This paper presents a novel, qualitative, bio-photographic study with intertextual analysis highlighting the relationship between community pharmacy workspace and practice. Sixteen pharmacists working across pharmacy types such as independent shops, large and small pharmacy chains and multiple pharmacies such as those in supermarkets participated in data capture and feedback consultation. Findings disclosed workspaces unfit for purpose and a workforce ill at ease with their new professional identity, involving increasingly complex tasks in health provision and retail. There was conflict between delegating to others and taking personal responsibility, and there were pressures from a demanding public within the context of a target-driven, litigious society. The study highlights that innovative, mixed methods in this context reveal nuanced, rich data.
- Built environment
- narrative medicine
- Social science
- Pharmacology and toxicology pharmacology
- Public health
- UK community pharmacy practice
- bio-photographic methods
- public-professional communication
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- Built environment
- narrative medicine
- Social science
- Pharmacology and toxicology pharmacology
- Public health
- UK community pharmacy practice
- bio-photographic methods
- public-professional communication
Our objectives were to identify how UK community pharmacy workspaces impacted on professional practice, self-identity and relations with staff and customers following the introduction of the UK’s new National Health Service (NHS) contract, to support a more contextually embedded understanding of pharmacy practice and professionalism. To account for the complex systems that define community pharmacy today, the study used a novel, mixed-methods approach using bio-photographic data capture supported by intertextual analysis. The team have reported on the use of these methods in other papers, work that has spanned a range of primary healthcare settings, including community pharmacy and general practitioner primary care.1 2 3 4 The methods assist researchers to gain a clearer understanding of the practice of health professionals, patient-centred practice and professionalism. Methodological refinement in this study enhances the notion of transference across settings and helps validate the integrity and adaptability of the techniques used.
Community pharmacy has undergone a major upheaval in recent years, resulting from a new NHS contract and changes in healthcare policy.5 6 In April 2005, the NHS introduced a three-tiered pharmacy service comprising essential, advanced and enhanced services. Essential services, provided by all pharmacists, included the dispensing of medicine and the promotion of healthy lifestyles. Advanced services, which required pharmacists to be accredited, included medicine use reviews and prescription intervention services.7 Enhanced services, commissioned at the discretion of primary care trusts, included smoking cessation programmes, supplementary prescribing and sexual health services such as contraception and chlamydia screening and treatment. These are provided in Wales through local health boards.5 6 The Department of Health’s report Pharmacy in England6 identified pharmacies as being able to play a useful role in vascular risk checks, and in Wales this possibility is currently under discussion. Reregulation of increasing numbers and ranges of former prescription-only products to pharmacy medicine status provides increasing opportunities for pharmacists. At the same time it raises a number of questions about current professional competencies, communication skills and balance of workloads.
Since the three-tiered delivery system was introduced, community pharmacists wishing to offer advanced and enhanced services were required to build consultation rooms that comply with specific guidelines set out in the new contractual framework. The consultation rooms had to be clearly designated areas for confidential consultation, separated from publicly accessible areas and offering space for pharmacists and members of the public to sit down together and talk without being overheard.5 However, while the investment led to an increase in sales of specific items such as incontinence products, due to the enhanced public confidence in pharmacists, a reduction in the pharmacy retail floor-space reduced income from sales. On average, retail generates 15% of turnover in community pharmacies, particularly the sale of toiletries and over-the-counter medication.
According to a 2007 survey commissioned by the Pharmacy Practice Research Trust,8 the new pharmacy contract has also led to increased workload and problems regarding the appropriate delegation of tasks to support staff. This, in turn, has caused considerable concern about the degree to which information should be shared with the public and, in view of the lack of clarity about the specific components of advanced or enhanced services, a reluctance to offer such services.
Direct contact with the public in community pharmacy has intensified as a result of enhanced service provision associated with patient consultation.9 However, Pronk and colleagues noted that there has been little clarity about the nature of public–professional interaction.9 Furthermore, Skoglund and colleagues remarked that communication within the pharmacy continues to be characterised by the “professional dominance” model, indicated through closed questioning, public passivity and professional hierarchies.10
The social construction of workspace
The literature above rests heavily on an understanding of change in community pharmacy in relation to professionals’ ability to manage new diagnostic and consultative roles while upholding the pharmacy’s strong ethos of retail. However, our previous research indicates that understanding change in community pharmacy is more complex than that, and that if we wish to gain a deeper understanding of pharmacy practice we must also take into account the “in situ” nature of pharmacists’ work. It is not enough to examine the impact of policy directives, new contracts and new services on workloads: we must also understand the physical environment in which these directives, contracts and services are rolled out and enacted.
Our group have previously described healthcare work environments as “the media in and through which social relations are produced, reproduced, contested and transformed” (p532),2 and we suggest that professional workspace goes beyond a person’s physical surroundings to something that is socially constructed.11 12 Workspace both mediates and is mediated by the professional group within it, and so workspace reveals not only the environment itself, but also people’s response to their surroundings.13 14 This broader vision supports the view that “we should attend to the mutually reinforcing and reciprocal relationship between people and place” (p1825).15 Knott and Franks have endorsed this view, describing space as any body, object or community within it, and the need to “gather all these dimensions together within a single “place”” (p227).16 Such an integrative approach requires an equally integrative data capture technique,17 which through synthesis of methods enables researchers to adequately account for the complexity of the context of space and its social interactions, objects and procedures.2 3
Until recently the photograph has been used in healthcare research primarily as a stimulus for data generation.18 Less commonly, the photograph has featured as an aesthetic product or evocative image. As a stimulus for data generation, the photograph has only really come into its own through the photo-interview, to “give birth” to stories and as an aide-mémoire.18 In the photo-interview, photographs have helped research participants identify people and places, while offering additional commentary to assist researchers in their understanding of data. Taking the work of Radley and Taylor as an example,19 20 photo-interviews were used for secondary data collection to examine photographs patients had taken of a hospital ward that showed aspects of their stay in relation to their experience of illness and recuperation. Data were discussed through the interviews to clarify patients’ reflections on healthcare and recovery. Photo-interviews disclosed the process of remembering as one of transference between different representations. By responding to photographs, patients were indicating that the physical setting was integrally linked to recovery through a “coexistence” of body and ward.19 20 In our own work we have used photographs as ends in themselves, illustrating and defining different workspace settings in general practice and community pharmacy, depicting professional practice and how it is enacted in different environments and revealing professional self-identity. We have also used photographs to challenge other researchers to move beyond the more conventional reliance on single-source data that concentrates exclusively on the spoken or written word. This is in recognition of the fact that textual expression alone can offer only a partial insight into human experience and that by using photographs we can understand better how participants see, feel, think and memorise experience.1 2 3 4
Like the photograph, biography offers a departure from the more traditional, qualitative data collection methods. Biography gives insight into language in use and indicates how we “word the world”.21 Biography may also lead to personal revelation and offers research participants a forum for telling of their lives through the recreation of the lived world, without direct influence from the researcher. Traditionally, biography has helped formulate hypotheses in research, based on the notion that biography, in and of itself, lacks reliability. However, according to Hatch and Wisniewski, biography also provides us with a range of alternative notions of reliability, including “adequacy, aesthetic finality, accessibility, authenticity, credibility, explanatory power, persuasiveness, coherence, plausibility, trustworthiness, epistemological validity and versimilitude” (pp128–9).22
Biography within a health research context can clarify how individuals give meaning to health and illness, instilling social “realism” into data collection.23 This can include object-oriented biography, widely recognised by healthcare researchers as allowing participants to situate events within a meaningful and socially significant frame of reference, where human agency is accomplished with the support of non-human agency. In their range of forms—including oral testimony, written text, auto-biography and the examination of personal artefacts, such as diaries, letters and memoirs—subject-centred and object-orientated biographies can be analysed both as “stand-alone” products and as grouped data—“intertextually”. Intertextual examination (including the synthesis of biographical and photographic data sources) explores how texts respond to, refer to, transform and are transformed by other data, and how the range of representations of the social world relate to one another:
We understand the social world through the lens of prior representation, because whenever something is invoked which happened somewhere else, or in some other time, or to someone else, then representation is being utilised. (p3)24
Consequently, intertextual examination makes links between datasets based on the manner in which one dataset triggers, invokes and eventually clarifies understanding of the possible representations of the social worlds. Intertextual analysis can assist the researcher in considering the impact of different methods on each other and, in combination, can reinforce each dataset’s discrete set of results.
To reiterate, the aims of this study were twofold: to explore the implications of the new pharmacy contract on professional and pharmacy service delivery and to further validate a novel, qualitative, mixed-methods approach within health services research.
Sample, recruitment and study brief
The Swansea and South West Wales local research ethics committee confirmed that ethics approval would not be required for this study, as community pharmacists are not NHS employees. However, to uphold good research practice we submitted the study brief to the joint scientific review board at the School of Medicine, Swansea University. Initial meetings were held with key pharmacy stakeholders. These included members of a large pharmaceutical company, the UK National Pharmacy Association and the Royal Pharmaceutical Society of Great Britain and representatives of a national pharmacy retail chain. The meetings gave support to the study and helped identify an appropriate sample group in preparation for recruitment.
A list of 61 community pharmacies within the greater Swansea region was obtained from the Swansea local health board. Pharmacies within the UK fall into one of three categories: independent pharmacies or small local chains (“independents”), national dedicated chains of pharmacies where the primary business is pharmacy (“dedicated”) and pharmacies located within large national supermarket chains where pharmacy does not represent the primary business (“multiples”). To achieve a target sample representative of the three categories, with at least three participants from each category, pharmacists from each category were contacted by letter in batches of six until the study cohort was achieved. All potential recruits received an information pack with the study letter explaining that participation would entail writing a two-page biography about their workspace, taking at least five digital photographs of their workspace and optional involvement in a feedback consultation workshop towards the end of the study. Our 2007 study of general practice workspace and practice indicated that the data collection brief should be broad, for too much prescription, such as predefined workspaces or the style of biographical writing, can lead to restrictive practices.2 Rose has endorsed this view, arguing that there should be as little researcher influence as possible.21 Consequently, the only requirement of participants in this study was to avoid involving, wherever possible, identifiable patients and professionals during data collection.
The final cohort exceeded our hopes and comprised 16 participants: five pharmacists from independent pharmacies, five from dedicated pharmacies and six from multiples (having achieved the sample, we included an additional pharmacist working in a multiple). The study researcher liaised with all participants, coordinated data collection and provided participants with digital cameras and writing paper, which were collected back from them a fortnight later. Participants also received a thank-you gift as recognition of their time and effort in supporting the study.
Representatives from all three groups of pharmacies (independent, dedicated and multiples) as well as stakeholders were invited for a follow-up feedback consultation workshop at the end of data collection. Two pharmacists from each group attended, as well as one stakeholder who provided advice throughout the project. The workshop lasted 2½ hours and was tape recorded. The team presented data from the study and explored participants’ responses to the team’s initial findings, to the experiences of those involved in data collection and to the data collection technique itself. Participants reflected at length on the findings and the experiences of those involved in the research process and there was extensive dialogue about the immense value of in-depth work of this nature in the field of community pharmacy research.
Sixteen complete bio-photographic datasets were returned. All data were retrieved and downloaded. Data were analysed by a multidisciplinary research team comprising a health researcher with expertise in qualitative research methods (FR), a human geographer (MD) with expertise in qualitative methodology and a PhD student in health psychology (GJ). Datasets were various, with people writing biographies ranging from one to four pages and taking between five and 25 photographs. While this wide a range of responses can be challenging to analyse, the brief had stipulated “no less than five photographs” with no upper limit and “not less than two-pages of text” with no upper limit, indicating that the team recognised the need to give participants flexibility in their response. We suggest that the variety of length of responses does not have an ultimate effect on interpretation of this kind of dataset. As with many qualitative studies, the team must work with what they have, considering variation to be important for what it says about people’s ability and willingness to respond to a brief and provide personal, in-depth information. In the case of both extensive and limited datasets, the team considered all aspects of the data equally, and discussed images separately, as individual, discrete units, as well as complete bodies of work. Data were analysed independently to encourage personal reflection and understanding, and then intertextual links within the data were considered. Individual analysis was followed by extensive group work over a 6-month period that led to mutual consensus between the analysts on the prevalent themes and data contexts. Having used these methods in other studies, we foresaw some of the challenges that might arise, such as the manipulation and clarification of different data types at one and the same time (bio-photographic data), while working towards a position of enhanced understanding. We considered how the community pharmacy setting helped contextualise the data and situated the world of the objects, spaces and people within a broader social, historical and institutional context. We spent time discussing the relationship between biography and photography, while being careful to give textual and photographic data equal weight. This discussion was supported by the intertextual framework, which specified that the researchers must uphold consistency and integrity during the complete process of clarification. In particular, the different data types highlighted how spaces, objects and people impacted on everyday working practices and pharmacists’ sense of self. Biographical data were also subjected to a discrete thematic analysis to distil data, through a summarised overview of each biography and important quotations, down to their essential characteristics. This helped capture the fundamental meaning or main significance of each biography while uncovering thematic aspects, using team members' reflective views to provide a richer understanding. It was a clear opportunity for the group to work together as an important aspect of analysis. Group work encourages debate about the relationship between parts and wholes of texts and images.
Photographic data were subjected to their own discrete analysis though visual techniques that built on our previous research.1 2 3 4 The team used a predefined schematic framework that took account of visual content and context, but also of object clustering and positioning, the “affect” of data (the feelings to which the photographs gave rise), the frequency of spatial presentation, objects’ functioning and what the photographs revealed about professionals who were working within different settings. The photographs were considered for the different social and professional practices they displayed and how settings reflected group working and individual working practices. Data findings from all datasets were synthesised at the end of group work to create a complete picture. The transcript of the feedback consultation workshop was analysed using well-validated, common procedures for the analysis of thematic content.25 26 27 The team examined key themes and categories in the data, which were grouped, refined and considered in relation to outputs from both the photographic and biographical data sets.
Findings from the bio-photographic analyses and the subsequent reflective consultation session are presented in terms of the major issues arising in relation to workspace, practice and patient–professional relations in line with the study aims and objectives. Findings highlight the challenges that pharmacists have faced since the NHS contract was introduced, through:
the inadequacy of space for practice in the context of policy requirements;
the conflict between the delegation of tasks and personal responsibility, in the face of a new litigious culture, with increasingly strict legal requirements regarding pharmaceutical products and their packaging and presentation to the consumer; and
the “double alienation” of pharmacists, from both consultative and technical roles, as a result of the new demands of care provision and conflict over devolved responsibility for some aspects of community healthcare.
Inadequacy of space for practice
While dispensaries differ in size, layout and location across pharmacy types, there is a clear perception among community pharmacists of a gap between independent, dedicated and multiple pharmacies with regard to how change has been experienced. Pharmacists working in large multiples are, in general, perceived as more satisfied with the new arrangements, describing refurbishments that are sympathetically matched to their new consultative and diagnostic roles as well as to related functions of dispensing and sales. Pharmacists working in independent and dedicated pharmacies, on the other hand, describe having neither sufficient space nor sufficient funds to manage the changes effectively, with many describing workspace as cramped because of the need to accommodate a host of new activities. With greater limitations on physical space, dispensing has become a more stressful activity:
The physical dimensions of the work space are not large and therefore the number of staff in this relatively small area can create a feeling of claustrophobia! (P1, independent)
Work can accumulate for checking on an already crowded work bench. (P4, dedicated)
In spite of the new consultation rooms, changes to workspace appear to have affected pharmacists’ ability to offer customers adequate privacy, both in informal settings and during the more formal consultation in the booth:
I often have to ask people (politely) to move away so I can have some privacy with this patient. (P3, dedicated)
The consultation room is quite small, and should have been made much larger in my opinion. It can feel quite intimidating inside if trying to talk to a patient. If the patient is claustrophobic it is very small. (P2, independent)
The inappropriate location of some pharmacies that have to share space, such as in the large stores, also affects pharmacists’ sense of self-worth and professionalism:
The pharmacy is located in the back corner of the store, which is generally standard practice for most pharmacies. For profitability and security reasons that is understandable however as a professional I am left feeling pushed away in the corner. (P16, multiple)
During the feedback consultation session with pharmacists and pharmacy stakeholders, the relationship between space and dispensing as a central function of the pharmacist’s role was discussed in detail. Participants described loss of autonomy and a growing feeling of demoralisation, resulting in part from a tendency to move away from old practices such as individual compounding and sorting of medication—which have now become almost obsolete activities. There are new expectations for medication packaging, dictated by legal requirements that bear little relationship to the modern interior design of the pharmacy, which have led to an imbalance between the needs of industry and the needs of the pharmacist. Many participants expressed concern that the new pharmacy space was not fit for purpose. This was evident in both the workshop transcript and photographs from pharmacists’ datasets (see below and fig 1). The image in the figure indicates the very cluttered nature of the space, the manner in which items spill over from shelf to shelf and the lack of additional storage room. The photograph also concentrates on the confined nature of the space and indicates that pharmacists find themselves functioning with little space for manoeuvre:
Even the refits which are going in today, this week, are not designed for modern pharmacies. (P2, independent)
They were never designed for different storage requirements of the modern pharmacist. (P2, workshop participant)
The old design layouts are inadequate for current regulations of dispensing processes, which require more space for the same amount of medication. Whereas before we used to have a pot like that [gestures the size of a small tub] with 500 in it, we’ve now got boxes that will fill up that space with 500 because everything has gone to packs of 28. So whereas you could have a small dispensary and have your full range of stock, now you have got to have a warehouse to have the same amount of stock. (P3, workshop participant)
As compounders we have become redundant. (P4, workshop participant)
As we have mentioned previously,4 community pharmacists see their major role as dispensers of medication or expert technicians, with efficient, orderly, controlled spaces key to the smooth running of the pharmacy:
As individuals we are a controlling breed. (P2, workshop participant)
It would appear from these biographical and photographic accounts that anything that impedes the central function of the pharmacist or upsets the balance between dispensing and other activities can influence the pharmacist’s sense of wellbeing:
We have to cope by keeping everything as tidy as possible. (P7, dedicated)
I do believe that the manner of organising space is what affects my capacity to offer excellent service. If my space is clean, tidy, clutter free and organised, I feel calm, in control and professional. (P9, multiple)
Tidiness to me breeds economy and profitability, as well as looking professional and imparting a more organised less stressful environment. (P15, independent)
The proportion of time dedicated to the different tasks—dispensing, sales and consultation—is described as out of kilter with the working space available. This undermines the pharmacist’s ability to respond appropriately and professionally to patient requests and creates conflict between retail and healthcare roles. Being observed to be rushed, while attempting to multitask, also affects the pharmacist’s professional image, giving customers a misguided impression of their duties and responsibilities:
I very much liken my working day to being a ping-pong ball, bouncing between the different areas of the pharmacy whilst responding to different patient requests (P1, independent)
Increasing demands for advice by patients (P6, dedicated)
Some customers wish to use pharmacy counters and pharmacists to pay, and beat queues at other tills (P13, multiple)
This is exacerbated by ever-increasing public demands that have led pharmacists to describe patients as a distraction—something to escape from and a diversion from the major tasks at hand. Pharmacists attempt to direct or moderate customer questions or unforeseen interruptions through actions and body language, such as not wishing to look customers in the eye and hoping to appear continuously occupied. Thus the open-plan setting of many of the newly refurbished dedicated and multiple pharmacies, designed to facilitate greater transparency of working and greater visibility, has increased rather than decreased their anxiety:
We appreciated the old layout … where you could dispense without interruptions from customers asking for prescriptions or other store related questions. (P5, multiple)
While pharmacists recognise the need for good patient access (“I can see around the shop … allows open access into the sales area at all times, patients can have easier access to the pharmacist and vice versa” (P11, independent)), many point to pharmacy access that has not been well thought through and pharmacy layout that gives a bad impression and causes major interruption to work:
The prescription reception area is too cramped and can only accommodate one person at a time, thus leading to a build up of people around that area. (P5, dedicated)
We have large thick walls between dispensary and chemist counter with gaps for supervision and observing customers. This can be quite distracting to the dispensing process, which needs to be meticulous. Also phone calls could be potentially overheard. I don’t think a shop is the ideal place to run a dispensary especially with the new extended roles coming on stream. (P6, dedicated)
For the best part of a year I have felt uncomfortable with the fact that the first words that spring to mind when I walk in through the door are not “professional” or “quality” but probably “car boot sale”! (P4, dedicated)
Pharmacists emphasise the impracticality of shelving units, the problems of maintaining tidiness and the lack of practical workspace.
This theme has highlighted the inadequacy of space for practice as the new pharmacy contract takes effect, with patients presenting with unrealistic expectations of the pharmacist’s role.5 6 Patients expect pharmacists to manage multiple tasks, such as dispensing medication, consulting about minor ailments and conducting retail transactions, and want pharmacists to contend immediately with their needs—expectations that pharmacists describe as unreasonable. Moreover, the new contract has placed pharmacists under extreme pressure leading to what is seen to be an identity crisis within the profession. This is expressed in terms of the dilemma of delegation versus litigation and the double alienation from consultation, diagnostic and technical professional roles. These will be considered in the next two sections.
The conflict between the delegation of tasks and personal responsibility
Delegating tasks and building good relationships with pharmacy and sales staff is increasingly important at this stage in professional pharmacy development, where work has become more diverse and its volume has increased. However, as one of the workshop participants pointed out, pharmacists are “not getting to grips with delegating to staff … the focus isn’t there” (P3, workshop participant). This has resulted in a conflicted workforce, torn between delegating to others and taking personal responsibility for all eventualities. While a few biographies do point to the importance of team working and the success of delegation (“as a team we provide a friendly and efficient service” (P7, dedicated), “the dispensary is a busy & pressured environment &, in order to cope with the work load, I usually work with 3 or 4 technicians” (P1, independent)), most do not mention delegation, while pharmacists voice their concerns about an ever-increasing culture of litigation. The conflict is exacerbated by the myriad targets and government-driven quotas that must be achieved if pharmacists are to comply with the new pharmacy regulations and allotted medicine use reviews. Pharmacists describe a more litigious society (“if it’s not right someone can sue the pants off you” (P3, workshop participant)), with members of the public wishing for service on demand, unable to accept the growing pressure this is putting on pharmacists (“40 years ago someone would come in for a prescription and they would wait an hour long while you made it … now if you haven’t got it within three minutes …” (P5, workshop participant)). Pharmacists emphasise that they have been trained in good ethical principles that give priority to patient safety:
We control what goes on, we don’t delegate … there is this thinking around supervision, responsibility and so on, and it has been impressed on us to such a degree, that there is a fear that you dare not move away … The major issues are delegation, can we delegate and when we delegate who are we delegating to …? This is an all consuming process that goes on within a dispensary which we can’t stop, we do not want to stop it, we want to attend to it, we want to do it safely, accurately and speedily, that at the moment is our all consuming attention. It cannot go on without me. (P1, independent)
Personal responsibility and accountability appear to go hand in hand, with modern-day pharmacies being controlled and controlling environments. Pharmacists are well aware of the strict monitoring mechanisms in place to ensure patient safety at all times, which has an impact on the determination of space. They are also aware of the National Safety Agency’s documents that describe the physical layout of pharmacies with regard to medicine packaging and floor design, and of the need for good patient–professional communication to reduce medicine hoarding and medicine wastage.28 Pharmacists describe the pressure that has been put upon them to write standard operating procedures for each pharmacy (“We have entered into this crazy world over the last few years of standard operating procedures” (P2, workshop participant)) and to ensure that there are rules and regulations in place to support these procedures. However, one workshop participant argued for greater uniformity of process, so that rules can be applied to any and all pharmacies around the country:
That might make it a lot easier for the pharmacist in some way to delegate the work, because here are the rules, they are uniform, they apply anywhere, in any pharmacy. (P2, workshop participant)
The double alienation of the pharmacist
Pharmacists take great pride in their work:
I take great pride in pharmacy as a profession and accordingly myself as a professional, my workplace setting should reflect and contribute to my professional self-identity. (P16, multiple)
Pride centres not only on a positive sense of self, but also on the belief in good professional practice—one’s ability to dispense efficiently and effectively and have good technical skills. The dispensary is seen to be the “nerve centre” of the pharmacy (P1, independent). Pride in professional identity can be likened to the “dignity of labour” and the importance of doing “good work”, taking personal responsibility for the objects of the trade, where the essential dignity of work lies. Double alienation occurs when, as in the case of many of the pharmacists in this study, pharmacists experience conflict between their roles. In this case it is a conflict between their role as a health professional (to provide enhanced services stipulated in the new pharmacy contract, such as consultation and advice) and their role as an expert technician (dispensing the correct and appropriate amount of medication swiftly and efficiently—the pinnacle of professional activity). Double alienation results from contextual, social or organisational requirements of the work setting, where settings at best protect and enhance professional self-identity and at worst lead to a heightened sense of personal alienation. Frustration at the way in which the setting impinges negatively on professional practice is particularly evident in the following statement:
I am seen to many people as another shop assistant, rather than a well-educated professional (no disrespect intended). It is very belittling as a pharmacist to be doing the role of a salesperson more often than not. (P9, multiple)
This concept of double alienation is reflected in the choice of images from one study participant, which highlighted the dominance of the dispensary in the pharmacist’s eyes, but at the same time, the over-abundance of non-health-related items at counter and shop front (from perfume to hairspray, from ornaments to glass figurines). Figure 2 illustrates this clearly. During the feedback workshop, participants referred to these images in terms of the ambivalent nature of the pharmacist’s role at present, torn between dispensing and retail sales. Participants noted that this has had a negative effect on their self-esteem and has affected their ability to find satisfaction with their professional position. Participants discussed the notion of being a jack-of-all-trades, torn between diametrically opposed aspects of their job and viewed by the public as both salespeople and pharmacists. This has had a disempowering effect, leading to a certain degree of disillusionment about their ability to be fully autonomous, recognised for their professional stance and proud of their ability to dispense medication.
In fig 3, photographs provided by an independent pharmacist indicate the proximity between the dispensary and the shop floor, with non-health-related products clearly in evidence. The dispensary and shop floor are separated only by a small counter. In many multiples, there was much less over-spill of items than the figure illustrates, but nevertheless, particularly in smaller independent and dedicated pharmacies, a mingling of objects was frequent. In response to this issue, participants at the feedback workshop discussed the role of the shop counter as a space of “go-between”, between one aspect of the pharmacist’s work—the dispensing—and the other aspect of their work—their ability to deal with sales and consultation issues. Participants described a range of problems around dealing with members of the public who had private concerns they wished to air, emphasising in particular the difficulties of constant interruptions from other members of the public. Participants considered the need for greater public and professional privacy but were keen to emphasise the importance of sustaining informal consultation, alongside the more formal consultation that takes place within the consultation booth.
The bio-photographic methodological approach supported by intertextual analysis was found to be highly effective by participants (“very productive” (P1, workshop participant)), for its ability to ensure a thorough reflection on workspace, through data sets both complementary and discrete. It is important to note that participants were not asked or expected to rate or assess their space using the bio-photographic material, for example, rating space according to standards of practice. In addition, participants were discouraged from working too prescriptively in their interpretation of the data, with a brief that avoided leading them to an interpretive stance too quickly. Nevertheless, participants found that the data stimulated thought on the impact of space on practice, the difference between space as viewed and space as described, and the different lines of communication. Participants also considered what the data revealed in terms of the practices they alluded to and in relation to their own working practices, including the ethical standards and principles to which they adhered. The approach enabled community pharmacists to provide thoughtful feedback on their workspace and they described how they had become fascinated with the method and how it drew them into the study:
I think it is very interesting what has come out. (P4, workshop participant)
I was quite sceptical at first, when I thought you have got very narrow, a relatively small group of people, very broadly talking about your space, and I thought I am not sure what would come out of it, but I was very impressed. (P2, workshop participant)
Participants also emphasised an empowering element of data capture that allowed them to think without researcher involvement and so better consider their workspace in the light of practice (“If it had been more directed, maybe you wouldn’t have got so much information” (P3, workshop participant)). Finally they suggested that the research process had enabled the team to analyse the data and get to the nub of the issues with which pharmacists were currently grappling (“You have managed to identify in this study what it has taken the profession the last 20 years to understand” (P1, workshop participant)).
This paper has explored community pharmacists’ responses to change in practice stimulated by the introduction of the new NHS pharmacy contract revealed through a novel methodological technique. The paper has highlighted the inadequacy of current workspace arrangements for professionals, providing examples of a conflicted workforce, alienated from both positions of consultation and technical expert. The paper has illuminated pharmacists’ concerns about delegating to others and at the same time being accountable for all aspects of practice whist trying to cater to an increasingly demanding public and a target-driven policy agenda. The paper presents a professional workforce that, in spite of these concerns, takes great pride in its professionalism, wishing to communicate with the public and staff and to be seen as supportive in effective environments. The study has disclosed these findings through a rich data-capture technique that provides both biographical and photographic examples of pharmacists’ workspaces and practice, a technique that has been validated through positive feedback with study participants and pharmacy stakeholders. While little research to date has considered the impact of the new NHS contract on patient-professional communication and the relationship between workspace and practice, this study raises a number of pressing questions that now need to be taken forward, which we posit in conclusion:
What can be done to ensure a better fit between pharmacy workspace, particularly the dispensary and pharmacy practice, to bring pharmacies more in line with modern-day dispensing?
How should the new regulations concerning packaging of medication and the legal requirements governing pharmacy practice be taken into account when designing new pharmacy spaces?
How can we overcome pharmacists’ “identity crisis” revealed within an environment where new regulations expand the set of demands put upon them?
How can the traditional role of the pharmacist, embodied in the dispensing and compounding of medication, be married to the new role that now requires greater patient consultation?
How can a balance be achieved between the demands of retail, dispensing and consultation, through better delegation of tasks, as one unified construct of professional service delivery, in UK community pharmacy today?
Answers to these questions require in-depth understanding of the complexities that surround current community pharmacy practice, and we would recommend further qualitative investigation with a wider population base taking into account legal requirements, skill mix and local population variation, to include nuance in population perspectives.
This study has shown that pharmacists are clearly uncomfortable about delegating work to others and this has implications for pharmacy training and continuing professional development work. With greater awareness, pharmacy education planners and providers can work towards developing pharmacy training to instil appropriate competencies in newly qualified pharmacists, the pharmacy leaders of the future.29
Working towards a pharmacy environment that evokes trustworthiness—where information is provided by informed, patient-friendly professionals—may lead to greater dialogue between stakeholders towards a reduction in unnecessary prescribing and unwanted medication collection.28 7 With sufficient resources and staffing, and greater clarity over role distribution, it may also lead to better staff recruitment and retention, greater job satisfaction, reduction in staff stress and enhanced staff health and wellbeing. These changes would help address the shortcomings of the current situation, providing a basis for pharmacists to feel more professionally integrated within their role, with positive consequences for community service provision.
We would like to thank all study participants for their thoughtful reflections and helpful insights. We would also like to acknowledge the support of AstraZeneca who, without influencing the research agenda, funded the research and educational programme within which this study fell. Finally we would like to acknowledge the excellent administrative support of Ms Vicky Davies.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
In this study the terms customer, patient, public and client are used interchangeably.
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