**4. Discussion**

Survey responses provided data from across all categories of pharmacy and from CPTs, with varying educational backgrounds. The GPhC 'Survey of registered pharmacy professionals 2019' [25] provides data to sugges<sup>t</sup> that the sample within this research could be considered representative of CPTs in Wales. The GPhC reported that 6% of the 23,506 registered PTs were resident in Wales (1410) and that 56% of PTs in Wales work in community pharmacy. This suggests there were 789 CPTs in Wales in 2019, which is consistent with the estimated sample size of 841 in 2018. The 2019 survey showed that 64% of CPTs in Wales accessed the register via the grandparent route, i.e., prior to 2011, which is comparable with the research sample in which over two-thirds of CPTs qualified prior to 2011. The average number of hours worked per week by CPTs in Wales in 2019 was reported as 32.4, which is broadly equivalent to the average reported in this study. The 2019 survey showed that 55% of CPTs in Wales worked in a large multiple and 20% in a small to medium chain; again, this is consistent with our findings, where over half worked in a large community pharmacy and a fifth worked in a small or medium sized chain. Finally, 57% of PTs across all sectors in Wales reported that they held an ACPT qualification—which was slightly higher (two-thirds) in our study sample. It is therefore reasonable to conclude that the research sample is representative of CPTs in Wales and therefore the results can be generalised to the wider population of CPTs in Wales.

The aim of this study was to explore the roles and responsibilities of CPTs in Wales and identify potential barriers and enablers to role development. In summary, the dispensing of medicines remains a core role for CPTs in Wales, despite there being opportunity to delegate the role to appropriately trained, non-registered support sta ff, which make up 64% full time equivalent (FTE) roles in community pharmacies in Wales [26]. This finding is consistent with Salameh et al.'s (2018) [27] exploratory study, in which all 16 PT participants reported dispensing as a day-to-day responsibility, and the recent 2019 GPhC survey [25], in which 85% of CPTs in Wales reported supplying medicines and medical devices as a main role. Failure to enable delegation of the dispensing process and fully utilise the skill mix within the pharmacy team, is a barrier to CPTs in Wales fulfilling their potential, even within their existing roles.

The results also sugges<sup>t</sup> that final accuracy checking is becoming a core role and that ACPTs spend approximately half their time final accuracy checking. However, the data also sugges<sup>t</sup> that not all trained ACPTs are being enabled to final accuracy check, often due to capacity issues. This finding is consistent with a recent workforce survey [26], which concluded that "the required opportunities and infrastructure should be made available to increase the percentage of community pharmacy technicians accredited to accuracy check prescriptions to match hospital levels over the next 3 years". Similarly, the data sugges<sup>t</sup> that there is limited engagemen<sup>t</sup> in service-based roles, e.g., smoking cessation and inhaler techniques counselling, even when CPTs have completed the required training and there are data suggesting CPTs are willing to undertake these roles. These findings are consistent with Doucette and Schommer's [28] survey research, which found that insu fficient sta ffing levels, insu fficient time and lack of employer recognition for specialized skills, were barriers to PTs engaging in emerging tasks. These findings support the need for the community pharmacy sector in Wales to urgently address the capacity issues which are a current barrier to CPTs engaging in roles which they are trained and/or are willing to be trained to undertake. Taking these measures would support the Welsh Government's vision of localised delivery of public health and clinical services.

There is evidence of an explicit career pathway, from Dispenser to PT in the community pharmacy sector in Wales. In 2018, the Welsh Government announced a commitment to support the education of up to two hundred PRPTs over three years and community pharmacy contractors were invited to nominate suitable candidates—it is likely that this funding will continue to support the development of dispensers to PTs [29]. The data sugges<sup>t</sup> that many PTs recognise important di fferences between the two roles in terms of responsibility, knowledge required and respect or value for the PT role—this is a marked divergence from existing research [12,27]. The majority of participants previously worked as dispensers, and despite this, they appear to have transitioned and adopted a professional identity. Salameh et al. (2018) [27] found that professional identity formation was one of four key areas required to optimise the PT role in the community sector, hence these results are encouraging in terms of laying the foundations for future role development.

The existing IET appears to be su fficient to support the foundation PT role, with the majority of PTs reporting that their initial training enabled them to undertake their role on day one. IET could be further improved by ensuring the curriculum accurately reflects the PT role, placing a greater emphasis on experiential learning and improving workplace support for PRPTs. What appears to be more of a barrier is the lack of understanding of the IET and/or the role of a pre-registration pharmacy technician (PRPT) by colleagues. This could be related to the use of distance learning courses, where PRPT training is often facilitated by a single pharmacist who may review work and/or act as an expert witness, but where summative assessment decisions are made by external assessors employed by the education provider [12]. The new combined qualification which is currently being introduced [30], must meet the GPhC (2017) revised standards for IET [31], which state that systems must enable PRPTs to meet regularly with colleagues to review and document their progress. Similarly, the GPhC 'Guidance on tutoring and supervising pharmacy professionals in training' [32] explicitly states that a designated educational supervisor must have oversight of training and assessment in the workplace, overall responsibility for supervision and sign the final supervisory declaration. The new qualification standards allow PRPT training to be supervised by a PT, not just a pharmacist, as was previously the case. It is hoped that the new standards will improve colleague engagemen<sup>t</sup> and understanding of the IET curriculum and the PRPT role, which could lead to increased confidence in PT competencies and facilitate more informed decision making around the use of delegation and potential PT roles.

Despite some conflicts within the data, it does appear that workplace support is an important enabler for CPTs, particularly support from pharmacists and managers. The support provided appears to be informal in nature, e.g., encouragemen<sup>t</sup> and confidence building, and often provided by colleagues with whom the CPT has a good working relationship. Whilst this could be su fficient to support CPTs within their existing roles, CPTs would benefit from access to more formal support in the workplace, such as mentoring or peer support, to enable them to further develop their roles with confidence.

This study has several limitations. The questionnaire data did not include the participants' age or gender—the authors acknowledge that gender could be considered a relevant factor, as 90% of the PT profession are female [22], whilst noting that the gender of the interviewees was balanced. The quality of data could have been a ffected by recall bias, when participants were asked to report on their practice as a 'day one' pharmacy technician and their career since. It may also have been a ffected by the willingness of participants to report on some topics, e.g., being open about the barriers experienced [33]. The validity of the survey data could have been a ffected by non-response bias, though the authors note that the 2019 GPhC study [25] yielded a 25% response rate for PTs in Wales across all sectors (not just community sector), and this highlights the di fficulty in reaching this population. Although the response rate is low, this is consistent with those of similar studies with PTs. However, the authors acknowledge that care should be taken when generalising these findings. Due to the limited volume of research into PT roles in Wales, or indeed the UK, there was little opportunity to use previously validated questions. The wording of one question, 'Which role/s did your further training enable you to undertake' was potentially ambiguous. The word 'enable' could have been interpreted as competence and/or confidence to undertake the role, or as opportunities to undertake the role within the workplace. The limitations of Likert scales include the assumption that subjective data can be quantified and that intervals on a Likert scale are equally spaced. The issue of quantifying subjective data was addressed to some degree, by the inclusion of free text boxes, to enable participants to provide further context [20]. The questionnaire was purposely designed to enable participants to describe their role in their own words, rather than compelling participants to select roles from a pre-determined list. However, the use of open-ended questions is a known factor in survey fatigue [34] and may have a ffected completion rates. The questionnaire was also designed to quantify the amount of time participants spent undertaking each role, to identify core roles and responsibilities. Unfortunately, under half of respondents completed this section correctly. Some participants simply did not assign a percentage to each role, whereas other participants assigned percentages which did not add up to 100%. The erroneous responses had to be omitted from the analysis of this section, which reduced the reliability of the data.

The authors recognise that the validity of the interview data may be compromised by the low response rate and note that time constraints did not allow for further recruitment of participants. Telephone interviews present specific challenges for researchers; e.g., the sample of participants who are accessible via telephone may not be representative, it may be more challenging to develop a rapport with participants over the telephone [35], participant responses may be a ffected by the perceived anonymity that distance provides, researchers cannot use visual aids and neither party has access to non-verbal language and cues [36].

The lead author and interviewer (RC) is a PT and acknowledged that their experiential knowledge of the profession shaped their approach to the research, e.g., the barriers and enablers explored. RC also considered the potential impact of 'role power' and was careful to di fferentiate the research from other employed roles. To avoid a one-way discourse during the interviews, a semi-structured interview format was favoured.

An alternative approach to undertaking this research may have been to observe CPTs in the workplace, or to conduct more in-depth interviews to establish core roles. This approach would also have enabled further exploration of how professional identities are developed, which was beyond the scope of this study, but could highlight another important area for further qualitative research. The scope of this study was limited by time and resources; however, it is recognised that future research would benefit from the inclusion of pharmacist perspectives, particularly around the issues of delegation and e fficacy of IET.

This study has been circulated internally at the General Pharmaceutical Council (GPhC) to individuals working in education, policy, revalidation, communications and insight, intelligence and inspection. At the time of writing, the outcomes of this are as ye<sup>t</sup> unknown. The study has also been shared with the Pharmacy Dean at Health Education and Improvement Wales (HEIW) and the Chief Pharmaceutical O fficer for Wales. The study has been referenced within HEIW's Wales Community Pharmacy Workforce Survey 2019 [26].

#### **5. Recommendations and Conclusions**

The findings of this study indicate that CPTs' knowledge and skills are not being utilised to the full extent even within existing roles. There is also evidence to sugges<sup>t</sup> that CPTs are willing and able to undertake extended roles such as smoking cessation services, if they are enabled to do so. If the Welsh Government's vision for community pharmacy services is to be fully realised, the existing potential of the PT workforce within Wales must be recognised and the further development of PT roles must be prioritised. Whilst the ability to make firm conclusions is limited by the small response rate, there are a number of recommendations that could be taken forward, based on these findings. These are:

1. Community pharmacy employers and stakeholders should recognise the potential of the CPT workforce and address the barriers to optimisation of the current CPT role in Wales.


**Supplementary Materials:** The following are available online at http://www.mdpi.com/2226-4787/8/2/97/s1, Participant Interview Schedule.

**Author Contributions:** Conceptualization, R.C. and J.H; Methodology, R.C., J.H. and D.J.; Validation; D.J.; Data curation, R.C. and D.J.; Formal analysis, R.C. and D.J.; Investigation, R.C.; Supervision, J.H. and D.J.; Writing—original draft, R.C. and D.J.; Writing—review and editing, R.C., J.H. and D.J. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding. Funding for the academic Master's fees was received from the Wales Centre for Professional Pharmacy Education, Cardiff University (prior to transfer to Health Education and Improvement Wales).

**Acknowledgments:** The authors would like to acknowledge the contributions of the pharmacy technicians who participated in this study.

**Conflicts of Interest:** The authors declare no conflict of interest.
