**4. Discussion**

This study evaluated the opinions of pharmacists from four states regarding the value of and potential changes that might enhance the impact of pharmacy technician certification. In doing so, it updated previous assessments of certification undertaken over a decade ago after many changes in the pharmacy landscape and after continued calls for standardization in technician education and training. It also undertook this evaluation under the auspices of an organizational behavior framework, thus focusing more on general abilities that transcend practice setting while considering potential organization and further practice change.

Although approaching the topic from a different angle, namely with an organizational behavior framework, the study corroborates other research on pharmacist workforce, such as how technicians see themselves in regard to their own preparedness [29]. The results also align with a recent qualitative study of both pharmacists and technicians identifying a competency/preparedness for practice framework that identified six domains, including: communication in patient care, collaboration with other personnel, knowledge in pharmaceuticals, organization of care (including staffing and workflow issues), emerging leadership responsibilities, and personal development [36].

Pharmacists responding to the survey saw certification alone as having only a very modest impact on technician competence in various job responsibilities and behaviors. This is not surprising, given that certification involves a self-study process that does not include a didactic or experiential component and was basically designed to impart certain foundational knowledge concepts for test-takers [24]. As such, it also is not surprising that the competencies accorded the highest impact by certification were basic pharmacology and math computational skills. However, respondents saw certification as having a greater impact when it is combined with other types of education/training and with previous work experience. In comparison to certification alone, for certification in combination with other educational activities and/or work experience, the impact was evaluated much higher on competencies such as medication preparation, compounding, billing/administrative functions, problem-solving, and leadership. As such, the responding pharmacists likely recognize the importance of longitudinal and multiple types of exposure to more complex and cognitive functions administered or instructed in a variety of ways [37]. Likewise, there have been calls in Doctor of Pharmacy (PharmD) education to include various types of learning experiences for skills such as problem-solving, leadership, and managing change [38].

These results sugges<sup>t</sup> that respondents see certification as an important component of a larger effort to promote technician competence and professionalization [39]. In fact, the action deemed most important by respondents in certification having an even greater impact was integration of the certification process with vocational training. This was echoed in the aforementioned stakeholder consensus conference and other calls for standardizing technician preparedness and entry into the field [18]. In the current study, pharmacists viewed technician vocational training as least impactful in potential hiring decisions, and this reflects concern pharmacists have expressed about the variation of quality in those vocational programs [40]. However, the pharmacists in the current study see certification's alignment with vocational programs as a potential way to further standardize and raise the quality of technician preparedness for practice. These phenomena warrant additional study.

Respondents reported nearly the same level of importance on content related to technical pharmacy skills and to the inclusion of "soft skills" such as leadership and ethical decision-making. Indeed, the evaluation of the impact of certification alone on items such as communication and leadership were relatively low. Previous research has found community pharmacists of the mindset that technicians are the "face" of the pharmacy [41] and have also expressed concern about technicians dealing with controlled substances (i.e., issues around ethical decision making) [42]. Thus, while it is unlikely that anyone expects a self-study examination process to fully prepare technicians for specific job competencies and soft skills, respondents did think it was an important component to add and perhaps integrate with other types of education and training. This is further amplified by a high importance rating given to the need for more support from employers, which likely also alludes to the need to increase technician salaries as well as to better leverage certification in their own in-house training. Previous qualitative research indicates pharmacist support for including more so-called soft skills [43]. Viewed as less than somewhat important in this study was the need to simply make the current certification examinations more di fficult.

Respondents reiterated their perceptions of the importance of communication skills and professional judgment when these skills were rated rather highly in hiring decisions, only after previous work experience and expected overall abilities on the job. Certification was deemed to be relatively important, and alone, was deemed more important than vocational training as well as the technician's ability to adapt to practice change. Perhaps respondents believe that technicians' ability to adapt to change and their emotional intelligence will, or can be groomed by the employing organization. The results here would appear to corroborate recent explorations into the desired characteristics of pharmacists, as well. Alston et al. [31] found characteristics such as communication skills and moral integrity to be the most highly sought after among recent pharmacy graduates for new positions, and Wheeler et al. saw these types of competencies, as well as proven ability and experience, to be among the most frequent requirements listed in pharmacist job positions posted nationwide [44].

A composite view of certification was undertaken through the use of general items about various facets of the process. Respondents agreed that technicians with experience are able to leverage certification e ffectively, thus adding to perceptions of its importance but need for integration with experience, which would appear to be incumbent both on employers and certification boards. The responding pharmacists also agreed that certification should be required for designation into advanced status, as is becoming more common with career laddering options [45]. Respondents also agreed that technicians who are certified are more committed to their profession but slightly disagreed or were neutral in regard to employer commitment. Perhaps pharmacists are of the belief that having gained more marketability through certification might result in technicians being open to opportunities with other employers. The respondents also slightly disagreed or were neutral with the notion that certified technicians are more adept in customer service and commit fewer errors. Again, certification is not necessarily meant to improve skills that would be associated with reduced errors, but perhaps better integration and more emphasis on public health/safety and customer relations would be beneficial components to the certification process.

Taken together, the results sugges<sup>t</sup> that pharmacists placed a good bit of value on technician certification but are aware that certification alone does not prepare technicians for greater competence in all facets of work and that the role it plays currently is in providing much needed background knowledge in certain areas. The results also sugges<sup>t</sup> that respondents see certification as a needed component of technician education and particularly required for advancement into higher status/roles in the organization and helping to imbue greater commitment and professionalism through the self-study process while acknowledging that certification needs to be better synchronized and leveraged with other experiences and education. As such, these results call for action by employers, certification organizations, educators, and other leaders in the profession concurrently, thus echoing sentiments expressed for quite some time [46,47]. Even colleges/schools of pharmacy in the U.S. can consider interprofessional education options that include exposure of technicians to Doctor of Pharmacy curricula while providing Doctor of Pharmacy students an opportunity to gain greater appreciation for technician roles, which can ultimately assist as well in their supervision of technicians and thus technicians' competence [48]. Additionally, technician certification vendors (and educational organizations) might want to gear future education and assessment based more on the setting than on the particular task.
