Paul A. M. Gregory

Negotiation of interprofessional culture shock:The experiences of pharmacists who become physicians

Summary Professions generally operate within a shared set of values, symbols, and norms; in short, professions may be characterized as having somewhat unique sub-cultures. As inter-professional teamwork and collaboration gain prominence, understanding the inter-cultural dimensions of professional interactions may be useful in explaining how and why such teams function. One way of examining the unique (and common) elements of professional sub-cultures is to study the experiences of professionals who have “migrated” from one field to another. In this paper, the “culture shock” experience of pharmacists who have become physicians is described and discussed. Results from interviews with 32 pharmacist-physicians were used to frame four major themes that depict salient and unique characteristics of the cultures of pharmacy and medicine.

Pharmacists' experience of conflict in community practice

BACKGROUND Interpersonal conflict may be characterized as intellectual disagreement with emotional entanglement. While interpersonal conflict has been studied and described in different health care settings, there is little research that focuses on community pharmacists and the ways in which they experience conflict in professional practice. OBJECTIVE To describe and characterize the experience of interpersonal conflict within community pharmacy practice. METHODS A self-reporting narrative log was developed in which actively recruited pharmacists reported and reflected upon their day-to-day experiences of interpersonal conflict in professional practice. Focus groups of pharmacists were convened following data analysis to provide context and confirmation of identified themes. Based on this analysis, an explanatory model for interpersonal conflict in community pharmacy practice was generated. Participants were actively recruited from community pharmacy settings in the Toronto (Canada) area. A total of 41 community pharmacists participated. RESULTS Interpersonal conflict in pharmacy practice is ubiquitous and results from diverse triggers. A conflict stance model was developed, based on the worldview and the communication style of the individual pharmacist. CONCLUSIONS Specific conflict stances identified were: imposing, thwarting, settling, and avoiding. Further testing and refinement of this model is required.

Trust in interprofessional collaboration: Perspectives of pharmacists and physicians

Background: Trust is integral to effective interprofessional collaboration. There has been scant literature characterizing how trust between practitioners is formed, maintained or lost. The objective of this study was to characterize the cognitive model of trust that exists between pharmacists and family physicians working in collaborative primary care settings. Methods: Pharmacists and family physicians who work collaboratively in primary care were participants in this study. Family health teams were excluded from this study because of the distinct nature of these settings. Through a snowball convenience sampling method, a total of 11 pharmacists and 8 family physicians were recruited. A semistructured interview guide was used to guide discussion around trust, relationships and collaboration. Constant-comparative coding was used to identify themes emerging from these data. Results: Pharmacists and family physicians demonstrate different cognitive models of trust in primary care collaboration. For pharmacists, trust appears to be conferred on physicians based on title, degree, status and positional authority. For family physicians, trust appears to be earned based on competency and performance. These differences may lead to interprofessional tension when expectations of reciprocal trust are not met. Conclusions: Further work in characterizing how trust is developed in interprofessional relationships is needed to support effective team formation and functioning.

How do community pharmacists make decisions? Results of an exploratory qualitative study in Ontario

Background: As the complexity of pharmacy practice increases, pharmacists are required to make more decisions under ambiguous or information-deficient conditions. There is scant literature examining how pharmacists make decisions and what factors or values influence their choices. The objective of this exploratory research was to characterize decision-making patterns in the clinical setting of community pharmacists in Ontario. Methods: The think-aloud decision-making method was used for this study. Community pharmacists with 3 or more years’ experience were presented with 2 clinical case studies dealing with challenging situations and were asked to verbally reason through their decision-making process while being probed by an interviewer for clarification, justification and further explication. Verbatim transcripts were analyzed using a protocol analysis method. Results and Discussion: A total of 12 pharmacists participated in this study. Participants experienced cognitive dissonance in attempting to reconcile their desire for a clear and confrontation-free conclusion to the case discussion and the reality of the challenge presented within each case. Strategies for resolving this cognitive dissonance included strong emphasis on the educational (rather than decision-making) role of the pharmacist, the value of strong interpersonal relationships as a way to avoid conflict and achieve desired outcomes, the desire to seek external advice or defer to others’ authority to avoid making a decision and the use of strict interpretations of rules to avoid ambiguity and contextual interpretation. This research was neither representative nor generalizable but was indicative of patterns of decisional avoidance and fear of assuming responsibility for outcomes that warrant further investigation. Conclusion: The think-aloud method functioned effectively in this context and provided insights into pharmacists’ decision-making patterns in the clinical setting. Can Pharm J (Ott) 2016;149:90-98.

Conflict in community pharmacy practice: The experience of pharmacists, technicians and assistants

Background: Intraprofessional conflict among pharmacists, regulated technicians and assistants may undermine attempts to advance patient care in community pharmacy. There is no available research examining this issue in light of the evolution of the profession and roles within the profession. Methods: A combination of interviews and focus groups involving pharmacists, technicians and assistants was undertaken. Each participant completed the Conflict Management Scale as a way of identifying conflict management style. Data were analyzed and coded using a constant-comparative, iterative method. Results: A total of 41 pharmacy team members participated in this research (14 pharmacists, 14 technicians and 13 assistants). Four key themes were identified that related to conflict within community pharmacy: role misunderstanding, threats to self-identity, differences in conflict management style and workplace demotivation. Interpretation: As exploratory research, this study highlighted the need for greater role clarity and additional conflict management skills training as supports for the pharmacy team. The impact of conflict in the workplace was described by participants as significant, adverse and multifactorial. Conclusions: To support practice change, there has been major evolution of roles and responsibilities of pharmacists, technicians and assistants. Conflict among pharmacy team members has the potential to adversely affect the quality of care provided to patients and is an issue for managers, owners, regulators and educators.

Postgraduation employment experiences of new pharmacists in Ontario in 2012-2013.

Background: A recent shift in the pharmacy workforce away from stable, long-term employment has been reported by students. Few data exist regarding the postgraduation employment experiences of students. Methods: An electronic survey exploring postgraduation employment experiences was distributed to 2012–2013 graduates from the Universities of Waterloo and Toronto (including the International Pharmacy Graduate program). Follow-up interviews were undertaken to explore survey findings. Results: Three key themes emerged: 1) the rising prevalence of the “survival job” in pharmacy; 2) tension between professional satisfaction and practical considerations; and 3) an employment market characterized by personal networks, not merit. Discussion: Fewer students are securing full-time positions with benefits, and more are relying upon temporary, part-time work with multiple employers. Implications of this employment pattern for the ability to form pharmacist-patient relationships and provide pharmaceutical care require further investigation. Conclusion: Further exploration of themes identified in this study is required, as is annual study of the experiences of new graduates. Their experiences will shape the future of professional practice and are of interest to academics, educators and practitioners.

How are pharmacists in Ontario adapting to practice change? Results of a qualitative analysis using Kotter’s change management model:

Background: The pace of practice change in community pharmacy over the past decade has been significant, yet there is little evidence documenting implementation of change in the profession. Methods: Kotter’s change management model was selected as a theoretical framework for this exploratory qualitative study. Community pharmacists were interviewed using a semistructured protocol based on Kotter’s model. Data were analyzed and coded using a constant-comparative iterative method aligned with the stages of change management outlined by Kotter. Results: Twelve community pharmacists were interviewed. Three key themes emerged: 1) the profession has successfully established the urgency to, and created a climate conducive for, change; 2) the profession has been less successful in engaging and enabling the profession to actually implement change; and 3) legislative changes (for example, expansion of pharmacists’ scope of practice) may have occurred prematurely, prior to other earlier stages of the change process being consolidated. Interpretation: As noted by most participants, allowing change is not implementing change: pharmacists reported feeling underprepared and lacking confidence to actually make change in their practices and believe that more emphasis on practical, specific implementation tactics is needed. Conclusions: Change management is complex and time and resource intensive. There is a need to provide personalized, detailed, context-specific implementation strategies to pharmacists to allow them to take full advantage of expanded scope of practice.

Promotion and tenure: Clinical faculty at schools of pharmacy in Canada

As a result of an evolution in roles and responsibilities of pharmacists, pharmacy education in North America has become more clinical in nature. In order to meet teaching and research requirements, Canadian pharmacy schools are hiring non-traditional faculty members who possess advanced clinical degrees and training rather than traditional academic qualifications. Policies with respect to tenure and promotion have not kept pace with these changes in hiring practices. Research was undertaken to examine the application of tenure and promotion policies and guidelines to clinical pharmacy faculty members across Canada. Document review was complemented by key informant interviews. A series of themes emerged indicating areas of concern regarding application of traditional “arts and science” tenuring/promotion policies for clinical pharmacy faculty members. Based on these themes, a model for development of guidelines to acknowledge the value and importance of creative scholarly activity within pharmacy (“the 5 C’s”) is proposed and discussed.

What does it take to change practice? Perspectives of pharmacists in Ontario

Background: This is a time of rapid change in the profession of pharmacy. Anecdotally, there are concerns that the pace, extent and rate of practice evolution are lagging. There is little evidence documenting the influencers and mechanisms that drive practice changes forward in pharmacy in Canada. Methods: An exploratory qualitative method was selected, using both one-on-one interviews with self-categorized typical pharmacists and larger focus groups to provide context and confirmation of themes generated through interviews. Data were analyzed and coded using a constant-comparative iterative method, in order to generate themes related to the factors influencing pharmacists to actually change their practice. Results: A total of 46 pharmacists meeting inclusion criteria participated in this study in focus groups, interviews or both. Nine themes were identified: 1) permission, 2) process pointers, 3) practice/rehearsal, 4) positive reinforcement, 5) personalized attention, 6) peer referencing, 7) physician acceptance, 8) patients’ expectations and 9) professional identity supportive of a truly clinical role. One theme that did not emerge was payment, or remuneration, as a specific or isolated motivational factor for change. Interpretation: The complexity of practice change in pharmacy and the multiple factors highlighted in this study point to a more deliberate and concerted effort being needed by diverse pharmacy organizations (educators, regulators, employers, professional associations, etc.) to support pharmacists through the change management process. Conclusions: The “9 Ps of practice change” identified through this study can provide pharmacists with guidance in terms of how to better support evolution of the profession in a more time-efficient and effective manner.

The role of disengagement in the psychology of competence drift

Background: The framing of competence as a binary “either‐or” process may be shaped by the measurement tools and assessment methods used to define it. Blunt measures such as passing or failing a licensure examination, or revoking/suspending a license after a single dispensing error fosters anxiety amongst professionals and potentially leads to behaviours where learning needs are actually hidden from educators, employers or regulators. Such framing may not accurately capture the lived experience of those labelled “incompetent” and in fact may be counterproductive to remediation and skills enhancement. Objectives: To examine the construct of competence as a lived experience amongst pharmacists who had been identified and labelled as incompetent by their regulatory body. Methods: A multiple single‐case research design (described by Kratochwill and Levin) involving 14 practicing pharmacists identified as not meeting competence standards by their regulatory body in Ontario, Canada was used for this research. Constant‐comparative qualitative analysis of semi‐structured interview data was coded, categorized and used to identify and describe major research themes. Results: Two major themes were identified, related to the personal and professional consequences of being labelled “incompetent” by ones regulatory body, and the importance of psychological engagement in ones own profession in facilitating maintenance of competence. Conclusions: This study highlighted the importance of disengagement as both a cause and consequence of competence drift and pointed to the impact of regulatory policies, practices, and assessment systems that may actually inadvertently contribute to this disengagement.