Journal of Health Organization and Management Patient-centred professionalism in pharmacy: values and behaviours Rebecca Elvey Karen Hassell Penny Lewis Ellen Schafheutle Sarah Willis Stephen Harrison

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Patient-centred professionalism in pharmacy: values and behaviours Rebecca Elvey, Karen Hassell, Penny Lewis, Ellen Schafheutle and Sarah Willis Manchester Pharmacy School, University of Manchester, Manchester, UK, and

Professionalism in pharmacy

413 Received 3 September 2013 Revised 9 April 2014 Accepted 21 May 2014

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Stephen Harrison School of Community-Based Medicine, University of Manchester, Manchester, UK Abstract Purpose – Research on patient-centred professionalism in pharmacy is scarce compared with other health professions and in particular with pharmacists early in their careers. The purpose of this paper is to explore patient-centred professionalism in early career pharmacists and to describe reported behaviours. Design/methodology/approach – This study explored patient-centred professional values and reported behaviours, taking a qualitative approach. In all, 53 early-career pharmacists, pharmacy tutors and pharmacy support staff, practising in community and hospital pharmacy in England took part; the concept of patient-centred professionalism was explored through focus group interviews and the critical incident technique was used to elicit real-life examples of professionalism in practice. Findings – Triangulation of the data revealed three constructs of pharmacy patient-centred professionalism: being professionally competent, having ethical values and being a good communicator. Research limitations/implications – It is not known whether our participants’ perspectives reflect those of all pharmacists in the early stages of their careers. The data provide meaning for the concept of patient-centred professionalism. The work could be extended by developing a framework for wider application. Patient-centred professionalism in pharmacy needs further investigation from the patient perspective. Practical implications – The findings have implications for pharmacy practice and education, particularly around increased interaction with patients. Social implications – The data contribute to a topic of importance to patients and in relation to UK health policy, which allocates more directly clinical roles to pharmacists, which go beyond the dispensing and supply of medicines. Originality/value – The methods included a novel application of the critical incident technique, which generated empirical evidence on a previously under-researched topic. Keywords Values, Behaviours, Professionalism, Patient-centred, Pharmacists, Pharmacy Paper type Research paper

Introduction The aim of this paper is to explore patient-centred professionalism in early-career pharmacists and to describe reported behaviours. First, we present existing understandings of patient-centred professionalism in relation to medicine, nursing and pharmacy. We then This work was undertaken by the authors who received funding from the Pharmacy Practice Research Trust. The views expressed in the publication are those of the authors and not necessarily those of the Pharmacy Practice Research Trust. The authors thank the pharmacists and support staff who took part in interviews.

Journal of Health Organization and Management Vol. 29 No. 3, 2015 pp. 413-430 © Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-04-2014-0068

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present our methods, which generated data from the perspectives of early career pharmacists, those who work with and train them. We analyse patient-centred professionalism in pharmacy in terms of the qualities and attributes that constitute the overall concept of patient-centred professionalism in pharmacy and compare and contrast our findings with existing understandings of patient-centred professionalism. Interest in healthcare professionalism has grown in recent years, both in Great Britain (GB) and the USA. There are many reasons for this, including changes to healthcare governance arrangements, tighter monitoring and evaluation of the performance of healthcare professionals and high profile medical scandals. There have also been increasing challenges to traditional medical dominance and autonomy, greater consumer influence and opportunities for patients to access more information about their own health, illnesses and healthcare. (Harrison and McDonald, 2008; Roland et al., 2011) Current forces in healthcare range from the need to respond to the most serious failures, where patients have suffered severe neglect and harm (The Stationery Office, 2013), to the aspirations of those working to achieve the best possible healthcare, in which patients are fully involved and supported (The Picker Institute, 2012). However, while there is much interest in healthcare professionalism, the concept and what it means in practice are not always clearly defined or understood. The majority of published material on healthcare professionalism relates to medicine. Medical professionalism was traditionally conceptualised using a “trait” approach, whereby professionalism was defined via lists of traits, typically: theoretical knowledge obtained in a professional training school; application of this knowledge in practice; working for the greater good; altruism; remuneration on a fee-for-service basis and self-regulation and autonomy (Carr-Saunders and Wilson, 1933; Flexner, 1910). More critical analyses of professionalism focused on processes and power relations and emphasised concepts such as “social closure”, that is, restricting entry to a profession and having a “monopoly of practice” over an area of work (Macdonald, 1995). Since the 1980s, interest in redefining medical professionalism increased and in the 1990s, the idea of a “new professionalism” (Irvine, 1999) emerged. Much effort has been focused on redefining medical professionalism, with lists of characteristics considered desirable for practitioners to exhibit being put forward by academic researchers and professional bodies. In what is essentially a return to a “trait theory” approach to how a profession is defined, these characteristics tend to focus on professional knowledge (Epstein and Hundert, 2002) and “noncognitive” (Arnold and Stern, 2006) attributes such as communication skills. Service for the public good has always been integral to trait theory approaches, but definitions of professionalism in the medical literature increasingly and explicitly focus on patients and the phrase “patient-centred medical professionalism” is now commonly found in the professionalism literature (Askham and Chisholm, 2006). Whilst patient-centred professionalism seems to be an emerging concept and understandings may continue to develop, several themes recur throughout the existing medical literature, particularly maintaining (American Board of Internal Medicine (ABIM), 1995) and protecting (Rosen and Dewar, 2004) patient interests and sharing decision making with them, etc. Jones and Green (2006) in their recent research with early career general practitioners suggest that the construct of professionalism for doctors is shifting. Medical professional relationships are newly characterised as democratic not hierarchical, and relationships with patients are characterised as patient-centred not paternalistic. Patient-centred care and professionalism have also received considerable attention in the nursing literature; nurses’ understandings emphasise patient participation and involvement, the relationship

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between the patient and the healthcare professional and the importance of nurses’ values and communication skills (Hutchings et al., 2010; Kitson et al., 2012). Professionalism in pharmacy Compared to medicine, the issue of professionalism in pharmacy has received less attention. Sociologists in the past defined pharmacy as an incomplete or marginal profession, largely because pharmacists were perceived as being too closely associated with commerce, or because the profession was thought to lack occupational cohesiveness and autonomy (Denzin and Mettlin, 1968). Despite evidence that commercial and professional agendas need not necessarily lead to conflict (Holloway et al., 1986; Kronus, 1975), many argue still that the shopkeeper image of the retail pharmacist holds back pharmacy’s professional status (Hughes and McCann, 2003). More recent work challenges these functionalist perspectives of the pharmacy profession and presents a more positive view of the status of the profession by seeing pharmacists as medicines experts who imbue medicines with social significance, working to “transform” natural objects (drugs) into more valued social objects (medicines) (Dingwall and Wilson, 1995; Harding and Taylor, 1997). While this view has some credence and has gained momentum, it is nevertheless argued still that pharmacists do not have a monopoly on this transformative or “social enhancement” element of their work, particularly because of challenges to their expertise from general practitioners (Hughes and McCann, 2003) and consumers (Hibbert et al., 2002) resulting in their professional status still being contested. Having already obtained “social closure” some time ago, the “professionalization” strategy (i.e. the process of becoming a profession) for pharmacy has for the most part focused instead on increasing pharmacists’ skills base and raising their profile with patients, physicians and other social groups. Core to the “reprofessionalisation” movement in pharmacy, has been the concept of “pharmaceutical care” (Hepler and Strand, 1990). This paradigm shift encourages pharmacists to acquire a “social mandate to ensure the safe and effective drug therapy of the individual patient” and to take responsibility for related patient outcomes. Thus, this pharmacy re-professionalism is based on delivering highly skilled care and advice around the use and management of medicines, in a manner that puts patients first. Current UK health policy outlines directly clinical roles for pharmacists, which go beyond dispensing and supplying medicines (Department of Health, 2008) (see also Appendix). Published research in pharmacy professionalism generally, and into patient-centred pharmacy professionalism specifically, is currently scarce. Research from the USA found that while professionalism is often alluded to by university departments and professional bodies, the elements that it was assumed to consist of were rarely explicitly defined (Hammer, 2000). Subsequent work undertaken in the USA to define pharmacy professionalism has emphasised attributes or characteristics such as altruism, honesty and respect for others (Hammer et al., 2003; Rapport et al., 2010). This recent work on pharmacy professionalism has followed a similar approach to that taken in medicine, that is, devising lists of traits, and includes many of the same attributes. Recent work from the UK has found similar understandings of pharmacy professionalism amongst university students and staff, with communicating clearly and respectfully and attributes such as altruism, accountability, integrity and communication skills all considered important (Schafheutle et al., 2012). Further research into understandings of patient centred-professionalism, with practising pharmacists and support staff, has emphasised

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competence, ethical practice and relationships with patients based on trust and respect (Hutchings et al., 2010; Rapport et al., 2010). The concept of patient-centred professionalism is still emerging and developing in pharmacy, as it is in other health professions. Although some research has investigated how patient-centred professionalism is understood by practising pharmacists, the concept and what it means in practice, has not been fully explored. This particularly applies to pharmacists early in their careers, despite these early years being a critical time for professional development. Furthermore, previous studies have tended to investigate patient-centred professionalism in the abstract, without ascertaining how professionalism manifests as actual behaviours. To address some of these gaps, we conducted a study designed to generate a broad range of views on pharmacy patient-centred professionalism and to explore the topic from multiple perspectives. (The overall study findings are reported elsewhere (Elvey et al., 2011)). The aim of this paper is to explore patient-centred professionalism in early career pharmacists and to describe reported behaviours. Methods The approach to the topic under investigation was qualitative, with focus groups used to generate data. As we were interested in exploring the concept of patient-centred professionalism for early career pharmacists and also in how professional attitudes manifest as actual behaviours, we judged that it would be important to investigate the topic from multiple perspectives, with both early career pharmacists themselves, and those who train, develop and observe them in practice. Accordingly, our sampling strategy was purposive and we sampled three type of participant from the two main patient-facing sectors of pharmacy practice (see Appendix for details of pharmacy in GB); early career pharmacists, preregistration tutors and pharmacy support staff, working in community and hospital pharmacy. The sampling criterion for group composition aimed to maximise homogeneity in terms of role played in the pharmacy team, with participants sampled according to work role in order to establish some common ground between them that would act as “social glue” (Lehoux et al., 2006) during discussions about professionalism. The study took place in northwest England. Each of the three different types of participant was approached to take part in the study using different methods: All pharmacists who had registered in northwest England within the last two years were identified using the Register of Pharmacists and invited to attend a focus group. To recruit pre-registration tutors, an e-mail invitation was sent via the regional tutor network, invitations were also distributed at local and regional training events. To recruit support staff, all registered Pharmacy Technicians in northwest England were identified, using the Register of Pharmacy Technicians and invited to attend a focus group. Snowball sampling was also used, to gain access to other types of pharmacy support staff, such as dispensers and healthcare assistants, for whom no register exists. In addition, a lay user of pharmacy services, was recruited to the study. The role of the lay pharmacy services user was to give a patient’s view on our findings and to assist with validation of our data; he participated in a discussion with the research team where he was asked about his views on pharmacy professionalism, and also shown some extracts from focus group transcripts that were used as the basis for future discussion. All participants were given information sheets and provided written consent. The study was reviewed by the North West Research Ethics committee and approval was confirmed on 22 December 2009.

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In terms of data collection, focus group topic guides were designed to facilitate an exploration with participants of how they conceptualised and defined professionalism, at first in general terms, and then also in relation to patients. The opening question for each group was: “What does professionalism mean?”. Further prompting was then used to encourage participants to identify and articulate the elements they would include in a definition of patient-centred professionalism. As well as discussing professionalism as an abstract concept, the critical incident technique (CIT), which is used to generate data related to specific events (Flanagan, 1954), was employed. Our rationale for using the CIT was to move beyond discussion of abstract concepts and gain particular examples of behaviours which demonstrated elements of (un) professionalism being played out in practice. To generate the critical incidents, participants were asked to recall specific scenarios or behaviours, that they considered (un)professional. Other questions related to whether, and if so, how, professionalism differed between “early career” and more established pharmacists, and between pharmacy and other healthcare professions. When participants suggested professional attributes, or gave examples of behaviours, they were asked whether or how these might impact on patients. The interviews were audio-recorded, transcribed verbatim and then checked for accuracy. The computer software package NVivo was used to organise and manage the data. Data analysis followed the comparative approach, so categories were generated through reading the transcripts, from the data themselves and from the research questions. The “framework” technique was followed to structure the process of analysis. Framework has five stages: familiarisation, to gain an overview of the data set as a whole, its range and diversity, through immersion in the data, particularly by reading interview transcripts and notes;constructing a thematic framework, through a process of identifying the themes and concepts to which the data can be referenced; indexing, that is, applying the framework to the data; charting, whereby summarised versions of data are arranged thematically; mapping and interpretation, when the data are analysed in order to meet the objectives of the study, by reviewing the charts and notes, drawing comparisons and contrasts between accounts or perceptions (Gale et al., 2013; Ritchie and Spencer, 1993; Ward et al., 2013). The first stage – familiarisation – was achieved by two of the authors (R.E. and P.L.) being present at the data collection stage and through handwritten notes being made on salient points during the groups. These two members of the team also discussed the emerging themes after each group so that the process of identifying them could begin at this early stage. The more systematic familiarisation with the data was achieved by the research team reading the transcripts, and noting data that provided evidence to answer the research questions, as well as noting other salient points and themes that participants had mentioned. R.E. read all the transcripts and the other team members read a sample, salient concepts were discussed during several data analysis meetings The following two stages – the indexing and charting, were the most intertwined. A framework was developed, through an iterative process, whereby the data were fine coded and organised into categories, which were revised and refined as further indexing was undertaken. The data were arranged by participant type, to assist in comparison between groups. In this context, analysis sought to both make comparisons between focus groups as well as paying attention to individual voices: in fact, on analysing the data, it was interesting to note that there were clear areas where the participants were in agreement, and also others where there were intragroup differences of opinion.

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Results In total, 53 pharmacists and members of pharmacy support staff took part in the study. On two occasions, only one pharmacist arrived to take part in the focus group; on both occasions the participants agreed to take part in an individual interview so these were conducted in place of a focus group. (An early career hospital pharmacist, identifying key HP I and a community pharmacy pre-registration tutor, identifying key CT A) Table I gives details of each focus group. Analysis of the data revealed three major constructs around which the majority of the narratives centred: competence; ethical values and communication. The presentation of the findings below unpacks each of these in turn and shows the range of views expressed.

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Competence Participants in this study emphasised competence, that is, having the knowledge and skills to provide a high level of service to patients, as core to professionalism. “Having knowledge” or “being knowledgeable” were mentioned across all participant groups. Early career pharmacists emphasised the importance of having up to date knowledge to provide patients with reliable advice, and that being without it was simply unprofessional: CP F: […] knowledge obviously is vital and portraying the right advice all counts to being […] a professional. CP E: I think you have to be seen by the public as someone that they can trust so […] you’ve got to be like a good professional and give good advice.

The importance of patients being able to rely on the information or advice that pharmacists provide, was also expressed by tutors, who observed that patients seek out pharmacists in particular to consult, seeming to make a distinction between a pharmacist and other, non-pharmacist, staff: CT L: […] most patients […] come into a pharmacy and say, “Can I speak to the pharmacist?” and they may be seeing you as being the expert in pharmacy so as a professional they see you as the expert in your […] subject and have that expectation […] of you being different.

Focus group ID number 1 2 3 4

Table I. Focus groups and participants

Participant type

Number of participants

Early career community pharmacists Early career hospital pharmacists Early career hospital pharmacists Community pharmacy pre-registration tutors 5 Mixed pre-registration tutors 6 Hospital pharmacy pre-registration tutors 7 Community pharmacy support staff 8 Community pharmacy support staff 9 Hospital pharmacy support staff 10 Hospital pharmacy support staff Notes: C, community; H, hospital; P, pharmacist (early career); T,

Identifying key used in text

6 4 4 8

CP A-F HP A-D HP E-H CT B-I

4 6

CT J-L and HT A HT B-G

5 CS A-E 4 CS F-I 5 HS A-E 5 HS F-J tutor; S, support staff

CT J: I think that’s very true, you are the expert […]. HT A: I think it’s true.

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CT J: […] on the drugs (Focus group 5).

Whilst there was consensus that being knowledgeable was vital, tutors and support staff thought that professionalism also included recognising and knowing the limits of one’s knowledge, and taking action to seek further information when necessary: CS I: And also admitting if they don’t know something […]. CS G: Yes.

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CS I: […] saying they’ll do their best to actually find out […] (Focus group 8).

Accordingly, not recognising or admitting the boundaries of one’s knowledge or experience was considered unprofessional. A tutor provided a critical incident, when a pre-registration pharmacist, who had been keen to advise patients without seeking any help from other staff. When quizzed about a discussion with one client, it became apparent that he had given advice that was potentially dangerous. (The patient described symptoms suggesting anuria, a sign of kidney failure or obstruction, so required immediate medical attention). Furthermore, he had falsely claimed to be a (registered) pharmacist (this trainee did not go on to register as a pharmacist): When patients asked to speak to the pharmacist […] he used to say “Oh I’m a pharmacist, it’s alright” take them to one of our areas where you can’t hear so well what’s going on and [one day] this gentleman […] said he hadn’t urinated for 48 hours and what could he do? So one of the dispensary technicians who sort of overheard […] afterwards said […]“ […] what did you do?” […] [the trainee] said […]“I sold him some Aquaban® [a diuretic] and told him to drink lots of water” (CT C).

As well as providing reliable advice about medicines, the importance of supplying medicines with accuracy was raised. Pharmacists’ work involves a considerable amount of legal and clinical “checking” – for example, making checks of prescriptions in terms of their legality, as well as a clinical assessment of the appropriateness of the prescribed medicine and dose, and an accuracy check of the packaged and labelled medicines before they are given to a patient. In total, two community pharmacy tutors cited accuracy (when dispensing medicines) as a professional attribute. Early career pharmacists engaged in a small amount of talk about mistakes – they agreed that it was professional to admit to one’s mistakes, although one suggested pharmacists’ fear of the consequences of being known to have made a mistake could deter them from doing this. It is notable that no actual examples of their own mistakes were volunteered by the early career pharmacists. The sole example of a mistake made by an early career pharmacist was provided by a tutor describing the following critical incident: T_CP_10: […] I can give you an example […] just the other week (an early career pharmacist) at the end of the day he realised that he made up a Zineryt (antibacterial solution) and had forgotten to put a pad in so he went on his way home to take it round to the patient to fit the pad in […]. T_CP_12: Oh that’s good. T_CP_10: […] which was great and I think that was really professional of him to go there and say, “Listen I’ve made a little bit of a mistake” to be bold enough to be able to do that and to put the situation right […].

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In GB, pharmacy practice is governed by various laws and standards which relate to how medicines may be supplied and adhering to these was seen as central to professionalism by our participants. The “code of ethics” produced by the pharmacy regulatory body, standard operating procedures (SOPs) which are found in all pharmacies and set out how tasks (e.g. dispensing a prescription) must be carried out were mentioned repeatedly, as well as other organisational rules and regulations. Both early career pharmacists and pharmacy tutors spoke of using the code of ethics in particular to guide their practice, whereas support staff tended to mention SOPs and company rules. However, participants also suggested that in practice, situations could arise where following the rules might not meet the individual patient’s needs. In GB, most medicines are supplied on a “prescription only” basis. The usual process is for the patient to bring a prescription to a community pharmacy, and exchange this for their medicine, however, an “emergency supply” of a prescription-only medicine is legally permissible. The member of support staff quoted below described a critical incident, during which an early career pharmacist prioritised following rules rather than acting the patient’s best interest when a patient was unwell but did not have a prescription for the medicine: SS_CP_3: He was a newly qualified pharmacist. There’s following the rules and there’s breaking them completely but there has to be a bit of grey […] you have to judge every case differently. I had a chap come in for his nebuliser, waiting for a lung transplant, difficulty with his breathing and […] we didn’t have [the prescription] so the pharmacist wouldn’t let it go even though we’ve got other records […] so I didn’t want to leave this poor man struggling for breath at the counter so I got one of the other technicians to dispense it and I checked it myself […] and [the early carer pharmacist] said, “You do that but I’m having nowt to do with it”.

Early career pharmacists similarly acknowledged that rule-following “to the letter” may not always be desirable, particularly for the patient. Thus in some situations, while rules state that medicines should not be altered from the form in which they are supplied, for example as a tablet or a liquid, sometimes they are altered. An early career pharmacist described a case (a critical incident) where administering the medicine “as designed” was difficult: HP I: I’ve got [a patient] at the moment that’s refusing [to swallow tablets] […] At the moment we’re crushing a drug we probably shouldn’t crush […] because that’s the only way she’ll have it but she might die if she doesn’t have it, so […] she’s taken that risk on, the patient […] and the consultant’s taken that risk on […] And said “Yes, crush it,” […] deviating from a set of SOPs […]. Interviewer: Right and where does professionalism come in there? […]. HP I: […] you’ve got to weigh it up […] risk benefit and I think that’s a professional attribute to be able to […] weigh up a clinical situation like that […].

A further critical incident was described by another early career pharmacist, who recalled coming into the hospital during the night and preparing a high risk medicine usually prepared in an aseptic (sterile) dispensing area which was not open at the time. She believed this to be the right thing to do, for the patient, but was reprimanded the following day: HP F: […] it was a, it was Cytotoxic antibiotic […] I had to do it I think there was no other option, the patient’s condition was quite severe so […] I really didn’t think […] “Oh it can wait till the morning” […] it had to be done […] [because] it was a […] Cytotoxic I got told off in the morning for doing it but […] I wasn’t bothered whatsoever because I knew I did my job […].

Ethical values Most interviewees, when asked directly to characterise patient-centred professionalism, mentioned values and attitudes such as honesty, trustworthiness, commitment, integrity, compassion and being “patient-focussed”, essentially, being a “good” pharmacist, who put the patient first. Being “there” for patients when needed, doing more than the minimum, “going the extra mile” were used to characterise good pharmacists. Early career pharmacists in both sectors described working hard to ensure patients were supplied with their medicines, particularly during “out of hours” periods or when a medicine was not easily available:

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EC_CP_1: When you work really awkward shifts like a night shift or […] a Sunday and you get (someone who has) run out of medication (for example) a patient that’s on seven antiepileptic (drugs) […] to do an emergency supply I think that would be a professional act.

Early career hospital pharmacists often cover night shifts, during which they get called to the hospital to dispense medicines. In the critical incident presented below, the participant recalled a situation where she had initially refused the doctor’s request to go to the hospital, but later did so, and was struck by the severity of the patient’s condition: HP A: I got called at two or three in the morning from some doctors in A&E asking me to come in and dispense [an ointment] and at […] first I kind of said, “Well can you not just use some other paraffin ointment? […] it doesn’t sound urgent […] Try and find an alternative” […] I got another call about fifteen minutes later […] saying, “Look you really need to come in […] the patient suffers from Erythematous Psoriasis which can be life threatening and at the time […] newly qualified […] I didn’t know […] how serious it can be […] I went in and I got a couple of tubs [of ointment], dispensed them and left without seeing the patient […] I couldn’t get back to sleep […] because I felt […] infuriated […] the next day […] I saw the patient and she was very red everywhere and she was in quite severe pain […] I think next time […] I’ll just have to do it […] and just get over it”.

Putting patient needs before financial profits was raised in relation to community pharmacy. Pharmacies sell products and also receive a fee for each prescription item they dispense, but there was little discussion of this type of community pharmacy income, with a few early career pharmacists giving the example of contacting other pharmacies if an item was out of stock, so that the patient could obtain the medicine there (and miss out on the sale or dispensing fee if they ordered it and made the patient come back). However, pressure to provide certain services, in particular medicines use review (MUR)s, and to meet targets for the numbers provided, was singled out as a particular, threat to patient-centred professionalism by early career pharmacists and tutors alike. Hospital pharmacists who do not provide MURs perceived their community counterparts to be under pressure. The MUR is a service which involves the pharmacist reviewing a patient’s medicine regimen with the aim of ensuring patients get optimum benefit from their medicines. Pharmacies are paid with public (National Health Service) funds for these services. Early career community pharmacists reported discomfort amongst their peer group about the targets they were asked to work to: CPE: […] most [pharmacists] that I know want to put the patient first […] they get all these targets thrown at them […] it’s not what they want, they want to be patient-centred.

Community pharmacy tutors expressed similar concerns and felt that people earlier in their careers might find it more difficult to resist pressure to fulfil organisational demands, which may bear no relation to patients’ needs: CT D: […] certainly in my company […] it’s more about “How many MURs have you done today?” than it is about “What is the quality of them?”.

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CT I: I think that’s a threat to professionalism […] I think […] targets are a threat […] [particularly to] new pharmacists who are not confident […] with being an older person you’ve got a lot of confidence and I would not be told what to do if it compromised my professionalism. CT B: No.

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CT I: […] I think that is quite difficult when you’re inexperienced. (Focus group 4).

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The participants quoted above referred to pressure to meet targets felt by pharmacists employed by large companies. However, one early career pharmacist, who worked as a locum was notable in his conviction that he did feel able to prioritise patient need and attributed this to being self-employed, as opposed to an employee: CP F: […] if I don’t think the patient’s gonna get anything out of me doing an MUR and the company who I’m working for is just gonna earn the 27 quid I won’t do it […] if the company says to me “Do three MURs today” […] I won’t do them unless I think “Yes […] this person will achieve something out of it”.

Treating patients with compassion and respect were mentioned by all groups of participant. Support staff and tutors repeatedly talked about behaving towards patients with kindness and tolerance, in ways they would wish to be treated themselves, or see their loved ones treated. Maintaining patient confidentiality was raised, with hospital-based participants in particular mentioning avoiding discussing patients “behind their backs”, or in open areas in the hospital. Although this was mentioned by early career pharmacists themselves, some hospital support staff had observed pharmacists discussing patients openly during break times. A community pharmacy tutor recalled a very negative example (a critical incident) of early career pharmacists behaving disrespectfully towards a patient: […] had a hard time with a patient they start taking the mick out of them […] the patient actually had a mental illness […] [the pharmacists] […] were immature […] this patient […] they’ve had a stroke as well so the speech was slurred […] the two pharmacists […] thought he was drunk […] they started to […] make jokes of him […] one of them actually swore at the patient […] that’s more extreme unprofessionalism (CPT 12).

Communication Participants talked at length about the importance of good communication and interaction with patients. Skills and qualities such as being able to communicate clearly and confidently, being polite, treating patients with respect and listening to them, were mentioned repeatedly throughout the focus groups and there was a strong sense that these were key to fostering trusting relationships between patients and pharmacists. Data analysis revealed differences in what different groups saw as the most important aspects of communication and the examples provided in terms of early career pharmacists’ practice. Tutors and support staff emphasised the importance of communicating with patients clearly; being able to use a range of styles and adapting one’s language to the particular interaction. However, they had observed variable skills amongst community pharmacists and found that some used overly formal or technical language that was unsuitable for patients: HS D: I think at first when [early career pharmacists] start taking those drug histories they’re using terminology that the patient doesn’t understand […] they’re not saying simple words for the patient.

Tutors and support staff also raised the importance of having a confident, convincing manner when advising patients, but again recalled early career pharmacists who seemed to struggle with this:

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CS E: Sometimes you do find newly qualifieds will go out there and counsel […] but I find they’re not confident enough to give that advice to that customer […]. CS B: Yeah a lot of them do literally physically sound scared when they’re speaking to customers, you can hear their voice. CS A: Shaking […].

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CS E: And the customer’s quite shocked as well when they [find out they’re the pharmacist].

Whilst early career pharmacists in this study did not mention a lack of confidence per se, they expressed some uncertainty about their communication styles with patients, particularly in terms of how approachable patients perceived them to be: CP A: In the past I’ve seen examples of patients feeling a bit embarrassed or threatened by the pharmacist so they don’t actually divulge whatever information it is or ask any questions.

Being “approachable enough” for patients was considered important, although this did not necessarily mean behaving in the same way as patients, indeed the early career pharmacists quoted below expressed a need to maintain some separation between themselves and non-pharmacist staff and patients. The need to be flexible and to adapt one’s style with different patients was also recognised: HP F: […] the technicians I’d say are definitely more informal and […] speak [to patients] like they would speak to any other person from the street […] whereas I think that […] we feel like we have to portray this professional image so we’re a little bit different. CP A: In the past like I’ve been very friendly to a patient and they’ve not necessarily liked that, they would want a bit more distance. CP D: Professional distance and support. CP A: Yeah […] whereas somebody else would actually tell me that they feel that I’m being a bit distant towards them when in fact I was just acting normally […] so each person has got their own perception of what they consider to be professional behaviour.

Pharmacists, both early career and experienced tutors, considered staying calm and maintaining a polite and pleasant manner with patients, even when under pressure, to be key professional attributes. Both positive and negative examples of early career pharmacists’ behaviour were provided. First, an early career hospital pharmacist described a critical incident, during which she believed she had successfully moderated her own response when faced with an emotional parent: HP B: Oncology […] prescriptions are particularly large and take a long time to do […] one lady came with her daughter and we told her it was gonna be forty-five minutes to an hour to which she got really angry and shouted at me […] as a person your natural reaction is “Well you can’t shout at me” but as a professional you have to bite your tongue and I had to […] take her in a room and calm her down.

When the pharmacist explained to the parent why extra time was needed to prepare the prescription – the medicine was complex and high-risk – she seemed to understand, became calmer and apologised for shouting. However, other examples were provided of

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pharmacists being less able to assert themselves when faced with patients complaining or making demands. Whilst early career pharmacists did not report any examples of their own unprofessional behaviour in this regard, one recalled working alongside another pharmacist who had been so intimidated by a patient he had retreated to the back of the shop to “hide”. The community pharmacy technician who described the critical incident below had felt compelled to intervene when an early career pharmacist was tempted to give into the demands of a patient for methadone (a highly regulated controlled drug opiate prescribed as a heroin substitute) when he was not legally entitled to receive it: CS H: […] nice young lad but petrified of everything […] we had an addict come in and he’d [failed to collect his medicines when he should have done] so he wasn’t allowed his methadone and he were like proper kicking off […] the pharmacist said “I don’t know what to do […] shall I just give it him?’ I said ‘[…] do not give it him, no, no.” […] I told [the patient] straight […] cos […] I’m so used to addicts now they don’t bother me at all.

Although early career pharmacists often cited listening as a communication skill and agreed that it was important, they did not provide concrete examples of where this occurred in practice. The community pharmacy tutor who described the critical incident below recalled a trainee who was surprised at how much time he spent listening to a patient’s “story” about matters which were not his direct responsibility: CT L: […] [the patient] was basically getting everything off her chest and I just let her. I thought […] when she calms down […] maybe we can get to a point where she either goes and sees the doctor again or she’s happier taking the Penicillin and at the end […] she was all happy, she was gonna go and see the doctor again.. And I said to my pre-reg […] “How would you have handled it?” and he said, “Well it took a long time […] about fifteen minutes […] I would have probably sort of cut her short […] sometimes the judgement of early career pharmacists […] is they will probably try and cut everything short and say”, “[…] what are you telling me for? It’s between you and the doctor […] this isn’t my problem so what are you telling me for? […]”.

Discussion This study explored patient-centred professional values and reported behaviours in early career pharmacists. Through our analysis, patient-centred professionalism was conceptualised as having three main constructs; competences, values and communication. There was agreement amongst our participants on many of the qualities and attributes that constitute patient-centred professionalism; being knowledgeable, knowing the rules of practice, putting patients’ needs first, respectful communication were all seen as important. Analysis of the data showed numerous examples of where patient-centred professionalism was present; the early career pharmacists interviewed expressed awareness of patient-centred professional attributes, commitment to professional values and gave examples of their own patient-centred behaviour in practice. There are parallels between these findings and previous definitions of patient-centred pharmacy professionalism, including recent work undertaken in the UK with practising pharmacists (Hutchings et al., 2010) and university populations (Schafheutle et al., 2012), as well as previous USA work with university populations (Hammer et al., 2003) which emphasise competence, ethical practice, altruism, trust and relationships with patients. For participants in this study, it was essential that patients can trust in pharmacists’ competence and their commitment to ethical values, and for pharmacists to inspire and maintain that trust through their interactions with patients. These findings fit

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with the principles of the pharmaceutical care model (Hepler and Strand, 1996), which emphasises practice focused on the care of the individual patient and indeed suggest that pharmaceutical care is now embedded, certainly in the value systems of our participants; they also follow previous analyses (Dingwall and Wilson, 1995; Elvey et al., 2013; Harding and Taylor, 1997) which saw pharmacists as medicines experts. Furthermore, there are similarities between patient-centred professionalism as presented here for pharmacy and as understood in medicine (Askham and Chisholm, 2006) and nursing (Kitson et al., 2012), in particular the emphases on trust, values and communication skills. Running throughout the narratives of early career pharmacists was their strong focus on supplying the patient with the right medicine and/or the right advice. Numerous examples were provided, of early career pharmacists applying their knowledge and professional judgement to complex situations, doing their best to make sure patients’ needs were met. These behaviours demonstrate patient-centred pharmacy professionalism at work in both sectors of practice; supplying medicines with accuracy and timeliness is a vital function for any healthcare system and requires competence and dedication. Being patient-centred in pharmacy does not mean fulfiling every patient demand for a medicine; sometimes pharmacists need to refuse to supply medicines, when it is not safe or legal to do so, but doing this in the right way can be hard, especially when faced with patients who are ill, demanding or distressed. Despite the general agreement throughout the data set of the importance of strong communication skills and early career pharmacists’ engagement in some talk about explaining to patients about medicines, tutors and support staff described working with early career pharmacists who appeared unassertive or avoided stepping forward to advise patients. Although there was some evidence of early career pharmacists successfully explaining to patients why they cannot have a medicine or need to wait for their prescription to be filled, other reports suggested that early career pharmacists lack assertiveness and struggle to stand their ground or handle conflict. It is not surprising that behaviours sometimes fell short of ideals, particularly considering the early stage of their careers that these pharmacists were at; experienced GPs (Walter et al. (2012) and medical consultants (Lewis and Tully, 2009)also find handling patient demands for medicines hard). Support staff were also critical of early career pharmacists’ use of overly formal or technical language. Pharmacists, early career and tutors alike, agreed that maintaining a calm and polite manner was part of professional behaviour, but there are varying forms of “politeness”; early career pharmacists thought patients had found them variously too aloof on one hand and over-friendly on the other. Of course, differences between patients make always achieving the right tone difficult, but it is interesting that such nuances were not discussed by support staff; whilst our pharmacist participants were certainly focused on caring for patients, some discerned differences between their style with patients and that of support staff, so patient-centred professionalism for pharmacists involves retaining more distance than it does for pharmacy support staff. Another difficulty in relation to pharmacists’ medicine focus is when associated behaviours are interpreted as incompatible with being patient-centred. Participants described early career pharmacists as inclined to “rush” towards a conclusion, without stopping to consider what was best for the patient, by assuming a patient has only a minor problem because of the product prescribed, or seeing little point listening to the whole “story” about medicines prescribed by the GP. This medicines, or task-focused, attitude of course does not preclude patient-centredness, but analysing a situation from

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the starting point of the medicine can perhaps compromise taking a more holistic view, considering what would be best for the patient overall or asking the patient what they want or understand. Today, patient participation and involvement are prominent in healthcare rhetoric; the current professional ethical guidance for pharmacists (General Pharmaceutical Council, 2012) includes encouraging patient participation as a key principle. In practice, pharmacists can explain to patients about medicines, when done well this can enable patients to be involved in their care and these activities were described by our participants. However, pharmacists in this study never couched such actions in terms of “patient participation”. In Hutchings et al.’s recent work on patient-centred professionalism also, patient participation and involvement were absent from pharmacy definitions (Hutchings et al. 2010), but present in the parallel definitions developed in nursing (Hutchings et al. 2012); early career general practitioners too have emphasised these concepts (Jones and Green, 2006). This difference should not be treated as evidence that pharmacists do not want patients to be involved in decisions about their care, but it does show variance in understandings of patient-centred professionalism between pharmacy and other professions. Our participants certainly expressed commitment to being there for patients but do not seem to have developed the same understanding of “new” professionalism as some early career GPs, who prioritise more democratic relationships with patients but also more choice in terms of their own working conditions (Jones and Green, 2006). There is, of course, scope for understandings of patient-centred professionalism to change over time, in pharmacy and to become more focused on working in partnership with patients. Alternatively, it is possible that our findings reflect a fundamental difference in the way that patient-centred professionalism manifests in pharmacy, compared to other professions, that is likely to endure. Comparing our findings with previous understandings of professionalism shows some areas of good fit, for example, the traditional professional traits of altruism, applying knowledge in practice (Carr-Saunders and Wilson, 1933; Flexner, 1910), making judgements based on indeterminate knowledge (Jamous and Pelloile, 1970), or the more critical emphasis on a defined area of practice (Macdonald, 1995) in that our participants believe pharmacists are accepted by patients as medicines experts. A main criticism traditionally levelled at pharmacy, of being a commerce-oriented profession, was based on pharmacists selling goods for money. This was considered a problem because profit-making in this way does not fit within traditional understandings of professionalism. Our participants did not raise the issue of selling medicines. They did, however, perceive a threat to professionalism from commercial pressure to meet service targets for MURs, concerns which have been documented previously (Bradley et al., 2008; McDonald et al., 2010). Thus, it seems that a function of the rise of pharmacy chains (where most community pharmacists now work) has been to shift a potential threat to professionalism from the direct profit motive of pharmacy owners, to corporate pressure on employee pharmacists. Empirical research in the 1970s showed that business-oriented pharmacists also had professional, altruistic, values (Kronus, 1975). Our findings provide evidence that early career pharmacists certainly have professional values and want to work in the interests of patients, but that behaving in line with these can be hard. One early career pharmacist in this study who reported only performing MURs when it was in the patient’s interest, was self-employed (as a locum) and perceived himself as successful in avoiding commercial pressures, a finding which mirrors McDonald et al.’s (2010) work on incentives in community pharmacy. Furthermore, our data provide an example which suggests that resisting commercial targets can be part of patient-centred professionalism in community pharmacy.

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We accessed participants’ understandings of patient-centred professionalism via their descriptions of both abstract concepts and concrete examples from their own experience. The latter were elicited using the CIT which has previously been applied widely in healthcare research, including in pharmacy practice (Lewis et al., 2005), but usually in oneto-one interviews, so our use of this technique, in focus groups, was novel (Lewis et al., 2012). Our interviewees may not be typical of the broader pharmacy workforce and it is not known whether the understanding of patient-centred professionalism presented here reflects that of all pharmacists in the early stages of their careers. We asked participants to give examples of professional and unprofessional behaviours; social desirability bias may be present due to early career pharmacists’ reluctance to report behaviour which they knew would be seen as unacceptable, although participants were assured of confidentiality and encouraged to speak openly within the focus groups. The exploratory work reported here could be used as a foundation for an observational study. Another possibility for extending the work could be by using a consensus technique to develop a framework of patient-centred professional attributes and applying the framework with a wider sample. Our findings represent an “insider’s” view of pharmacy patient-centred professionalism, it would be interesting to study in more detail other health professionals’ views of pharmacy. Patient-centred professionalism in pharmacy also needs further investigation from the patient perspective. Conclusion Our main aim in this study was to explore the contemporary notion of patient-centred professionalism for pharmacy, focusing on pharmacists and their work at the level of the individual patient. In doing so, we contribute fresh, empirical data that are valuable as a first contribution to a topic that is both important for patients and in relation to current UK health policy which has sought to allocate a more directly clinical role to pharmacists, going beyond dispensing and supplying medicines. Dingwall and Wilson (1995) previously called for more studies which set out clearly what sort of a profession pharmacy is and the findings reported here, grounded in real-life examples, illustrate how pharmacy patient-centred professionalism manifests in practice. The recently qualified pharmacists included are an important group to study, given that patient-centred professionalism in pharmacy was previously poorly understood and that the early years of practice are a particularly crucial time for professional learning and development. Investigating the subject from multiple perspectives contributed a rounded understanding and permitted analysis to compare and contrast the views of different participant groups. Therefore, our data provide substantive meaning for the concept of patient-centred professionalism, particularly our finding that in pharmacy, the focus is on providing information to patients and finding solutions to problems, is in contrast to understandings from other health professions, which prioritise working in partnership with patients. There is scope for patient-centred professionalism in pharmacy to develop further and for understandings of the concept to shift over time. There are implications for pharmacy education and training, particularly around interaction with patients, as the early career pharmacists in this study sometimes lacked communication skills. This may be remedied increasing pharmacy students’ exposure to patients during the undergraduate curriculum, earlier practice placements as well as integration of the pre-registration year into a five-year degree programme. This has been recommended by the ongoing Modernising Pharmacy Careers programme (under Health Education England), who have recognised the importance of developing consultation and communication skills (Health Education England, 2014).

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Rosen, R. and Dewar, S. (2004), On Being a Doctor. Redefining medical Professionalism for Better Patient Care, King’s Fund, London. Schafheutle, E., Hassell, K., Ashcroft, D.M., Hall, J. and Harrison, S. (2012), “How do pharmacy students learn professionalism?”, International Journal of Pharmacy Practice, Vol. 20 No. 3, pp. 118-128. The Stationery Office (2013), Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary, The Stationery Office, London. Walter, A., Chew-Graham, C. and Harrison, S. (2012), “Negotiating refusal in primary care consultations: a qualitative study”, Family Practice, Vol. 29 No. 4, pp. 488-496. Ward, D.J., Furber, C., Tierney, S. and Swallow, V. (2013), “Using framework analysis in nursing research: a worked example”, Journal of Advanced Nursing, Vol. 69 No. 11, pp. 2423-2431. Further reading Eden, M., Schafheutle, E. and Hassell, K. (2009), “Workload pressure among recently qualified pharmacists: an exploratory study of intentions to leave the profession”, International Journal of Pharmacy Practice, Vol. 17 No. 3, pp. 181-187. Varnish, J. (1998), “Drug pushers or health care professionals?: the public’s perceptions of pharmacy as a profession”, International Journal of Pharmacy Practice, Vol. 6 No. 1, pp. 13-21. Willis, S., Elvey, R., Schafheutle, E., Lewis, P, Harrison, S. and Hassell, K. (2011), “Can patientcentred professionalism be engendered in young pharmacists?”, The Pharmaceutical Journal, Vol. 287 No. 7667, pp. 203-204. Appendix Pharmacy in Great Britain The pharmacy workforce in Great Britain (GB) consists of pharmacists and pharmacy technicians (who must join a professional register in order to practice), plus pharmacy support staff such as dispensers and health care assistants. In GB it takes five years to train as a pharmacist; four years at university undertaking a masters’ degree (MPharm), plus 12 months “pre-registration” training in practice settings, during which a pre-registration tutor is responsible for the supervision and assessment of the pre-registration trainee in practice. There are two main patient-facing sectors of pharmacy practice: hospital and community (which represent around 70 and 20 per cent of the workforce respectively). In both settings, pharmacists have traditionally worked in the dispensary, preparing and supplying medicines. In recent years, pharmacists’ roles have evolved to become more clinical, with technical work shifted to support staff. In hospitals, pharmacists see patients on ward rounds and in clinics, check their medication regimes and work in multi-disciplinary teams, advising professionals and patients on medicines. Community pharmacies, or the “chemist’s shop” as they are commonly known, are private businesses, ranging from single shops run by a pharmacist owner, to chains of stores, owned by large companies, where pharmacists are employees. Community pharmacies sell and dispense medicines and provide other services such as medication reviews and public health services.

Corresponding author Dr Rebecca Elvey can be contacted at: [email protected]

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