**1. Introduction**

Pharmacy technicians and other workforce support personnel are recognized as essential in the evolution of pharmacy practice to a more patient-centric focus and public health orientation [1]. The previous few years are witness to considerable research into pharmacy technician roles, moving beyond descriptions of technician practice in one particular facility into broader examinations of roles that can be consistently delegated across organizations and even practice settings [2–5]. The growth in literature has helped spur recent systematic reviews of pharmacy technician practice. In one such review, Mattingly and Mattingly noted that approximately half of studies on pharmacy technician practice had been published in the previous decade and that on-the-job training was allowing them to assume more administratively based positions [6]. They found the benefits to technicians for these shifts in practice to be more indirect and/or intrinsic, thus associated with very little raises in pay. Another review centered more around uptake of specific roles associated with pharmacist provision of medication therapy managemen<sup>t</sup> (MTM) services [7]. That review included 44 manuscripts describing pharmacy technician involvement with medication reconciliation (70% of papers reviewed), documentation (41%), medication therapy review (30%), medication record development (5%), physical

assessment (5%), and patient follow-up (2%). The authors concluded that standardized training for pharmacy technicians that delineates administrative support from pharmacists' role of clinical decision making could help pharmacists achieve greater e fficiency in MTM delivery.

These reports in the literature evince significant strides in technician practice but that which still stands much room for further growth and improvement. There have been a number of pleas for greater technician involvement in various roles such as telephonic prescription transfer [8], immunizations [9], and quality assurance [10]. However, technician work is already reported to be stressful [11] and for relatively little pay that does not improve with greater regulatory requirements for registration and/or licensure in the United States (U.S.) [12] Aside from assistance with medication reconciliation, much of the attention and growth of technician practice responsibilities have been under the auspices of re-engineering models such as "tech-check-tech" or "technician product verification" where technicians are delegated more tasks in the dispensing process and in some cases a fforded a considerable amount of authority in supervising one another's work up to the point where the prepared medication order is provided to the patient [13]. Even while the presence of such "checking technicians" has been demonstrated to be safe, there is some reluctance in advancing technician roles much further [14].

At least a significant if not primary reason for this reluctance is the lack of standardization, even agreement, on the education, training, and professional development necessary for entry into practice and continued employment and advancement [15]. Leaders in pharmacy have long called for national (U.S.) standards for technician education, training, state licensure, as well as for properly defined "entry-level" versus "advanced" technicians [16,17]. The momentum for such clarity in standards has gained even more traction following a stakeholder consensus meeting of pharmacy leaders from various settings and from agencies with regulatory authority [18]. However, the current picture still sees wide variation in technician training and credentialing requirements from state to state. Entry-level practice requirements for technicians throughout the nation indicate that just over half of U.S. states require no education/training or certification of any type; five require certification, only; four require education/training only but not certification; seven require some sort of education/training and certification; another seven require either education/training or certification; and seven have no requirements for education, registration or licensure [19].

Given the lack regulatory authority by one national body, achieving further clarity on entry-level and advanced practice has remained elusive [20]. Moreover, various stakeholders, including some large employers might favor the status quo [21]. In addition to concern about rising labor costs in the face of tight profit margins, some employers might have preference for on-the-job training that fits their organization's specific requirements for the jobs they have designed.

Despite these factors, many stakeholders have embraced national certification as administered by either the Pharmacy Technician Certification Board (PTCB, administering the PTCE ® examination) or through the National Healthcareer Association (NHA, administering the ExCPT examination). Several U.S. states now require certification for pharmacy technicians for registration and/or licensure. Other states are considering adopting the requirement for entry or for the designation of so-called "advanced" or similar such designations [22]. The state of Washington requires national certification in addition to experiential work in several, mandatory areas of knowledge [23]. Additionally, some employers have begun to mandate certification to coincide with in-house training, even requiring that PharmD students working as interns acquire certification, as well.

Both national certification procedures involve a self-study process culminating in an examination with components in the names and indications of common drugs, basic pharmacology, federal jurisprudence, dispensing processes, compounding, sterile intravenous admixture, medication safety/quality assurance, and issues surrounding controlled substances [24,25]. Impending changes examination sugges<sup>t</sup> a more parsimonious set of domains, for example removal of sterile intravenous admixture from the PTCE [24].

The principle aims of certification have thusly been on imparting essential knowledge in carrying out the duties of a pharmacy technician. There is no experiential component or skills-based assessment. However, evidence suggests that engagemen<sup>t</sup> in the certification process imbues a greater sense of professional identity and thus might spur greater professionalism and greater commitment to a pharmacy career [26].

While various stakeholders debate requirements for education and training of pharmacy stakeholders, it is important to discern the value of national certification. Previous studies on the value of certification were conducted approximately a decade ago [27,28]. These studies found modest contribution of certification toward various skills and attitudes. Much has changed since the publication of those studies, and that research was conducted in the absence of context, or consideration of other types of education and training. That is, those studies did not determine the extent to which certification might assist or be leveraged during other components or possible education training modalities, such as vocational education and on-the job training.

To that end, the overall aims of this study were to ascribe value to the certification process, and specifically: (1) to determine pharmacists' perceptions of the impact of certification on competence in specific job skills, its impact in combination with job experience, and its impact in combination with other types of vocational education/training; (2) to identify elements that could potentially enhance the value, or impact of national certification; and (3) to determine how pharmacists view certification in light of various personnel managemen<sup>t</sup> and organizational behavior phenomena.

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

## *2.1. Survey Design*

The study methods were deemed exempt from full evaluation and approved for conduct by the principal investigator's Institutional Review Board (IRB).

The study employed a cross-sectional design with use of a survey targeted to a sample of pharmacists from four U.S. states. The survey was comprised of several components. In the first component, pharmacist respondents were asked to identify the impact of certification, alone, on a technician's competence in performance of 21 di fferent job functions and responsibilities in accordance with previous job analyses [29] but in this case job behaviors and roles that were not unique to a particular setting and that comported with components of professionalism and an organization behavior framework proposed by Roberts et al. [30] in pharmacy settings. This organizational behavior framework provides a useful perspective for recognizing the contributions of constituents within an organization, and in turn how their behaviors may a ffect each other and the organization as a whole. The items used for scaling, then, were items such as prescription/medication order entry, medication preparation, compounding, billing, supervision of other technicians, problem-solving, leadership, time management, basic pharmacology, math skills, and ability to adapt to organizational change. These items were evaluated on a five-point Likert-type scale ranging from 1 = Not all, to 5 = Very much. Participants then evaluated the impact of certification using the same scale and same items but this time in combination with experience on the job, and then also evaluated those same items using the same scale but for certification's impact in combination with other types training/education, such as vocational and on-the-job training.

The next component of the survey contained eight items representing possible actions taken to improve the utility or increase the value of certification. The items were scaled on importance on three points from "Not Important" to "Somewhat important" and "Very important". In this case, the investigators did not believe in the necessity of additional scale intervals and preferred to keep the scale simple and balanced between the intervals (hence, three points only). The items included various components such as more content in specific areas, more support from employers, more specialty certifications, better integration of the examination with vocational education, and more stringent criteria to be eligible to sit for the certification examination. These items were taken from the literature expressing potential improvements made to educational and training mandates for technicians, dating back to older calls and to the more recent aforementioned consensus gathering [16–18].

The third component of the survey to further assist in ascribing value to national certification included 13 items evaluated on five-point Likert-type scales of agreemen<sup>t</sup> asking respondents their opinions on various items such as the extent to which certification assists newer versus more experienced technicians, the extent that certification is associated with more greater employer commitment, whether certification should be required for advanced status, whether it helps prepare technicians for emerging roles (practice and organizational change), and whether certification is a determining factor in hiring decisions. These items were based upon findings from a previous nationwide survey of certified pharmacy technicians that examined descriptively pharmacy technicians' commitment levels and from previous studies of pharmacists who initially ascribed value to national certification based upon technicians' preparedness for entry-level practice at that time [27–29].

The fourth component of the survey asked responding pharmacists to rank eight potential characteristics or experiences of technicians as to their importance in that hiring decision. The items consisted of whether they were certified, previous work experience, anticipated job abilities, communication skills, emotional intelligence, and ability to adapt to practice change. As there were no previous studies on desired skills of technicians, these were adapted from a recent study of desire skills for pharmacists [31]. The fifth and final component of the survey solicited certain respondent demographic and practice setting characteristics.

#### *2.2. Design and Sampling*

The survey was constructed and disseminated using Qualtrics XM [32] and delivered via email to potential respondents. A list of pharmacists' email addresses was acquired from IQVIA, a company that among other things maintains a list of pharmacists who have agreed to be maintained on a list of theirs to potentially be contacted for research and other purposes. There was no formal sample size determination, as there were many potential variables upon which to base power. It was hoped to acquire at least 200 or more respondents, and the study's budget provided the purchase of 1800 emails from IQVIA.

The sampling frame was derived from four states: California, Florida, Tennessee, and Ohio. These states were selected in consultation with the study sponsor (PTCB) in identifying states that were geographically diverse with varied scopes of practice and licensure for pharmacy technicians. Concurrently, and even more importantly, these four states were without requirements for certification but still had relatively large proportions of technicians who were certified, thus yielding a greater likelihood that pharmacists would have had an opportunity to work with both certified and non-certified technicians, and particularly technicians who had been newly certified as to provide context and potential comparison for their answers to the survey. The states were sampled in relative proportion to the size of their technician population, but with some under sampling from California and some oversampling from Tennessee and Ohio to better assure a reasonable number of respondents from these states. The total number of participants contacted for participation was: 600 from California, 500 from Florida, 360 from Ohio, and 340 from Tennessee.

The procedures employed techniques recommended by Dillman et al. [33] to optimize survey response. An initial email notification of the upcoming survey was sent in early April 2019. Approximately one week later, an email with basic purpose and IRB approval (cover letter) was emailed with a link to the survey. Two reminders were sent via email to the entire sample (not knowing who had already responded) approximately one week apart, with the survey having been closed on 23 May 2019.
