INTRODUCTION

Knowledge regarding workforce attrition (leaving) rates and the reasons for leaving professions are a vital element enabling the efficient planning and management of the healthcare workforce.¹ A recent rapid review of 51 studies published worldwide since 2005 found that attrition rates of healthcare workers, and more specifically, voluntary attrition are understudied and under-reported.² The studies retrieved data primarily from doctors, nurses, midwives and community health workers. The most common general reasons given for leaving a health profession were low remuneration, a lack of professional development and educational opportunities, weak regulation, unsatisfactory working conditions, high-stress levels and low job satisfaction.

The potential of pharmacy and the opportunities brought about by driving factors such as changes in population demographics, the increasing prevalence of long-term conditions, health workforce shortages and advances in technology and medicine have long been recognised internationally by the World Health Organisation (WHO) and pharmacy organisations, such as the International Pharmaceutical Federation (FIP).³-⁶ The Nanjing Statements published by FIP in 2017 guide Schools of Pharmacy worldwide to develop and expand their curricula to prepare graduates for a future that moves pharmacy away from the provision of medicines and towards the provision of extended clinical pharmacy services.⁷,⁸ In line with international trends, many extended pharmacist roles and services are proposed in New Zealand national documents.⁹-¹¹

In New Zealand (NZ), a career in pharmacy begins with an undergraduate degree, a four-year Bachelor in Pharmacy (BPharm) followed by a one-year pre-pharmacist registration training programme (internship) usually in a community or hospital pharmacy setting, under the supervision of a registered pharmacist preceptor. The curricula of New Zealand Schools of Pharmacy have been redesigned in recent times to ensure that graduates can fulfil roles expected of them currently, but also those expected of them in the future.¹²,¹³ Postgraduate qualifications and training available for pharmacists in New Zealand are regularly reviewed to ensure that pharmacist capabilities facilitate pharmacists' future role expansion.

Despite this apparent co-ordinated and considered approach from government and pharmacy stakeholders, recently graduated pharmacists have expressed dissatisfaction with the profession on informal social fora and more recently in a report.¹⁴ Not all NZ BPharm graduates become pharmacists, and not all pharmacists remain in the workforce.¹⁵

In 2018, there were 3787 pharmacists registered as practising in New Zealand. Pharmacy Council of New Zealand data reports that approximately 200 newly qualified pharmacists join the register annually (approximately 5% from overseas). Pharmacists work in a variety of settings, but most typically in community pharmacy (78.1%, 2018 in NZ) and hospital (12.8%, 2018 in NZ).¹⁶

Exploring reasons for people entering and leaving the profession is important for health workforce planning to ensure it meets community needs, the needs of the profession, the priorities and activities of professional bodies and to inform BPharm recruitment strategies, curricula and postgraduate papers. The focus of this study was to gain a better understanding of those lost to, or wanting to leave the pharmacy profession in New Zealand. Specifically, this study sought to explore the characteristics of those individuals who completed their pharmacy undergraduate degree (BPharm or overseas equivalent) in 2003 or later and who had left, or who were seriously considering leaving the New Zealand pharmacy profession in the next few years. It also sought to elicit their perspectives on pharmacy as a career, specifically their reasons for studying pharmacy, their reasons for leaving (or potentially leaving the profession) and what career area they had moved to, or wished to move to. A separate section of the survey elicited views on key NZ policy documents for pharmacists and pharmacy organisations. A manuscript from these data has been submitted elsewhere.

METHODS

RESULTS

The online survey dataset yielded a total of 360 unique entries (participants). Three people did not complete the online consent, giving a sample size of 357 available for inclusion in the study. After completing a rigorous data cleaning process by checking each of the variables, a dataset containing 327 cases was used for further analyses. The removed cases were: graduated before 2003 (n=3), and responses missing information about education, internship or working status (n=27).

It was not possible to accurately estimate the response rate as limited information is available regarding the prevalence of loss from the profession.¹⁶ However, an approximation of the proportion of eligible NZ pharmacists completing the survey is 10.6% (317/3,000) as approximately 200 students graduate with a BPharm annually.

The socio-demographic and the pharmacy profession characteristics of the study participants and all practising pharmacists are shown in Table 1 and Table 2.

Of those who were eligible to practice pharmacy in NZ (n=301), eight people (2.6%) had never practiced pharmacy following internship completion, and another three had practiced only in Australia; a loss of 3.6% for NZ at this point. Participants most commonly practised in a community setting (69.2%), followed by in a hospital setting (20.8%). Among those who had ever practised pharmacy in NZ (n=289), 64.0% reported practicing as a pharmacist at the time of the survey (Table 3). Sixty percent of them were employee pharmacists (79.6% full-time workers), a fifth (21.6%) were working as managers and 11.9% worked as locum pharmacists. Almost half of the currently working respondents were earning NZD70,000-99,000 annually. Unsurprisingly, given the nature of the study and the inclusion criteria, most of the respondents (n=147, 75.4%) reported being ‘Unsatisfied' with the NZ pharmacy profession. Of those who had left the NZ profession, 90.2% did not regret leaving but only one-third reported regretting studying pharmacy.

Table 4 shows that some of the features/characteristics of the participants are likely to be different between those already left (lost) and those still in the profession but seriously considering leaving in the future (potential loss). Age, years since graduated and years practised pharmacy in NZ (all representing the duration of their engagements in the pharmacy sector), and setting last practiced pharmacy in NZ are likely to differ across the groups. The results of the logistic regression analysis give indications of the direction of the relationship, i.e. who are more likely to be in the system despite the fact that they are considering leaving in the near future (Potential loss, n=196) compared to those who already left (Lost, n=131). Participants aged 30 and above [OR=0.56 (0.36, 0.88)], and those who had graduated more than 5 years ago [OR=0.35 (0.21, 0.57)] are less likely to be working in pharmacy when they are unsatisfied (potential loss) but those who had practised pharmacy in NZ for five years or longer are 2.2 times more likely to still be working as a pharmacist in NZ.

Table 5 shows what had influenced respondents to enrol in the pharmacy undergraduate degree programme, what they had expected from the profession and what made them leave/consider leaving the profession. Personal interests (intrinsic motivation) such as 'A keen interest in health' (14.5% of the total responses) and ‘A desire to work with and help people' (13.4%) followed by the extrinsic factors related to the pharmacy profession like perceived ‘Job security' (11.1%) and ‘Pharmacy is a trusted profession' (9.1%) were the most popular reasons for pursuing pharmacy as a career choice. Slightly over 1 in 10 (10.4%) of the responses belong to the 'Forced choice' category: ‘Did not get into first choice' (6.6%) and ‘Pressure from family' (3.8%). Altogether, almost half (48.0%) of the responses belong to the ‘Intrinsic' categories. The prevalence of the responses is similar for both categories of study participants i.e. the lost group and the potential loss group.

Contrastingly, almost three-quarters (72.7%) of the reasons for leaving/considering leaving the profession fall under the ‘Extrinsic' category: ‘Dissatisfaction with the pharmacy professional environment' (25.0%), ‘Lack of career pathways and opportunities' (24.0%) and ‘Under-utilisation of pharmacists' skills and knowledge' (20.6%). Of the small proportion of the ‘Intrinsic' reasons mentioned (227 of 934 responses), only a few relate to individual choices or personal circumstances, e.g. four responses for ‘Ill health', and 69 responses for ‘Relocated overseas'.

When survey participants were asked for further details regarding their dissatisfaction with the professional environment, they reported ‘Lack of recognition of pharmacy from government, other health care professionals, or the public', ‘Inadequate remuneration for services provided' and ‘Lack of consistent and effective representation of the pharmacy profession at high levels to ensure pharmacy is always considered/consulted' as the commonest reasons. These responses account for 18.9%, 18.4% and 16.1% of the responses received for this probing question respectively. Other reasons included: ‘Too much emphasis on making a profit in community pharmacy' (12.3%), ‘Poor working conditions'(10.8%), ‘A lack of support from management within the pharmacy profession' (10.5%), and ‘A lack of professionalism in the profession' (7.5%).

Similarly, regarding the perceived ‘Lack of career pathways and opportunities' which is the second most commonly cited reason (24.0%) for leaving or considering leaving the pharmacy profession, ‘Lack of a clear and appealing progression pathway', ‘Lack of promotion pathways', and ‘Lack of innovation', made up 33.7%, 32.1% and 22.0% of the responses within this probing question respectively. ‘Under-utilisation of pharmacists' knowledge and skills as a reason for dissatisfaction made up 20.6% of the overall responses. This category comprises a ‘Lack of involvement in patient care' (47.6%) and ‘Low/no clinical roles' (52.4%).

Most free text responses aligned with the categories above. Additional reasons for dissatisfaction provided by some respondents related to a recent introduction of discount and supermarket pharmacies leading to reduced profitability of independent community pharmacies, the lack of cohesiveness of pharmacy organisations, high compliance costs and poor working conditions. A small number of respondents stated experiencing negativity and a lack of support from other pharmacists;, a lack of job security; a blaming, bullying culture; harassment; a boring, monotonous environment; too many pharmacy graduates each year; and not having their ideas taken seriously.

The heat-map in Table 5 illustrates that the patterns of reasons across the ‘Lost' group and ‘Potential loss' group are very close which is consistent with the regression analysis results. There are no significant differences in the reasons given for studying pharmacy and those given for leaving the profession among the ‘lost' group and the ‘potential loss' group except for two of the reasons for studying pharmacy: ‘Job security' [OR = 0.53 (0.33 - 0.83)] and ‘Keen interest in healthcare' [OR = 0.59 (0.36 - 0.97)] and two of the reasons for leaving the profession: ‘Dissatisfaction with the professional environment' [OR = 2.85 (1.64 - 5.02)], and ‘Relocated overseas' [OR = 0.25 (0.14 - 0.44)].

Quotes from those interviewed illustrate the extrinsic reasons reported by survey respondents for their dissatisfaction with the profession.

The views above support the pattern of career change pursued or sought by study respondents. Figure 1 shows where responding pharmacists (n=109) have gone or plan to change career path to after pharmacy. The most popular destination was medicine with 28 respondents going on to, or planning to study medicine. Indeed 56.9% (n=62) went on to, or were planning, an alternative career in a different aspect of health. However, other respondents had moved, or had plans to move into, a variety of different non-health related fields.

Figure 1.  Where people have gone or plan to go to as a career after pharmacyThe numbers in the parenthesis denote the number of responses for each category where the total responses for this analysis is 109. Others category includes one each of: Non-health consultancy, Creative industry, Research non-pharmacy, Government, International relations, Medical publishing, Parent at home and Undecided 

Interviewees also suggested areas where the profession or environment could improve:

DISCUSSION

This study set out to explore the characteristics and perspectives of pharmacy as a career from recent BPharm graduates (graduating 2003 onwards) who had left, or were seriously considering leaving the NZ pharmacy profession in the near future. If the study recruited most of the eligible NZ graduates, our data suggest that at least 10.6% (327/3,000) of them have left, or are seriously considering leaving the profession in near future. In reality, the proportion is likely to be higher due to not all eligible individuals participating. In addition previous workforce data reporting retention rates support this figure being an underestimation.²⁵

The New Zealand Health Strategy and the Pharmacy Action Plan 2016-2011 describe a vision of pharmacists working in a broader variety of settings.¹⁰ The plan also seeks to attract students and retain pharmacists who possess the appropriate skill mix to support the expansion and development of new models of care, and to offer higher-level medicines optimisation services.¹¹ Accurate data on attrition rates are essential to informed workforce planning decision-making but unfortunately these data are no longer published in New Zealand for pharmacy. Inconsistent data collection was found to be a worldwide issue by Castro Lopez et al.² Attrition is also a concern as studying pharmacy is a substantial investment and commitment for students and their families. Whilst considering leaving does not necessarily equate to leaving, Reitz et al. found a significant association between behavioural intention and actual turnover and retention in nurses.²⁶

Limitations of the study include not using a validated instrument to measure job satisfaction, and not exploring the viewpoints and alternative career pathways of all eligible people. In addition, this study only solicited the views of a self-selected sample of relatively newly qualified pharmacists who had left or were considering leaving the profession; it does not present a representative view of all recently qualified pharmacists or earlier graduating pharmacists (prior to 2003) considering leaving the profession. There is also potentially an element of responder bias where former pharmacists felt less inclined to participate in this study, with only those holding strong views or having poor experiences responding. It is important that the health workforce represents the community that it serves. Cultural differences in normative practices for choosing careers, including pharmacy, have been reported and it is possible that cultural influences on leaving pharmacy may exist in New Zealand.²³,²⁷,²⁸ However, we were unable to explore this in our study and further research is warranted. Resource constraints limited the study to only ten interviews of purposively chosen respondents. These were used to provide a better understanding of these individual's views and experiences and provide illustrative examples rather than attempting to achieve transferability to all dissatisfied pharmacists'. To understand the dissatisfaction of current pharmacists in a more comprehensive manner, it is proposed that a further study be undertaken.

Having a keen interest in health, science or a desire to work with and help people were the most common reasons given for choosing to study pharmacy. This aligns with other recent studies looking at reasons for choosing pharmacy as a career and the findings of a UK study exploring pharmacists' professional identities.²⁹-³¹ The NZ competence standards and policy documents relating to pharmacy in New Zealand raise no alarm bells of an intrinsic mismatch between the reasons for studying pharmacy and the practice of pharmacy.⁹-¹¹,³² However, dissatisfaction with the professional environment, the lack of career pathways and opportunities, and under-utilisation of skills and knowledge were the most commonly reported reasons for leaving the profession in our findings. These factors have been found to be decisive in shaping an individual's behaviour towards career change in other settings.³³ Our findings are consistent with other studies, including the one that informed our questionnaire.¹⁸,¹⁹

Furthermore, the reasons for leaving are very similar to those reported by American hospital pharmacists dissatisfied with their career and leaving almost forty years ago (1982).³⁴,³⁵ The situation reported then, specifically the presence of enabling policies and curricula, boredom and the "obsolescence of skills and abilities" are still applicable to today, as illustrated by our study. Some of the solutions proposed in 1982, such as roles with increased clinical interactions, and promotions based on merit, competence and time in the role, are also reflected by our survey respondents.³⁴ In addition, our findings are in line with a systematic review of the global pharmacy workforce, which identified workload, job satisfaction, working conditions, roles and responsibilities, training and policies as factors affecting pharmacist retention.³⁶ Overall, pharmacists' pay and benefits, and opportunities for promotion and advancement were the reasons pharmacists cited most frequently for leaving a job and remaining in a job. These findings are echoed in other studies from around the world.³⁷-³⁹

When considering participants' dissatisfaction with pharmacy leadership, findings of a recent study of Swedish registered nurses' work satisfaction may offer some guidance. Karlsson et al. reported that nursing leadership may be able to increase intention to stay in the profession by meeting employee nurses needs for appreciation, a better work environment, competence development and professional career development.⁴⁰ Similarly, a focus on enhancing the management and leadership skills of pharmacists through incorporating them more into undergraduate curriculum was proposed to help retention by enabling promotion into senior roles.⁴¹-⁴²

As in other countries pharmacy organisations in NZ have developed standards for the development of extended roles and career development.⁴³-⁴⁵ However, there appears to be a mismatch between what these documents promote and what pharmacists experience in the workplace, according to our respondents. There is a risk that newly qualified pharmacists may have lost relevant clinical skills and knowledge before they, the profession, and patients can realise the benefits of these frameworks.

A strategy with the potential to mitigate this, and help to address some of the other issues raised in this study and others, is to initiate a national mentorship programme for newly qualified pharmacists. The Māori Pharmacists' Association and the Pacific Pharmacists' Association and some other organisations already provide support and mentoring to their younger members/junior employees. However, a national approach may have merit. The quality of mentoring was identified as an influence on advanced pharmacy practice in a Canadian study and mentoring has been comprehensively discussed in the recent work of Desselle, et al. and Mantzourani, et al.⁴⁶-⁴⁸

Interestingly, although most participants who had left did not regret leaving pharmacy two thirds did not regret studying pharmacy. The interviews and Figure 1, showing where pharmacists go after pharmacy, provide some insights into this phenomenon, finding that the skills and knowledge gained when undertaking a BPharm degree can be successfully transferred into many different areas, not just health-related. It can also be seen that the career changes reported would likely address some of the reasons for respondents' dissatisfaction with the pharmacy profession including wanting to experience better remuneration, use their clinical skills more, experience less stressful work conditions and wanting to be able to progress up a defined career structure. A study of pharmacists who retrained as doctors, however, found that sometimes reality does not always match expectations.⁴⁹

CONCLUSIONS

Recent policy documents aim for skilled pharmacists to be retained to provide extended clinical pharmacy services. Undergraduate and postgraduate curricula changes prepare graduates for these roles. However, the reasons for leaving/considering leaving the profession reported in this study suggest support and changes are required to the professional environment, remuneration and career pathways in order for the potential of the profession to be realised.