**4. Discussion**

Rogers' 5 Factors should help community pharmacy stakeholders determine the rate at which this innovation should be adopted [19]. Reflecting on the results and themes produced in terms of relative advantage, compatibility, complexity, or simplicity, trialability, and observability is necessary to make an informed decision. In summation, the perception of the supervising pharmacists was that having an immunizing technician improved workflow and allowed for improved time prioritization. However, some concerns were highlighted: The choice of the appropriate technician to receive the training was considered important, and the current low o ffer of immunization training was perceived to be a barrier towards implementation. In addition, initial hesitation and temporarily increased workload were expressed as challenges by supervising pharmacists who introduced an immunizing technician into the workflow.

Pharmacy technicians have a palpable impact on community pharmacy workflow, and advanced technician roles have been shown to positively a ffect technician job satisfaction [8]. In addition, patient care aspects in pharmacy technician roles contribute to increased self-actualization [21]. Providing pharmacy technicians with perceivably meaningful activities, such as involving them in patient care, can benefit their work performance [22]. Fostering innovations that can produce new workplace environments such as this can improve the traditional community pharmacy paradigm.

There were limitations to this research. During phase 1, interview questions were emailed to sta ff pharmacists prior to the interviews with the goal of providing opportunity for thoughtful consideration of the questions and minimizing disruption to workflow. While these goals may have been achieved, providing the questions ahead of time may have created bias since the participants had the opportunity to provide responses that were formulated rather than giving the reactionary responses expected during interviews where the participant cannot prepare ahead of time.

Although researchers were not able to contact and interview all 20 pharmacies in phase 2, researchers believed saturation was reached after conducting the 2020 interviews because the 2020 responses repeated the majority of the comments recorded in 2017, and because all five of the 2020 interviews yielded similar results. One pharmacy in 2020 had no current immunizing pharmacy technician, which was a recent change that had occurred less than one month prior to the interview (Table 3). As pharmacy technician immunization administration becomes more widespread, conducting similar research on pharmacy workflow with a larger and more diverse key informant group could lead to di fferent results.

This project was conducted in one state and within one pharmacy chain. Information about individual pharmacy prescription volumes, number of patients, and number of employees was not available to the research team, but could provide valuable insight into how immunizing technicians are utilized in workflow in stores with varying degrees of sta ff support and time available to engage with each patient. This pharmacy chain was a very early adopter of this new advanced technician role and chain leadership was very supportive. Results of similar work in a chain where pharmacists or pharmacy leadership are less supportive of immunizing technicians would likely lead to di fferent results. Results may also di ffer with pharmacists that are not comfortable with immunizing patients. All the pharmacists interviewed in this study already administered immunizations before immunizing technicians were added into the workflow. Additionally, because of the way the research was conducted, the pharmacists interviewed in 2017 were not necessarily the same pharmacists who were interviewed

in 2020. Conducting a similar project longitudinally with the same subset of pharmacists may provide a more detailed picture of the impact on workflow.

There is still much research to be done on this topic. Although pharmacists' perceive an increase in the number of immunizations administered [18] when immunizing technicians are integrated into pharmacy workflow, actual immunization data comparing stores with immunizing technicians to similar stores without immunizing technicians would strengthen these results. Similarly, pharmacists perceive that workflow is improved and pharmacist time is saved by utilizing technicians to administer immunizations, but conducting a study similar to that of Fleagle and colleagues in 2019 where workflow hours were analyzed would lead to definitive results about the amount of time saved for pharmacists. Additionally, the training available for pharmacy technicians to learn to administer immunizations is being expanded from a small program at Washington State University [23] to a program o ffered on a national level through the American Pharmacists Association [16]. Since one of the challenges identified by the study pharmacists was lack of availability of the training program because they had willing technicians who were not able to attend to date, the implications of broader access to the program have not ye<sup>t</sup> been realized. This training expansion will lead to a multitude of additional research opportunities as technicians in more geographic regions of the country with varying needs for additional immunizers begin undertaking this role.
