Purpose. Health-system pharmacy directors, managers, practitioners, students, and employers were surveyed to assess the situation of current and future leaders in pharmacy and generate recommendations for preventing shortages.
Methods. Online surveys were sent to pharmacy directors, pharmacy middle managers, current pharmacy practitioners, pharmacy students, and employers recruiting for management positions using ASHP’s membership and CareerPharm databases. Directors, managers, and practitioners were asked about their job satisfaction and future plans. The trends in demographics and attitudes toward the balance between family and work were assessed among directors, managers, practitioners, and students. Employers were asked about their perceived ease of filling managerial positions.
Results. While most pharmacy directors and middle managers were satisfied with their current positions, 80% of directors and 77% of middle managers anticipated leaving their jobs in the next decade. Men comprised 72% of directors, 50% of middle managers, 62% of practitioners, and 21% of pharmacy students. The majority of pharmacy students and practitioners reported being married to a working spouse and having children and expressed a desire to balance their personal life with their career. The top reasons cited by students and practitioners for not seeking leadership positions were having to give up clinical practice and competing responsibilities. More than half of employers felt it was more difficult to recruit managers now than it was three years ago.
Conclusion. A significant gap in pharmacy leadership in the next 5–10 years is expected, as well as a shift in work force composition and attitude. Mentoring and residencies are important methods of fostering new leaders in the profession.
- American Society of Health-System Pharmacists
- Data collection
- Job satisfaction
In 1967, Joseph A. Oddis, Executive Secretary of ASHP, envisioned the establishment of the ASHP Research and Education Foundation and suggested the creation of a “chair” for conducting research and other activities related to hospital pharmacy for ASHP, not unlike the department chairs found in universities.1 “Pharmacists would be selected to fill the ‘chair’ and to work and think and experiment in an atmosphere free of restrictions, boundaries and limitations of an organizational or hospital appointment. The ‘chair’ and its occupant would be a part of the Society, yet detached from it.” This “chair” has evolved into a Scholar-in-Residence program, whereby the scholar studies a specific topic important to health-system pharmacy. This is the report of the 2004 (March–June) Scholar-in-Residence program on leadership.
Concerns about current and future pharmacy leaders have been expressed in ASHP’s Leadership Agenda and anecdotal information. Mick Hunt,2 in his 2000 President-Elect presentation, discussed the danger of a pharmacy leadership gap in the not-too-distant future. He indicated “that a lack of leadership will mean that health-system pharmacy will no longer be in a position to enhance patient safety, to optimize medication therapies across the continuum of care, to make a real difference in the lives of the patients that we serve.” He advocated mentoring to help develop future leaders.
The Bureau of Labor Statistics projects a shortfall of 10 million workers in the United States in 2010.3 Baby boomers, the 76 million people born between 1946 and 1964, represent more than a quarter of all the Americans who will shortly reach their sixties and retire. “There will not be nearly enough young people entering the workforce to compensate for the exodus.”3 While the pharmacist shortage is decreasing, decreasing from a vacancy rate of 8.9% in 2000 to 5% in 2004, there remains a severe shortage of pharmacy managers (pharmacy director or assistant pharmacy director), increasing from a vacancy rate of 27% in 2003 to 36% in 2004.4
The objective of the 2004 Scholar-in-Residence’s project was to quantitatively assess the current and future pharmacy leadership situation and recommend approaches for avoiding a leadership crisis in the near future. The recommendations were derived from the scholar’s selected review of the literature on leadership and interviews with thought leaders in health-system pharmacy.
In March 2004, an online survey instrument was developed using SurveyMonkey to determine the current state and future trends of pharmacy leadership and the attitudes of pharmacists and students regarding the profession. The survey questions were pilot tested to assess their validity and ease of use.
E-mails containing a link to the survey were sent to five groups: directors of pharmacy, pharmacy middle managers, current pharmacy practitioners, pharmacy students, and employers who were using ASHP’s CareerPharm to recruit pharmacy managers or directors. Middle managers were defined as associate or assistant directors, supervisory pharmacists, and clinical coordinators. Current practitioners included clinical generalist pharmacists, clinical pharmacy specialists, and staff pharmacists. The term “leadership” referred to current pharmacy directors and middle managers, even though all pharmacists should be leaders in their workplace.
All pharmacy directors listed in the ASHP member database were sent the survey and two subsequent reminders. Pharmacy middle managers and current practitioners were randomly selected from the ASHP member database and sent the survey and one reminder. All ASHP Student Forum members were surveyed. All employers with a position listing in the ASHP CareerPharm from April 20, 2004, to May 6, 2004, were sent the survey and one reminder. The survey was conducted in April and May of 2004.
The survey was sent to 2936 pharmacy directors, and the adjusted response rate was 19% (517 responses; 190 surveys were undeliverable). For pharmacy middle managers, 1561 surveys were sent; the adjusted response rate was 31%, or 489 responses (111 undeliverable surveys). The survey was sent to 1834 current practitioners, with an adjusted response rate of 15%, or 290 responses (115 undeliverable surveys). The student survey was sent to 5725 people; the adjusted response rate was 15%, or 776 responses (394 undeliverable). A total of 366 employers were surveyed, and the adjusted response rate was 16%, or 55 responses (22 undeliverable).
While the response rates were low, these data represent a snapshot of the current pharmacy leadership in health systems in 2004. Table 1⇓ lists the demographics of the respondents. The majority of pharmacy directors’ (83%), middle managers’ (85%), and current practitioners’ (83%) primary work setting was a hospital or health system. Over 50% of the directors and 75% of the middle managers worked in organizations with an average daily census of fewer than 200 patients. The directors were evenly distributed among rural, suburban, and urban areas. The majority of middle managers and current practitioners worked in urban areas, where larger hospitals tend to be located.
Almost half of the middle managers and current practitioners had held their position for less than five years. The average age of the directors was 48 years and middle managers, 43. A majority of the middle managers had a spouse currently working and had one or more children. The majority of current practitioners were also in a dual-career marriage and had at least one child.
Survey respondents who were currently working were fairly satisfied with their current positions and, if starting over, would have made the same career choices (Table 2⇓). The data indicate that just over 30% in each category were very satisfied. When the directors were asked to compare their position satisfaction with that of five years ago, 34% were less satisfied, 28% felt about the same, and 37% were more satisfied.
While 70–80% of the respondents reported being satisfied in their current position, major turnover was anticipated; 80% of the directors were planning to leave their position in the next 10 years, with 36% staying less than 5 years. Seventy-six percent of the middle managers anticipated turning over in the next decade, 34% in less than 5 years. About the same percentage of the current practitioners also anticipated changing jobs in the next 10 years. When they leave their current position, only a small percentage of the directors, middle managers, and current practitioners anticipated seeking a similar position in another organization, but a quarter of them planned to retire. Of those indicating that they would stay in pharmacy but not in a health system, 14% were directors, 12% were middle managers, and 9% were current practitioners.
The directors were queried about their satisfaction with a number of job characteristics, using a 5-point Likert scale, where 1 = very dissatisfied and 5 = very satisfied (Table 3⇓). They were most satisfied with the sense of accomplishment they felt from doing their job, the amount of freedom they had to do their job, their ability to influence the decisions that affect pharmacy, interdepartmental relationships, and the responsibility and accountability they had for regulatory and accreditation compliance. The five job components that they were least satisfied with were the level of stress imposed by their job, having capital funds available to purchase automation or information systems, having personnel resources needed to implement automation or information systems, support to keep their staff salary structure competitive, and number of staff they had to complete the work. These directors listed job stress, inadequate compensation, or lack of resources (39%); the organization’s senior leadership (27%); and a better opportunity (17%) as the major reasons they would quit their job.
Middle managers’ main job satisfaction came from the ability to affect and improve services (74%) (Table 4⇓). They listed stress level (67%) and the recruiting, orienting, evaluating, and disciplining of staff (50%) as the least desirable parts of their job.
Given the significant director and middle manager turnover anticipated in the next 5–10 years, it is important to understand middle managers’, current practitioners’, and pharmacy students’ attitudes regarding balancing their career with personal life (Table 5⇓). When asked to identify themselves on a 5-point scale between “personal and family life is the primary focus” and “very career driven, will do whatever it takes,” about half of the respondents selected the midpoint, and a quarter leaned toward focusing on personal and family life.
When asked about their mentors, 63% of middle managers and 70% of current practitioners indicated that they did not have a mentor, though a majority (55%) of pharmacy students did (Table 5⇑). These mentors included pharmacy managers, clinical pharmacists, and clinical pharmacy faculty. Respondents without a mentor were asked why they did not have one. The common responses from middle managers and practitioners were that they did not believe they needed one, they never thought about it, they did not know how to locate one, or no appropriate person was available. The pharmacy students attributed their lack of a mentor primarily to having never thought about it, not knowing how to locate one, or noting that no appropriate person was available.
To begin to understand the attitudes of future practitioners, the pharmacy students were asked to rate the importance of specific job attributes (Table 6⇓). The most important job attributes were the ability to apply their knowledge, balance work with personal life, advance and grow professionally, and solve problems at an individual patient level. The least important were working less than full time, directing or supervising others, working only day shifts on Monday through Friday, and working independently.
To gauge the depth of the leadership pipeline, the directors were asked, if they were to resign, if someone whom they considered qualified would be available to replace them (Table 7⇓). More than half responded that they did not know of anyone who could replace them. When asked about their perception of the availability of qualified people for management positions, 77% of the pharmacy directors indicated that there was a moderate to severe shortage of such individuals. When current practitioners and pharmacy students were asked if they would seek a leadership or managerial position sometime during their career, only 30% of current practitioners responded favorably; 62% of pharmacy students indicated that they probably or definitely would seek such a position. The pharmacy students were attracted to leadership positions because they sought challenging and satisfying work (52%) and wanted to improve services (50%). Current practitioners and pharmacy students cited giving up clinical practice and having too many competing responsibilities (stress) as reasons not to seek such positions.
Of the pharmacy directors, 75% reported mentoring other practitioners (Table 7⇑). They listed inadequate time and staff to have a middle manager to mentor as the reason if they did not mentor. The directors and middle managers felt that management, leadership, and business training and educating senior leadership were key to ensuring the success of future health-system leaders and managers.
Employers recruiting for health-system management and leadership positions indicated that it took 3–6 months (46%) or 7–12 months (26%) to fill these vacancies (Table 8⇓). More than half indicated that recruiting was more difficult than it was three years ago, with 40% indicating it was about the same. The lack of practitioners with leadership or management experience (55%), lack of interest among current practitioners (50%), and suboptimal salaries (50%) contribute to this difficulty.
The limitations of these data must be kept in mind. The data were collected from a small sample, so the data may not be representative of all pharmacy directors, pharmacy middle managers, current pharmacy practitioners, and pharmacy students. Since this kind of data has not been previously reported in the past, this is a first attempt at assessing the current situation as of March–April 2004. Published data from a larger, statistically valid sample would be very useful.
While the data represent a small number of respondents, the respondents’ demographics appear reasonably representative, with over half of the respondents from community hospitals with under 200 beds, and equally divided among rural, suburban, and urban settings.
While most directors and managers were satisfied with their current position and would choose it again, many indicated that they would leave in the next 5–10 years. This is a significant amount of turnover in a short period of time. With about 6000 hospitals nationwide, over 4000 new directors may be needed in the next decade, perhaps 2000 in the next five years. Over half of the current directors do not have anyone on staff who they would recommend if they left their positions today. The ability to attract new people to leadership positions is key to preventing a leadership crisis in the future. Only 30% of current practitioners were willing to consider leadership positions, while 60% of students would consider such positions. Significant interest at the student level may be lost as people move into practice. In general, people seem unwilling to sacrifice their personal and family time for their career, which has implications for how leadership positions are structured.
In terms of retention, a number of factors to increase job satisfaction can be maximized and factors causing dissatisfaction can be minimized to encourage current directors and middle managers to stay in their positions. Clearly, the ability to make an impact and experience a sense of accomplishment are powerful satisfiers; however, the job stress and inability to balance the job with a personal life detract.
These survey data suggest a future crisis in ensuring enough competent, willing, and effective health-system pharmacy leaders. Unless some significant steps are taken now, the next generation of health-system pharmacy leaders may have to be nonpharmacists because the need cannot be fulfilled by pharmacists.
While current activities (e.g., ASHP Section on Practice Managers, the ASHP–Boston University Pharmacy Leadership Institute, ASHP Leading Edge program, ASHP Annual Leadership Conference, and other continuing-education programs) are beneficial, they are not nearly robust enough to ensure satisfied and effective leaders for the future needs. While the ASHP Health-System Pharmacy 2015 Initiative is an excellent plan for improving pharmacy services, leaders are needed to implement it.
Techniques such as knowledge cafes,5 mind mapping,6 and dialogues7 should be sought out and employed. These specific techniques come from systems thinking and are designed to elicit a variety of opinions from diverse people and develop consensus and innovative action plans.
Based on the survey the following key findings and recommendations were developed as an immediate call to action for individuals and professional organizations. The recommendations are intended as starting points or areas for further in-depth study.
Recommendation 1: To maximize pharmacy’s impact and make positions more attractive, recast the director of pharmacy role from a reactive department head to a proactive executive level position that uses systems thinking to assist the health system in meeting its strategic goals and objectives. Major turnover (77–80%) is likely to occur in the next 5–10 years among pharmacy directors and middle managers. To ensure the organization’s continued financial viability and patients’ safety, the concept of chief pharmacy officer is most appropriate.8 The pharmacy leader needs to function at the organization’s senior executive level to effectively manage pharmacists and pharmacy services and provide leadership in multidisciplinary activities with the medical staff, nursing staff, and support departments (e.g., information technology). A national effort to define and standardize executive-level competencies, measurable outcomes, and a position description must be undertaken. This effort requires ASHP to partner with major universities, large health care systems such as the Department of Veterans Affairs, the pharmacy component of group purchasing organizations, and other organizations. The expertise that resides in university health administration, business school faculty, and current effective pharmacy directors must also be sought.
Once the validated competencies and position description are determined, a gap analysis tool and outcomes measurement system should be developed and deployed to the field for use by pharmacy directors in all health care organizations. Continuous development opportunities must be available for pharmacy directors to meet these competencies, which should be incorporated, as appropriate, into pharmacy residency training standards.
To leverage experience and share lessons learned, the use of “think tanks” or “master classes” can help ensure frequent and continuous dialogue, debate, brainstorming, and networking among executive-level pharmacy leaders.
Recommendation 2: Educate health-system administrators and trustees on the value that executive-level pharmacy leaders can bring to the organization. A variety of avenues should be employed to conduct these educational endeavors, including health care administration training programs. It would be useful to develop, collect, and use outcomes measurement data to demonstrate the value and impact of an executive-led pharmacy service.
Pharmacy should consider adopting a program similar to the nursing magnet status program for pharmacy services.9 The nursing magnet designation means that an organization meets specific criteria in surveys conducted by the program. The recognition and sense of achievement and excellence are important not only to ensure quality pharmacy services but for the job satisfaction of the pharmacy leaders, managers, and staff. This satisfaction is critical to keeping current staff and making these positions attractive to younger practitioners in order to effectively manage turnover.
Recommendation 3: Investigate alternatives to the current pharmacy middle management model that requires managers to abandon clinical practice. The most common reason given by current practitioners and pharmacy students for not pursuing leadership positions is the requirement to abandon clinical practice. As such, it is prudent to adopt another management model. A model that divides the manager functions among several clinical pharmacists, as used by the pharmacy department at the University of Tennessee Medical Center, warrants thorough investigation. Changing the perception of clinicians so that they expect to be involved in both clinical and management duties is another approach. The “off service” approach, where certain individuals are removed from direct patient care activities for short periods of time and allowed to focus on other activities, also might work. Such a change in the management model would require clinical pharmacists to have the appropriate knowledge, skills, abilities, and attitudes to be successful, especially organizational and political skills, emotional intelligence, and the “people skills.”
Pharmacy technicians, a major untapped resource, could be assigned middle management duties. Continuing to require a pharmacist to check every technician function is an extreme waste of time. Clinical pharmacists’ contribution to monitoring and improving therapeutic outcomes is a far better use of their time and expertise. Programs should be developed that permit the highly competent, credentialed (or certified) pharmacy technicians to manage all aspects of the drug distribution system.
When appropriate, certain middle management duties could be delegated or shared with other departments, nonpharmacists, or pharmacy technicians, such as budget preparation, financial monitoring, and completion of documentation, reports, and records. These nonpharmacists could include masters-level individuals and executive administrative assistants.
Recommendation 4: Identify and encourage students, residents, and practitioners who are interested in and have the ability to be leaders and change agents. Another key finding of this survey was a potential significant gap in the leadership pipeline since there are not enough willing pharmacists to cover the anticipated turnover.
National and regional efforts to foster pharmacy leadership should be examined and shared. In the Student Leadership Institute, conducted by the college of pharmacy at Mid-western University—Chicago, St. Louis College of Pharmacy, and the University of Illinois at Chicago College of Pharmacy, local practitioners serve as mentors. ASHP’s partnering with state chapters and encouragement of them, perhaps by offering incentives, to conduct leadership development programs like those currently conducted in Texas, Iowa, and Wisconsin is another way to stimulate the interest in pharmacy leadership.
A formal, ongoing, longitudinal program, such as a leadership society, that provides short-term immersion-type activities for young practitioners, with veteran pharmacy leaders and managers serving as role models, and encourages ongoing mentorships at the practice site and nationwide should be investigated. Materials and programs on how to be an ongoing, effective mentor are needed to achieve effective mentoring. Readings, discussions, forums, case studies, stories, lessons learned, and discussions about the health care delivery system should be included in such a program to maintain its long-term survival. A self-development plan that assesses one’s personal style and teaches the “soft skills,” such as emotional intelligence, is also critical. Leadership opportunities must be available for all interested young people. Making them wait to “pay their dues” for involvement is counterproductive; once they start a family they may not have the time to be involved in such professional development programs. Mini-leadership and project experiences can provide entry-level leadership skills, as many entry-level supervisory positions no longer exist. In addition to skill development, these leadership experiences allow pharmacists to see if leadership is appropriate for them.
All current and future practitioners would benefit significantly from mastering “success skills.” These skills are useful to clinical practitioners, leaders, and middle managers and include such things as time management, goal setting, vision development, career planning, interpersonal relationship building, emotional intelligence, personnel management, and chairing committees. Conversations with successful practitioners also should be considered as a method of developing mentor relationships. Opportunities for these conversations should be widely available, and the conversations need not be too structured or rigid.
Recommendation 5: Analyze the ramifications of generational diversity and gender shift issues on the supply and effectiveness of current and future leaders. Pharmacy practice is shifting from a predominately male to predominately female profession, and the work force is comprised of multi-generational, dual-career couples with children. Practitioners and students are interested in balancing their career with their family and personal life. These were two important findings of this survey.
The issues, attitudes, and challenges regarding pharmacy leadership need to be defined for and clearly understood by young practitioners, current leaders, and managers. Specific action plans must be developed that include measurable goals and timelines. Evaluating and tracking the effectiveness of these action plans are also critical. Attitudinal, job satisfaction, and potential turnover data should be periodically collected, tracked, and evaluated for emergent trends to detect any shifts so that adjustments can be made to ensure the continual supply of pharmacy leaders.
Recommendation 6: Scrutinize the leadership and change-agent skills, abilities, knowledge, and attitudes being developed in residency programs and balance them with the clinical knowledge and practice being imparted. Residency training provides young practitioners with the skills, abilities, knowledge, and attitudes to be successful leaders. As evidenced by the low percentage of current practitioners who would consider a leadership or management position during their career, the current residency accreditation standards need to be revised. Residencies must impart an attitude of “creative dissatisfaction” with the status quo and a passion to continually improve pharmacy practice on behalf of patients—residencies must not be viewed as just one more hurdle to be overcome for a good paying job. The continued use of the term “practice management” needs to be evaluated and revised to appropriately convey the importance of change agents in leadership.
The number of residencies available must substantially increase to ensure the supply of potential leaders. Data on what residency-trained pharmacists are actually doing throughout their career should be collected, tracked, and evaluated for inclusion into future revisions of residency standards.
Recommendation 7: Promote the development of and recruitment for advanced-degree pharmacy management specialty residency programs and one-year specialty administration residency programs. Develop and conduct an ongoing networking and mentoring program at the national level that utilizes veteran leaders and managers as role models once residents move into their careers. The terminology used in defining residencies can send powerful messages, so the continued use of the term management versus leadership or administration should be consciously evaluated. Residency accreditation standards should also be scrutinized and updated as necessary to ensure their appropriateness for training future executive leaders. With the current emphasis on clinical practice management, residency programs must be robustly marketed to ensure a consistent resident pool. Residency-trained pharmacists should also be encouraged to continue to enlarge their network of mentors.
Recommendation 8: Enhance the leadership effectiveness and satisfaction of current pharmacy directors and middle managers to assist in job retention. Steps should be taken to maximize the directors’ and middle managers’ satisfiers and minimize the dissatisfiers. To assist in minimizing the job stress, ASHP should support current leaders by providing education and information on contemporary issues in a timely manner, as has been done recently with the United States Pharmacopeia Chapter 797 and the Joint Commission on Accreditation of Healthcare Organizations’ National Patient Safety Goals, and alerting practitioners to important professional trends and their implications. Continued publication in the American Journal of Health-System Pharmacy of articles on leadership, management, success skills, and related case studies would greatly benefit aspiring practitioners and students.
Leaders and managers could benefit from the publication of a health-system pharmacy leadership newsletter. This newsletter could contain brief summaries of the current literature on business, leadership, and personal development and discussions of the possible applications to health-system pharmacy. The American College of Health Care Executives (ACHE) has a young careerist newsletter available on its Web site and through the newsletter it publicizes its other publications in business, leadership, and personal development.
The ASHP continuing professional development policy should be augmented for current pharmacy leaders and middle managers to promote continued self-development. Examples of possible development opportunities include Web-based projects; local, state, and national meetings; distance learning; and self-study programs. These opportunities must encompass all aspects of leadership, management, business acumen, critical thinking, changes in the health care industry, professional historical context, future endeavors, and personal effectiveness.
The need for self-renewal opportunities, such as mini-residencies and mini-sabbaticals, would provide leaders the chance to get reenergized and regain their focus. An ASHP Foundation leadership trainee or fellowship program should be considered for members interested in leadership. Facilitating additional Scholar-in-Residence projects is another option. Programs such as the year-long Health Forum Patient Safety Fellows program and the Institute of Healthcare Improvement’s multidisciplinary project may also be adopted.
Further study of how to promote job satisfiers and minimize dissatisfiers should be conducted. Programs that provide a sense of achievement and recognition for achieving milestones (e.g., certificates, designations, degrees) should be investigated.
Recommendation 9: Examine how practitioners can better assist colleges and schools of pharmacy in professionalizing pharmacy students and presenting leadership opportunities in experiential training.10 The pharmacy students who responded to this survey indicated a significant interest in seeking leadership and management positions during their career. Health-system pharmacy should provide mini-leadership experiences for students seeking a joint doctor of pharmacy and master of business administration degree. Pharmacy leaders and managers could also provide administrative and management clerkships and deliver lectures to pharmacy students. Further, health-system leader and manager career options need to be presented to students, and all health-system pharmacy leaders and middle managers should seek out students and actively mentor them.
A significant gap in pharmacy leadership in the next 5–10 years is expected, as well as a shift in work force composition and attitude. Mentoring and residencies are important methods of fostering new leaders in the profession.
Doug Scheckelhoff, Colleen Bush, the survey participants, and the people who shared their expertise with the author are acknowledged.
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