**1. Introduction**

The Department of Health and Human Services supports the expansion of the role of the pharmacist, enhancing patient autonomy and providing competition within the current healthcare model [1]. Advancements in the role of the pharmacist in community-based practice to meet the needs of patients within the area they serve have been largely successful [2]. The impact of pharmacy-based immunization services has resulted in millions of additional immunizations being given annually [3,4]. Given the increased need to provide continued vaccination efforts in the United States [5,6] and promote community-pharmacist role advancement, a transition of current workflow responsibilities could be considered in order to support this change.

When pharmacists move from traditional dispensing roles to increasingly clinical roles, the need for pharmacy technicians to take on advanced roles increases. According to Koehler and Brown, pharmacy technician roles have historically evolved when the role of the pharmacist has changed, creating gaps and a need for technicians to perform new tasks [7]. Literature supports advancing the role of pharmacy technicians to improve patient outcomes within the pharmacy, particularly when training is available and there is a clear and tangible benefit to the technician [8].

In recent years, pharmacy technicians have taken on several new roles, including accepting verbal prescriptions, performing prescription transfers, and checking prescriptions. Results show these new technician roles have had a positive impact on pharmacy workflow. Fleagle and colleagues piloted a tech-check-tech program in a community pharmacy setting and found technicians were

at least as accurate as pharmacists in checking prescriptions, with the potential to save pharmacists approximately 23 working days per year by performing this task [9]. A qualitative study by Hohmeier and colleagues showed that high-performing pharmacy sites had pharmacy technicians engaged in both nonclinical and clinical support activities [10]. Clinical activities at high-performing pharmacies included responsibilities such as scheduling patient appointments with pharmacists, preparing patient charts for the pharmacists prior to appointments, and documenting patient communication [10].

A recent role for pharmacy technicians in the United States includes the administration of immunizations. Technician immunization advancement has gained momentum and support since it began in Idaho in 2017. Three states legally allow pharmacy technicians to administer immunizations [11–13]. Eid and colleagues assessed the regulatory nature of pharmacy technician vaccine administration with a nine-question survey sent to 51 state boards of pharmacy [14]. Findings demonstrated that, in addition to the three states where technicians were already allowed to immunize, nine other states did not expressly prohibit this advanced technician role [14].

Doucette and Schommer recently assessed pharmacy technician willingness to undertake new advanced roles and identified variables that could improve this willingness [15]. Administering immunizations was found to be one of the tasks technicians were least willing take on, but education and support from the pharmacy team were found to be variables that were most associated with improving willingness to perform these tasks [15]. The American Pharmacist's Association recently began o ffering an immunization training program specifically for pharmacy technicians [16]. McKeirnan and colleagues conducted a pilot study, training a small number of pharmacy technicians to administer immunizations, and found that immunizing technicians were competent, willing, and successful at this new role [17]. Time will tell how increased opportunity for technician education on this topic impacts technicians' willingness to administer immunizations.

One aspect of utilizing pharmacy technicians to administer immunizations that has not been explored is the impact on pharmacy workflow. Bertsch and colleagues showed that pharmacists who supervise immunizing technicians are supportive of this role, would encourage more technicians to become immunization-trained, and believe having immunizing technicians has increased the number of immunizations given at the pharmacy [18]. However, more information about how immunizing technicians are utilized in workflow may encourage the expansion of this new advanced role. This in mind, the objective of this work is to gather more information and provide additional insight on the topic of immunization and pharmacy workflow. Specifically, understanding how immunizing technicians are utilized in workflow, how often technicians are administering immunizations, and determining existing barriers to utilizing technicians in immunization workflow are the goals of this research.

#### **2. Materials and Methods**

This research was designed as a two-phase qualitative descriptive study utilizing key informant interviews. The first phase was conducted in 2017 [18]. Pharmacists within one pharmacy chain were contacted to participate in a key informant interview. These pharmacists supervised the first group of immunizing technicians in the United States trained during the pharmacy technician immunization training pilot project conducted by McKeirnan and colleagues in 2016. A description of the 2016 training pilot project can be found elsewhere [17]. The pharmacists from this chain were chosen as participants because they had more experience supervising immunizing technicians than any other pharmacists in the United States at the time of the first phase due to their technicians' participation in this pilot project.

#### *2.1. Study Phase One*

During phase one, pharmacists from the Albertsons corporation were contacted if at least one pharmacy technician employed at their pharmacy was included in the 2016 training pilot project. Pharmacy technicians were trained in December of 2016; key informant interviews were conducted six months later (May 2017). Researchers aimed to understand the perspective of these supervising pharmacists when incorporating trained immunizing technicians into their pharmacy. Two sets of interview questions were developed during this project. One was related to pharmacists' perceptions of the implementation ("perceptions questions"), and the second was created to inquire further into the impact on pharmacy workflow ("workflow questions"). Rogers' Di ffusions of Innovations theoretical framework was utilized to help researchers disseminate this novel information to others wishing to adopt this practice. The perception questions were coded to the Five Stages of the Adoption Process and the workflow questions were coded to Rogers' 5 Factors [19]. Rogers' 5 Factors are intrinsic characteristics of innovation that influence the decision regarding whether to adopt a new idea or innovation [19].

The perception questions were created to specifically target supervising pharmacists' initial trust and utilization of immunizing technicians, perceptions about the training program, and recommendations to other pharmacists who are considering having immunization-trained technicians [18]. The workflow questions focused on embedding immunizing technicians into pharmacy workflow. These workflow questions best paired with the theoretical framework of Rogers' 5 Factors in the Diffusion of Innovation [19]. In this theoretical framework, Rogers defines five characteristics of innovation that influence the adoption or rejection of an innovation by an individual. Rogers describes these characteristics as interrelated but conceptually distinct. These five characteristics include:


These characteristics were utilized to develop five of the seven survey questions, as displayed in Table 1.


**Table 1.** Key informant interview questions.

\* Question used from 2017 [18] and 2020 only.

The key informant interview question script was developed by the primary investigator (TB), a licensed pharmacist who had experience providing the WSU Pharmacy Technician Immunization Training program but was not involved in training any of the technicians who were supervised by the participating pharmacists. The interview questions were peer-reviewed by colleagues. Key informant interviews were offered to supervising pharmacists at all 20 Albertsons pharmacies in Idaho State that had at least one pharmacy technician who attended the initial 2016 immunization training program. Initially, each pharmacy was emailed a copy of both sets of study interview questions by the district clinical coordinator. The intent of emailing the questions ahead of the phone interviews was to provide opportunity for the participants to give the questions thoughtful consideration and to minimize disruption of workflow.

The primary investigator (TB) called each pharmacy during normal business hours and both sets of interview questions were asked. If the participant was not available or did not have time to answer all of the questions, the researcher offered to call back at a more convenient time. Pharmacists who were willing and available to participate were informed that participation was voluntary and that the decision whether or not to participate would not be shared with pharmacy management. Pharmacists were also told the conversation would be audio-recorded but individual participant names and locations would be removed prior to analysis and the dissemination of results. These study methods were found to be exempt from the need for review by the Washington State University Institutional Review Board (WSU IRB, #16030).

After all of the interviews were completed, the audio files were transcribed using an online transcription service (https://www.rev.com/) and redacted of information that could identify the participant or specific store. The transcriptions were reviewed, and each set of questions was coded separately using qualitative coding methods. Qualitative coding procedures, as described by Miles et al., were performed by two researchers [20]. First-level coding, the systematic labeling of items or concepts that appeared repeatedly in the text, was completed by hand independently. The researchers then met to discuss and cluster the codes into higher-level categories, performing second-level coding to create themes. Disagreements were resolved through discussion. Results from the perception questions demonstrated that saturation had been reached on this topic and a manuscript was published [18]. After reviewing the results from the workflow questions, researchers decided that saturation had not been reached on this topic. In order to achieve a more in depth understanding of the integration of immunizing pharmacy technicians into workflow further research would need to be conducted.

#### *2.2. Study Phase Two*

Phase two was conducted in January and February of 2020. Initially, the intent was to contact all 19 pharmacies that had participated in phase one of the study. However, permission was only given to contact five pharmacies located in northern Idaho. The same key informant workflow interview questions as shown in Table 1 were utilized again with the addition of one question previously included in the perceptions question list: "What percentage of the time does your technician(s) administer the immunizations?" The researchers believed comparing previous results of this question would help future adopters discern how immunizing technician utilization had varied over time in the workflow.

Key informant interviews were held by the same researcher (TB) who conducted the initial interviews in 2017. Individual pharmacies were called during normal business hours with consideration given to which times of the day would likely be less busy. Willing participants were informed this was a follow-up study for pharmacists who supervised immunizing pharmacy technicians. Following the same methods as phase one, all interviews were audio-recorded and transcribed, and identifying information was redacted. First-level and second-level coding were performed using the same methods described during phase one. After coding was complete, 2017 interview findings were compared with 2020 findings and mapped to corresponding domains in Rogers' 5 Factors of the Diffusion of Innovation [19]. An integral component associated with Rogers' theory of innovation is time; innovations need to be tested over time in order to determine value [19]. The second set of interviews were conducted three years later with the same set of pharmacies, minus those who were unable to participate. Researchers determined that a saturation point in thematic findings had been met, as the outcomes were similar enough between the two sets of interviews. The 2020 responses repeated the majority of comments recorded previously in 2017. The research yielded no new data after this specific lapse in time.
