administer laboratory tests and interpret the results; and delegate to pharmacy technicians depends on the state laws and regulations in which they practice (Adams, Frost, & Weaver, 2021). Support staff, such as pharmacy technicians, play an important part in increasing pharmacists’ time to provide patient care services (Andreski et al., 2018; Taylor & Mehta, 2020). However, there is a significant shortage of qualified pharmacy technicians (American Pharmacists Association [APA], 2022).

Restrictions in insurance reimbursement further limit patient care service offerings (Pollack et al., 2020). Medicare does not recognize pharmacists as eligible providers, so they are not able to bill for care under the medical insurance benefit. In some states, pharmacists can bill the medical insurance benefit for commercial and Medicaid health plans for services within their scope of practice (Guglielmo & Sullivan, 2018). However, pharmacies are still predominantly reimbursed under the prescription insurance benefit for medication dispensing (Daly et al., 2020). Thus, the workflow processes in many community pharmacies remain centered on medication dispensing despite declining reimbursement. Additional barriers include geographic separation from other members of the health care team with limited bidirectional flow of patient health information, poor patient awareness or receptivity to community pharmacy-based services, and constraints of the physical layout of the traditional community pharmacy (Goode et al., 2019).

On March 13, 2020, the President of the US declared a national emergency in response to the COVID-19 pandemic caused by the new SARS-CoV-2 (Executive Office of the President, 2020). The Secretary of the Department of Health and Human Services (HHS) enacted several temporary policy changes via the Public Readiness and Emergency Preparedness (PREP) Act and HHS guidances (National Alliance of State Pharmacy Associations, 2022). These policy changes expanded practice authority for pharmacists, pharmacy technicians, and pharmacy students to enable access to COVID-19 testing, vaccination, and therapeutics at community pharmacies nationwide. Amendments to the PREP Act authorized pharmacists to order and administer childhood vaccines (August 2020) and certain COVID-19 therapeutics (September 2021) (Azar, 2020; Office of the Assistant Secretary for Preparedness and Response, 2021). HHS guidances authorized pharmacists to order and administer COVID-19 tests (April 2020) and COVID-19 vaccines (September 2020) and authorized pharmacy technicians and interns to administer vaccines and COVID-19 tests (October 2020) (Office of the Assistant Secretary for Health, 2020a, 2020b, 2020c).

The logic model developed by Sonderegger and colleagues to visualize health workforce determinants provides a conceptual basis for evaluating the impact of the COVID-19 pandemic and the temporary scope of practice expansions on the community pharmacy workforce (Sonderegger et al., 2021). The logic model depicts the relationships between five domains—contextual factors, health system factors, health workforce processes, health workforce outcomes, and health system outcomes. The COVID-19 pandemic and scope of practice expansions are a contextual factor and health system factor, respectively. Examining the impact of these factors on community pharmacy workforce processes and outcomes may provide a deeper understanding of health system outcomes during the COVID-19 pandemic and reveal lessons learned to improve outcomes during future public health emergencies.

Although temporary scope of practice expansions addressed some challenges community pharmacies faced in providing patient care, other barriers remained, such as workforce shortages and payment for services. Despite these challenges, community pharmacies were called upon to respond to a critical public health need. The objective of this study was to describe ways in which the COVID-19 pandemic affected community pharmacy practice and its workforce. Specifically, we sought to answer the following research questions:

Research Question 1 (RQ1): What changes have occurred in patient care provided at community pharmacies since the onset of the COVID-19 pandemic and as a result of pharmacist and technician scope of practice expansions?

Research Question 2 (RQ2): What workforce-related factors affected community pharmacies’ ability to adopt and implement patient care services allowed under pharmacist and technician scope of practice expansions during the COVID-19 pandemic?

Research Question 3 (RQ3): How is the ongoing COVID-19 pandemic affecting community pharmacy workforce resilience and needs and what is the anticipated long-term impact?

New Contributions

This study is among the first to examine the realized impact of the COVID-19 pandemic on the community pharmacy workforce (including pharmacists and pharmacy technicians) in the United States at the national level. Several reviews and commentaries highlighted how the community pharmacy workforce could contribute to the COVID-19 pandemic response (Adunlin et al., 2021; Hess et al., 2022; Strand et al., 2020). Other studies have explored the implementation and impact of pandemic-related patient care services on patient access and the community pharmacy workforce at the regional level (O’Connor et al., 2022; Patel et al., 2022; Silva-Suárez et al., 2022).

Historically, policy-related barriers have limited the ability of the community pharmacy workforce to provide health care services beyond dispensing medications (Pollack et al., 2020). Pharmacy professionals are among the most regulated and there is significant variability in pharmacists’ and pharmacy technicians’ scope of practice across states (Adams, Frost, & Weaver, 2021). This study provides new evidence of how expanding the pharmacy workforce’s scope of practice at scale can influence workforce and health system outcomes.

Finally, the community pharmacy workforce has a long history of involvement in emergency preparedness and response (EP&R) in the United States (Aruru et al., 2021). Their duties have included procuring and distributing emergency and chronic medications, triaging patients, and administering medical countermeasures during pandemics, natural disasters, and terrorism attacks (Aruru et al., 2021; Koonin et al., 2011; Sharpe & Clennon, 2020). Of note, community pharmacists were activated at scale in 2011 to administer the H1N1 pandemic vaccine (Koonin et al., 2011). However, the COVID-19 pandemic brought new challenges, such as its duration and the number of responsibilities delegated to the community pharmacy workforce. This study provides valuable lessons learned on opportunities to best leverage the community pharmacy workforce to support future EP&R efforts.

Method

This study employed qualitative analysis of data collected via key informant interviews with leaders within national, state, or local pharmacy associations and chain and independent pharmacy organizations across the United States. For this study, community pharmacies were defined to include chain, independent, or outpatient pharmacy locations open to the public that offer some form of medication dispensing services and some level of patient care services (Bacci et al., 2019). Patient care services were defined to include any patient-specific activity whereby the pharmacist utilized the systematic process described by the Joint Commission of Pharmacy Practitioners to deliver patient care, such as immunizations, point-of-care testing, and medication therapy management (Bacci et al., 2019). Patient care services excluded activities related to the provision of product and counseling on new or refilled prescriptions as required by law. Pharmacy associations were included because their members or stakeholders include community pharmacies, pharmacists, and pharmacy technicians and due to their integral role in the scope of practice policy changes that enabled pharmacy professionals to respond to the COVID-19 pandemic. The research team chose to recruit individuals within leadership who oversaw and/or represented many pharmacy professionals and who could provide insights from an organizational perspective. This study was determined as not human subjects research and granted exemption from formal review by the University of Washington Human Subjects Division.

A purposive sample of key informants was identified based on input from the pharmacist members of the research team, contacts from previous research on the pharmacy workforce, and web searches. Geographic and community pharmacy types were considered in recruit key informants to account for the potential impact of variation in scope of practice prior to the pandemic and unique contextual features between different community pharmacy organizations (e.g., independent, supermarket, traditional chain) on participants’ perspectives and experiences. Chain community pharmacies were defined as a company that operates four or more pharmacies, including traditional drug store formats as well as pharmacies located in supermarkets and mass merchants (Bacci et al., 2016). Independent pharmacies were defined as a single pharmacy or several pharmacies owned by an individual or small group (APA, 2013).

Interviews were conducted from January to May 2022 using a semi-structured interview guide of predetermined questions with the flexibility to probe for detail and additional information (see Supplemental Materials). The research team, which included three pharmacists and two health workforce experts, developed the interview guide based on a literature search and their real-time experience of participating in the COVID-19 response. The interview guide drew on the research questions to elicit participants’ perceptions of the patient care services available at community pharmacies during the COVID-19 pandemic, changing roles of community pharmacists and technicians in response to the COVID-19 pandemic, and policy factors affecting the community pharmacy workforce and the patient care services they provide. The interview guide was piloted with two individuals who met the study inclusion criteria. Upon completion of the pilot interview, participants were asked to provide feedback on question quality, completeness, and clarity. Four questions were condensed into two questions to prevent duplication and two questions were revised for clarity. The pilot interviewees did not recommend any new questions. The data collected from these pilot interviews were excluded from the analysis.

Interviews were conducted via Zoom, a videoconference platform, and each lasted approximately 60 min. Videoconferencing was selected to conduct interviews because it allowed for face-to-face interaction among geographically dispersed interviewers and interviewees and because it has become a workplace norm in the pharmacy profession to maintain operations during the pandemic. Two research team members conducted the interviews, both of whom are trained and experienced interview facilitators and qualitative researchers. At least one additional research team member took detailed notes during each interview. The interviews were also audio recorded and transcribed by the teleconference platform. Interviews were conducted until data saturation was achieved, defined as the point at which substantially new information was no longer being collected (Saunders et al., 2018). Participants were not compensated.

Interview notes were analyzed using a rapid content analysis approach adapted from Gale and colleagues (Gale et al., 2019). A rapid analysis approach best suited the fast-changing impact of the subject matter, the COVID-19 pandemic, and the semi-structured nature of the interviews (Lewinski et al., 2021) Specifically, notes were combined to summarize key points from each interview. The interview summaries were then consolidated into one Microsoft Excel document to allow comparison across interviews. Research team members individually reviewed the consolidated summary to identify commonly recurring themes. The team then met to discuss key findings and achieve consensus on final themes. Interview transcriptions provided by the teleconference platform were utilized to confirm presented quotations.

Results

Fifteen interviews were conducted with 18 key informants. Three interviews were conducted with two key informants from the same organization at the request of the interviewees. Twelve interviews were conducted with one key informant. Key informants represented national pharmacy associations (n = 6), state pharmacy associations (n = 3), chain community pharmacy organizations (n = 4), and independent community pharmacies (n = 5). Key informants from chain community pharmacies included two supermarket chains, one traditional chain, and one mass merchandiser. Key informants with state or regional affiliations (n = 10) represented the Midwest (n = 3), South (n = 2), East (n = 2), and West (n = 2).

Theme 1: Patient Care at Community Pharmacies Focused on Fulfilling COVID-19 Response Needs

During the first 2 years of the pandemic, the community pharmacy workforce focused on ensuring ongoing access to prescription medications while adding the work of responding to the COVID-19 pandemic, both in the types and logistics of patient care being provided. New patient care services implemented at community pharmacies included COVID-19 testing, vaccinations, and monoclonal antibody treatment.

. . .in the early days when the lockdowns were happening, we had to make sure people had medication. We did a lot of proactive conversions to 90 days [supplies] and a lot of emergency refills. . . [Interview #8]

. . .prior to the pandemic, pharmacists in many states were immunizing for a variety of different conditions and age groups, but with the pandemic. . . due to the PREP Act and other different allowances, pharmacists are now administering COVID-19 vaccines. . . in addition, [pharmacists have been] able to do some testing to identify if a patient has [COVID-19] and then recommend for therapy. . . and refer out if necessary. [Interview #7]

Patient care not related to medication access or the COVID-19 pandemic, such as chronic disease management and transitions of care, was temporarily deprioritized to accommodate increased patient demand and staff workload related to pandemic management.

. . .it was just a huge effort to manage COVID-19 in the stores. . . we said to the stores, you have to focus on what’s in front of you to take care of patients. In a normal year, we would have been driving a new innovation and new pilot programs or doing additional training or something else. . . that did take somewhat of a backseat . . . because of the volume of work. . . [Interview #4]

The high demand for COVID-19-related care and transmissibility of the virus required community pharmacies to adapt how they provided patient care. Community pharmacies implemented more structured and predictable workflows through the use of appointment-based models for services.

. . .at one point we [were] doing [vaccine] walk-ins all day long, however, we shut that down and made it so walk-ins can only be from 2 to 3 pm. You [had] to have an appointment outside of that and we could control the [appointment] capacity on our scheduler [system]. . . we started [with an appointment] every 15 minutes. We pushed appointments to every 20 minutes. [Interview #4]

Community pharmacies also innovated ways to offer patient care curbside, in parking lots, or via drive-thrus to prevent potentially infectious individuals from entering the pharmacy.

But pharmacies, for the most part, didn’t close their door. They didn’t lose their operations. A lot of them went. . . to service people either by delivery services or by bringing materials to their car whether that’s through the drive-thru or through the parking lot, just to keep their patients and themselves and their staff and their family safe. [Interview #2]

Theme 2: Pharmacists’ History as Immunizers and Scope of Practice Expansions Facilitated COVID-19 Response Efforts

Key informants described the importance of pharmacists’ history as immunizers to support COVID-19 response efforts, particularly the vaccine rollout. Community pharmacies were able to leverage their experience with mass vaccination efforts for annual influenza vaccine and the H1N1 vaccine in 2011 to meet COVID-19 immunization demand.

There isn’t one [industry] that could have responded in the way that community pharmacies responded. . . states that went all in on pharmacy early had an easier time rolling out [the COVID-19] vaccine and doing it at a pace that mattered. . . [community pharmacy was] uniquely poised to be able to respond. [Interview #8]

Key informants also emphasized the importance of temporary scope of practice expansions at the state and federal level in supporting the community pharmacy workforce’s capacity to respond to the COVID-19 pandemic.

The emergency orders that had to go in place because we don’t have the scope of practice to authorize emergency refills without an emergency order. . . that’s sort of silliness. [Interview #8]

[COVID-19 has] helped usher in different roles and responsibilities within the pharmacy. That’s been the best thing that probably could have happened from a staff [perspective], or else the profession would be breaking more than it already is. [Interview #6]

The role of the pharmacy technician significantly changed during the pandemic. Pharmacy technicians across the country were activated to administer COVID-19 tests, vaccines, and monoclonal antibodies, which better enabled community pharmacies to meet the significant demand for these services.

I have a technician in my store that became certified to [administer] vaccines. . . It’s really freed up [time] and we would never have been able to do as many vaccines as we have done without technicians being able to [administer vaccines]. [Interview #12]

Key informants shared the examples of states that have passed legislation to make permanent the scope of practice expansions from the PREP Act. Participants believed that the COVID-19 pandemic will result in lasting changes to the care patients are able to access at community pharmacies and enable community pharmacies to contribute more to ongoing public health challenges.

We’ve had three bills that were passed last year and are now written into law that allow pharmacists to prescribe, and this was definitely a result of the pandemic. One is being able to prescribe based on point-of-care testing, they [pharmacists] can get a result and now they’re able to prescribe the antiviral or antibiotic using a statewide protocol. The other one is prescribing oral contraceptives. [Interview #15]

It feels to me like it’s five to seven years of practice acceleration for every year of [the] pandemic. . . we’re [further] down the road [from where] we would have been, which was frankly an unacceptable trajectory prior. . . it’s really acceleration on different ways of getting paid, technology systems, roles in the pharmacy, scope of practice, all of those things. [Interview #6]

Theme 3: Workforce Supply Shortages Impeded COVID-19 Response Efforts and Contributed to Burnout

Although scope of practice expansions supported the community pharmacy workforce’s capacity to respond to the COVID-19 pandemic, key informants identified workforce supply as an important barrier. These barriers existed before and were only exacerbated by the pandemic. Scope of practice expansions for pharmacy technicians during the pandemic enabled them to take on new roles, but the existing nationwide shortage of technicians hindered pharmacies’ ability to exercise the full potential of this workforce.

We’re always chronically low on trained pharmacy technicians. . . With the opportunity for technicians to start getting certified [to administer vaccines], the timing was not exceptional because we were asking them to do a training while working exceptional number of hours in a very stressful environment. . . . [Interview #14]

Pharmacies used several strategies to attempt to fill open pharmacy technician positions including wage increases and sign-on bonuses.

Many pharmacies are offering sign-on bonuses to technicians, up to $15,000. Chain [community pharmacies] are in the process of moving [wages] to $15 per hour for technicians. [Interview #1]

Community pharmacies were also challenged in maintaining operations when staff missed work due to illness. Staff members themselves were exposed to or became infected with COVID-19 or had to care for loved ones who were exposed to or got COVID-19. As the pandemic progressed, the combination of staffing shortages and increased workload led to widespread burnout and caused some community pharmacy workforce to transition to other practice settings or other professions, resulting in an even smaller workforce supply to meet the ongoing patient care needs.

You walk into a busy pharmacy and the pharmacists are filling prescriptions, but then leaving for a few minutes to do vaccination. It’s a lot to have to do several things at once and it’s highly stressful because pharmacists want to do a good job. They don’t want to make errors. They want to provide good patient care. Just the nature of the burdened system has made people burn out a lot faster than we’ve seen in the past. . . it can be harder for organizations to hire pharmacists just knowing what [they’re] facing on a day-to-day basis. [Interview #7]

I didn’t see anybody go to a different community [pharmacy] job. . . I saw a lot of people go to completely different positions with completely different roles and responsibilities, hours, everything. [Interview #9]

Community pharmacies trialed diverse strategies to remain open and support staff well-being in the short-term, including adjusting pharmacies’ hours of operation, limited hours of service (e.g., vaccines, testing), leveraging centralized call centers, and closing for lunch breaks. Some pharmacies utilized nurses, nursing students, corporate staff, or retired staff to supplement their existing workforce. Further, some organizations implemented ideas suggested by their staff to support well-being, such as dress down days, free lunch, and rally bonuses.

We did our own surveys, just to get a temperature check [on how] everybody felt and what are the little things day to day that would make it better here at work. . . things as simple as let me dress down instead of this shirt and tie. . . We also shortened our hours. . . giving more time at home in the evenings. . . makes a big difference. . . [Interview #9]

Despite the burnout and well-being challenges, the community pharmacy workforce expressed pride in what they collectively accomplished over the course of the pandemic.

There’s the opposite end of the coin, that is, people who feel so proud of what they were able to accomplish during the pandemic. . . if [community pharmacy] had better standardization and scope of practice. . . the ability to help independently solve patients’ problems or more easily collaborate, electronically integrate with other health care providers. . . they could have made [even more] impact. [Interview #8]

When asked how to solve or alleviate the workforce challenges in community pharmacies, participants spoke about inadequate payment to support the needed workforce.

[We need to] be paid like health professionals. Pharmacies need to be part of the medical benefit services and care. We need to be paid for patient care, everything we’re doing, not just dispensing. We work with patients, make sure medications are right, etc. and we don’t have a vehicle to be paid for that. [Interview #3]

It’s [the need to receive] payment for services. I think if pharmacists can be paid for their expertise, the public would benefit, patients would benefit, the pharmacy profession would benefit because we wouldn’t be on such thin margins. . . I think well-being would be better because we can be staffed appropriately. [Interview #7]

Theme 4: Maintaining Community Pharmacy Workforce’s Readiness Will Be Critical to Future EP&R Efforts

Participants described several lessons learned and opportunities for equipping community pharmacy to respond to future public health emergencies. First, key informants advocated for pharmacists’ and pharmacy technicians’ pandemic-initiated scope of practice expansions to be made permanent.

The goal is to secure those gains that were extended under the PREP authority. . . I know the emergency authorization is still in effect for a period of time, but it won’t always be, and so I think that that’s really imperative to make sure that there can be consistency in the delivery of services throughout the country. [Interview #2]

During the COVID-19 pandemic, the community pharmacy workforce had to build relationships with the government and public health system. For example, pharmacists and pharmacy technicians were not initially designated as essential workers making it difficult to obtain personal protective equipment early in the pandemic despite community pharmacies remaining open to ensure the public had ongoing access to medications for chronic and emergent conditions.

Pharmacists weren’t included or thought of as part of that health care provider or essential workforce and had trouble getting personal protective equipment. . . ordering it and assuring that they were actually receiving it. . . I think it’s required that our pharmacists are part of the essential workforce so that they are allocated those supplies and the same provisions and protections [like] others on the front line as well. [Interview #7]

Key informants observed that states that had existing relationships with community pharmacy or that integrated community pharmacy into their response approach early had an easier time with the COVID-19 vaccine roll out. These states were able to benefit from community pharmacy’s experience with and infrastructure to support mass vaccination efforts. Participants felt it will be important for these relationships to be maintained after the pandemic to support ongoing emergency preparedness.

. . .the right thing to do would be to have that strong [government] partnership always, so that when we were thrown into the pandemic, we all knew each other’s strengths, weakness, and we already had that relationship built. These were all new relationships we [had] to develop from the very beginning. . . keep that alive [would] definitely make a great collaboration for a future effort. [Interview #4]

. . .government stakeholders have recognized that [an] essential piece to the puzzle is having a pharmacist available and partnering in patient care, so I’m hopeful that that is something that we continue to see and that the unique relationships and community linkages that pharmacists have formed through the pandemic remain. [Interview #7]

Finally, key informants described steps the pharmacy profession could take to remain ready to support future EP&R efforts. These steps included more training on effective communication and health literacy. Key informants acknowledged the significance of misinformation and disinformation on the public’s willingness to access public health countermeasures. Participants described an opportunity to ensure pharmacists and pharmacy technicians are equipped to address misinformation and hesitancy. Key informants also felt it would be important for the community pharmacy sector to debrief on lessons learned from the COVID-19 pandemic to institutionalize the knowledge gained for future EP&R efforts.

I think when you look at vaccine hesitancy or health literacy in general. . .that’s [what] training [should] focus on. . . it’s a little bit of motivational interviewing, but it’s also effective communication strategies.” [Interview #14]

. . .when things slow down, it would be great to look back at how things went and what could have been done differently and better so that we’re prepared for the next time around. [Interview #1]

Discussion

This study is among the first to describe the realized impact of the COVID-19 pandemic on the community pharmacy workforce across the US and has potential implications for federal policies related to pharmacy practice and EP&R. An important finding is the volume of new work that community pharmacy teams took on because of the pandemic. Community pharmacies implemented new COVID-19 testing, vaccination, and monoclonal antibody services. The volume of this new work far exceeded the work of services that were paused because the pandemic caused high public demand over a short period of time. For example, there are numerous reports of community pharmacy teams administering hundreds to thousands of COVID-19 vaccine doses in 1 day (Grabenstein, 2022).

Further, this study found that the community pharmacy workforce’s ability to provide these new services was affected by facilitators, namely, scope of practice expansions, and barriers, specifically workforce shortages and lack of payment. Within Sonderegger and colleagues’ logic model, lack of payment is one of the health system factors with potential downstream effects on workforce outcomes, such as workforce availability, Thus, amplifying the facilitators and resolving the barriers could have important implications on sustaining the community pharmacy workforce’s role in public health and EP&R beyond the COVID-19 pandemic.

The temporary scope of practice expansions authorized via the PREP Act amendments and HHS guidances were identified as important facilitators of the community pharmacy workforce’s COVID-19 pandemic response efforts. This temporary scope of practice expansions had a more significant impact on the role of pharmacy technicians. With additional training, pharmacy technicians were authorized to administer COVID-19 vaccines and certain therapeutics (Office of the Assistant Secretary for Health, 2020c). A limited number of states allowed pharmacy technicians to administer vaccines prior to the pandemic (Adams, Frost, & Weaver, 2021). Interviewees emphasized that community pharmacies were able to take on the increased workload from new COVID-19 services due in large part to the expanded role of the pharmacy technician. Using pharmacy technicians as extenders is a well-established strategy for implementing patient care services in community pharmacies (Andreski et al., 2018; Hohmeier & Desselle, 2019; Taylor & Mehta, 2020). Delegating more technical tasks to pharmacy technicians, such as vaccine administration, allows pharmacists to spend more time directly with patients.

To maximize availability of appropriate care when and where it is most needed, state policymakers should explore laws and regulations that align pharmacists’ (including interns) and pharmacy technicians’ scopes of practice with their training and experience. Sonderegger and colleagues’ logic model endorses the potential impact of aligning health workforce availability and competences on health system coverage and efficiency. Some states have pursued legislation to expand community pharmacists’ and/or pharmacy technicians’ scope of practice permanently. For example, Arkansas passed new laws in 2021 to enhance patient access to pharmacy-based services, including testing and treatment for influenza, streptococcal pneumonia, and other health conditions; vaccine administration for individuals 3 years of age and older; and oral contraceptives (National Association of Chain Drug Stores, 2021). Another option is to move to a “standard of care” or “permissionless innovation” regulatory framework (Adams, Klepser, et al., 2021). This framework empowers practitioners to use their clinical judgment and holds them accountable for deviations from the standard of care rather than outlining the specific tasks the community pharmacy workforce may perform. Importantly, this regulatory framework provides flexibility as practice and public health needs evolve.

Although pharmacy technicians as extenders enhanced the supply of pharmacy services, pharmacy technician shortages were identified as a significant barrier in community pharmacies’ ability to respond to the COVID-19 pandemic. The technician shortage is thought to be caused by low job satisfaction, high-stress levels, inadequate compensation, and high turnover (Desselle & Holmes, 2017; Wheeler et al., 2020). Resolving the pharmacy technician shortage is critical to ensuring the community pharmacy workforce can respond to acute and ongoing public health needs. Existing solutions, such as advanced roles and requiring certification for pharmacy technicians, do not fully address the causes of the shortage. Using pharmacy technicians as extenders in advanced roles primarily affects job satisfaction (Mattingly & Mattingly, 2018). Requiring pharmacy technician certification improves job commitment (Wheeler et al., 2020). Regardless, financial compensation for pharmacy technicians is lacking and does not compete with other similar jobs. Future work should explore career advancement for pharmacy technicians that promote job satisfaction and adequate compensation to address ongoing workforce challenges.

Payment for patient care services presented another major barrier for community pharmacies during the COVID-19 pandemic. Reimbursement is among the most cited barriers to providing patient care services at community pharmacy (Daly et al., 2020; Goode et al., 2019; Pollack et al., 2020). The pandemic exacerbated the situation because the community pharmacy workforce was asked to rapidly provide new services without clear or adequate reimbursement pathways. Lack of or inadequate payment for patient care services and medication dispensing affects a community pharmacy’s ability to provide adequate employee compensation and is likely to be contributing to job dissatisfaction, burnout, and the technician shortage.

Payment that adequately reimburses community pharmacists for the services they provide not only will support needed staffing and promote professional satisfaction but will also likely ensure the community pharmacy workforce is prepared to respond to future EP&R efforts. Two bills, H.R. 7213 and H.R. 2759/S. 1362, have been introduced to the US Congress (H.R.2759—Pharmacy and Medically Underserved Areas Enhancement Act; H.R.7213—Equitable Community Access to Pharmacist Services). If passed, this legislation would establish reimbursement pathways for pharmacists’ services provided to certain Medicare Part B beneficiaries. Several states, including Washington, Tennessee, and Kentucky, have passed legislation mandating that commercial payers contract and credential with an adequate network of pharmacist providers and provide reimbursement for services via the medical benefit (Bonner, 2022). In other states, like Wisconsin, Oregon, and Ohio, pharmacists are eligible for reimbursement via the state Medicaid program. These policies enable pharmacists to be paid like any other health care provider for services that are within their scope of practice and may facilitate the community pharmacy workforce’s ability to respond to inevitable, future public health emergencies.

The timeframe of data collection and potential for recall bias are potential limitations of this study. Data were collected January—May 2022. Although the timeframe allowed participants to reflect on their experiences over the previous 2 years since the start of the pandemic, their ability to recall events and experiences fully and accurately may have been affected. Furthermore, qualitative studies are subject to participant and social desirability bias. A national sample of key informants representing multiple stakeholder groups was recruited and interviewed using open-ended questions to minimize risk of bias.

Conclusion

This study described how the COVID-19 pandemic affected community pharmacy practice and its workforce. Findings revealed that the community pharmacy workforce embraced important roles in addressing the public’s needs related to the COVID-19 pandemic, including providing COVID-19 testing and vaccination. However, their contributions and ultimate impact were delayed by the need to implement temporary scope of practice expansion policies and reimbursement pathways. Opportunities to institutionalize these policies should be explored to ensure needed resources are available and maximize professional satisfaction so that the community pharmacy workforce is able to respond to future, inevitable public health emergencies.

Supplemental Material

sj-docx-1-mcr-10.1177_10775587231204101 – Supplemental material for Impact of the COVID-19 Pandemic on the Community Pharmacy Workforce

Supplemental material, sj-docx-1-mcr-10.1177_10775587231204101 for Impact of the COVID-19 Pandemic on the Community Pharmacy Workforce by Jennifer L. Bacci, Samantha W. Pollack, Susan M. Skillman, Peggy Soule Odegard, Jennifer Hookstra Danielson and Bianca K. Frogner in Medical Care Research and Review

Footnotes

Acknowledgements

For more information, please visit HRSA.gov. The authors would like to thank Anne Bayse for her thoughtful review of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling US$671,875 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.

ORCID iDs

Jennifer L. Bacci

Susan M. Skillman

Bianca K. Frogner

Supplemental Material

Supplemental material for this article is available online.

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