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Differential acceptance of a new role for pharmacists
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Content
DIFFERENTIAL ACCEPTANCE OF A NEW ROLE FOR PHARMACISTS
by
Barbara Ann Adamcik
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Sociology)
May 1984
UMI Number: DP31834
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
OlsMdaalom P ’^bilisM ng
UMI DP31834
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
Microform Edition © ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code
ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106- 1346
UNIVERSITY OF SOUTHERN CAUFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CAUFORNIA 90089
This dissertation, written by
Barbara Ann Adamcik
under the direction of .. Dissertation
Committee, and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillm ent of re
quirements fo r the degree of
D O C T O R O F P H IL O S O P H Y
Dean
Date
April 25, 1984
DISSERTATION COMMITTEE
Chairperson
DEDICATION
This dissertation is dedicated to my mother, Edna
Francis Bollmeier MacDougall (1915 - 1973), and to my
children, Deborah, Sean and Christian.
11
ACKNOWLEDGEMENTS
There are many people whose paths have crossed mine and who
have made a significant difference in my life. Too many to
acknowledge here. Two people in particular stand out who
encouraged me to begin my long treck through school, first
as an undergraduate, and then as a graduate student. I
want to thank Drs. Leona Miller and Charles Edwards for
believing in me.
1 especially want to thank the members of my
dissertation committee. Thank you, Tom. Thank you, Ed.
Thank you, John. Each of these wonderful men gave me
something special as 1 struggled through this process. Dr.
Lasswell gave me encouragement, guidance, support and
permission to be less than perfect. Dr. Ransford gave me
hours at the blackboard and in his office untangling my
confusions and setting me back on the path. And Dr. Biles,
with a twinkle in his eye, gave me the pharmacist's
perspective, and most of all, he let me show him the
sociologist's perspective.
1 also want to thank my family. It's been a long haul,
especially for my children. I'm proud of each of you. I
wasn't always there when you needed me. I'm sorry.
iii
ABSTRACT
This study assessed the legitimacy of expanded roles for
pharmacists with different status audiences (practicing
pharmacists, pharmacy school faculty, physicians, nurses
and consumers). Pharmacy is a profession in transition and
is characterized by considerable ambiguity and uncertainty
concerning its status as a health care profession. This
poses dilemmas of role definition for both its
practitioners and others with whom pharmacists interact.
Significant changes have occurred within the profession of
pharmacy in the past few decades which have led to loss of
function, social power and status. The response of the
profession has been a movement toward a patient-oriented,
clinical role for pharmacists.
Hypotheses concerning level of support for expanded
roles were derived from two conflict-based models of
professionalization: (1) a process model which focuses on
conflict of interest and diversity within a profession and
the development of "segments" which struggle for control of
a profession’s direction; and (2) a power model which
focuses on conflict between professions and the central
IV
role of power in defining occupational territory.
Implications of these models for social role change are
discussed.
Data were collected by self-administered questionnaires
sent to California pharmacists, physicians, nurses,
consumers and pharmacy school faculty. Respondents were
asked to indicate level of support for 20 role activities
for pharmacists in two practice settings (community and
jiospital). Factor analysis of responses by pharmacists to
the 20 items revealed four common and one unique factors
for each practice setting: core activities, general
advisement, specialized advisement, clinical activities,
and drug information resource (community) and triage
activities (hospital).
Initial analysis of variance for each role factor
revealed significant differences between groups. Pharmacy
faculty were most supportive of the clinical activities
factors, followed by practicing pharmacists, consumers,
nurses, and physicians. Physicians and nurses were more
antagonistic toward clinical activities in the community
than in the hospital setting. These groups were also most
antagonistic toward activities which required independent
judgment or autonomous action relevant to patient care on
the part of the pharmacist. For each group, consensus was
higher (i.e. lower variance) for traditional core
activities than for the discretionary clinical activities.
Within the pharmacists group, higher levels of support
for clinical activities factors were found among
pharmacists who graduated since 1970 (younger cohort),
women pharmacists, minority pharmacists, and pharmacists
working in a hospital setting.
VI
CONTENTS
DEDICATION............ ii
ACKNOWLEDGEMENTS . ......................... iii
ABSTRACT................... iv
LIST OF TABLES............ x
Chapter
I. INTRODUCTION ............................................ 1
Statement of the Problem..................... 2
Purpose of the Study................................. 6
Theoretical Framework ............................. 7
Hypotheses . .........................................8
Procedures . ............ 9
Limitations of the Study .................... 10
Outline of Following Chapters ................. 12
II. PHARMACY, A PROFESSION IN TRANSITION . .. . . . 13
Changes and Trends in Health C a r e ............ 13
Physician Extenders........................ . 17
Nurse Practitioner........................... 18
Physician’s Assistant ................... 23
Rise of Consumerism . .........................27
Increased Dependence on Drug Therapy . . . 31
Adverse Drug Reactions ................... 33
Self-Care and Non-Compliance ............ 37
Changes and Trends in Pharmacy ................. 40
Development of Pharmacy ...................... 40
Pressure for Change..............................42
Clinical Pharmacy ............................. 45
The Practice of Pharmacy........................... 47
Practice Setting . . . . . . . ............ 47
Changes in Socialization . ..................51
Pharm.D. or B . S . ? ........................... 51
New Recruits .........................53
Levels of Practice..................... 54
Relevance of Changes in Pharmacy ..... 56
vii
Major Issues in Studies of Pharmacy.............57
Continuing Role Conflict ............... 57
Role S t r e s s ..................... 61
Ideal versus Actual . . . . . . . . . . 61
Perceptions of the Role of the
Pharmacist.......................... . 63
S u m m a r y ...............................................69
III. T H E O R Y ....................................................70
Assessment of Social Roles ...................... 71
Social Roles and Change ........................ 73
Models of Professionalization and Change . . . 79
Functional Model ............................. 80
Process Model .................................. 84
Power Model ................................ 88
Role Change in Medicine - Some Examples . . 94
Power and Stratification Within the Health
Care S y s t e m ............................... 98
Research Hypotheses .. . . . . ............... 114
IV. M E T H O D ................. 117
Overview of this Chapter.......................... 118
Description of Research Design . ..............118
Development of Survey Instruments ............ 119
Pharmacist Survey ............... 119
Demographic Data.............................119
Role Consensus............................... 120
What is a Pharmacist?..................... 124
Health Care Professionals Survey .......... 125
Consumer Survey ................................ 126
Pharmacy School Faculty Members Survey . . 127
The S a m p l e s ............................... 128
California Pharmacists .... ............ 129
Health Care Professionals ................... 130
Los Angeles County Physicians .......... 130
Southern California Area Nurses .... 131
Los Angeles Area Consumers...................132
use School of Pharmacy Full-Time Faculty . 133
Statistical Analyses............................. 134
Limitations.......................................134
Response Rates and Demographic Data of
Respondents...............................136
Pharmacists . . 141
Pharmacy School Faculty Members ............ 146
Physicians...................................... 149
Nurses ..... ............................. 149
Consumers.........................................150
Factor Analysis of 20 Role Tasks.................153
viii
Role Segments - Community Pharmacy .... 153
Role Segments - Hospital Pharmacy ..... 156
V. FINDINGS.................................. 159
Inter-Group Consensus for the Role of the
Pharmacist .........................159
Measurement of Support and Consensus . . . 160
Inter-Group Comparisons of Support for
Expanded Roles ................ 161
Intra-Group Comparisons of Support for
Expanded Roles ............................. 188
Delineation of Variables Associated With
Support for Expanded Roles ............... 206
S u m m a r y ...........................................224
VI. CONCLUSIONS AND RECOMMENDATIONS ................... 228
Conclusions: Inter-Group Comparisons .......... 228
Conclusions: Intra-Group Comparisons .......... 232
Conclusions: Effects of Conditional
Variables ................................. 235
Possible Applications of Findings ............ 238
Recommendations for Future Research .......... 246
REFERENCES .................................. 248
Appendix page
A. PHARMACISTS SURVEY........... 264
B. FOLLOW-UP POSTCARD TO PHARMACISTS ........ . . . 272
C. HEALTH CARE PROFESSIONALS SURVEY ................. 273
D. CONSUMERS SURVEY ................................. 279
E. PHARMACY FACULTY MEMBERS SURVEY .................. 283
F. FACTOR ANALYSIS: 20 ITEMS FOR COMMUNITY
PRACTICE....................................287
G. FACTOR ANALYSIS: 20 ITEMS FOR HOSPITAL
PRACTICE................... 289
IX
LIST OF TABLES
Tabla gage
1. Demographic Distribution of Health Care
Workers.............................. 102
2. Response Rates for Populations Sampled................ 136
3. Demographic Profile of Pharmacists. . ............. 139
4. Demographic Profile of Respondents to Versions
1 and 2 of Pharmacist Survey.............. 144
5. Demographic Profile of Pharmacy Faculty Sample. . 146
6. Demographic Profile of Health Professional
Sample......................... 148
7. Demographic Profile of Consumer Panel. . . . . . . 150
8. Role Segments Delineated by Factor Analysis of
20 Role Tasks by Practice Setting................152
9. Mean Responses of Pharmacists, Pharmacy
Faculty, Physicians, Nurses and Consumers to
Role Segments.......................................... 163
10. Comparisons of Degree of Consensus Among
Pharmacists, Pharmacy Faculty, Physicians,
Nurses and Consumers. ........................169
11. Mean Responses to 10 Traditional Role
Activités................................... 174
12. Mean Responses to 10 Expanded Role Activities. . . 179
13. Summary of Patterns of Support for Pharmacy
Role Activities. ......................185
14. Comparison Between Practicing Pharmacists and
Pharmacy Faculty on Role Segments................189
15. Comparison Between Pharmacists Who Graduated
Prior to 1970 and 1970 or Later on Role
Segments.............................................191
16. Attitudes of Older and Younger Pharmacists
Toward the Appropriateness of 20 Role
Activities. . •..................................... 193
17- Comparison Between Male and Female Pharmacists
on Role Segments................... .195
18. Attitudes of Male and Female Pharmacists Toward
the Appropriateness of 20 Role Activities. . . 197
19. Comparison Between White and Asian Pharmacists
on Role Segments. . ............................... 199
20. Attitudes of Caucasian and Asian Pharmacists
Toward the Appropriateness of 20 Role
Activities»........................................200
21. Comparison Between Hospital and Community
Pharmacists on Role Segments. ..............203
22. Attitudes of Hospital Pharmacists and Community
Pharmacists Toward the Appropriateness of 20
Role Activities....................................204
23. Ranking of Potential "Roles" for Pharmacists. . . 208
24. Clinical Versus Business Orientation By Group. . . 210
25. Dominant Orientation Among Pharmacists............ 212
26. Effect of Value Orientation on Support for
Expanded Roles..................................... 214
27. Experiences with Clinical Pharmacists..............216
28. Effect of Clinical Pharmacist Experiences on
Support for Expanded Roles. .... ............ 218
29. Effect of Clinical Pharmacist Experience on
Perception of Pharmacist as Drug Expert. . . . 220
30. Effect of Perception of Pharmacist as Drug
Expert on Support for Expanded Roles. ..... 222
XI
31. Conclusions Relevant to Hypotheses About Level
of Support for a Clinical Role for
Pharmacists............................................ 227
32. Model of Relationship of Degree of Consensus
and Magnitude of Support to Potential for
Social Role Change. . ............................ 24‘ l
Xll
Chapter I
INTRODUCTION
The study of occupations has been a focus of interest in
sociology for some time. In recent years occupational
structures and behaviors have been investigated in a wide
variety of settings. Traditional sociological analyses of
the professions, however, rarely have considered how and
under what conditions an established profession seeks to
change its position, or acceptance of the proposed changes
by others.
During the past 50 years, several significant changes
have taken place within the practice of pharmacy. For
example, in the mid-1920's nearly 80 percent of all
prescriptions were actually compounded by pharmacists,
whereas today pharmacists compound less than one percent of
all prescriptions that are filled. Paradoxically, during
the same period of time, the educational requirements for
pharmacists increased from two to five or more years.
Traditionally pharmacy has been conceived of primarily as a
product system. Modern pharmacy, however, has been rapidly
Moving away from a product—based system, and is becoming a
knowledge-based system.
1
Of all the major health care professions, pharmacy has
received the least amount of attention from social and
behavioral researchers. The reasons for this lack of
attention are not entirely clear, but a major factor may be
simply a lack of interest on the part of social scientists.
Pharmacy is somewhat of an "invisible" health care
profession, and those outside of it are relatively
uninformed about pharmacy and its problems. There are no
pharmacist "heros" portrayed in the media.
1.1 STATEMENT OF THE PROBLEM
Pharmacy is a profession in transition and is
characterized by considerable ambiguity and uncertainty
concerning its status as a health care profession. This
poses dilemmas of role definition for both its
practitioners and other individuals with whom pharmacists
interact.
Historically, pharmacy involved the compounding and
dispensing of prescribed medications, and its practitioners
fulfilled the role of "physician’s cooke (Copeman, 1967, p.
45)." The pharmacist of yesterday had an opportunity to
utilize the skills and knowledge acquired in training. He
also consulted with patients and acted as a community
health care advisor. With the advent of industrialization
and the large-scale manufacturing of medicinal products,
pharmacists have largely been left with only the dispensing
functions of "counting, pouring and labelling," and
record-keeping (Whitney and Archambault, 1981). Thus a
void has developed in the professional role of the
pharmacist.
Pharmacists, unlike their colleagues in the field of
medicine, do not usually have a professional specialty
within the broad field of pharmacy. Pharmacists have
primarily been labelled on the basis of practice location.
In response to recent pressures within and outside the
profession to define new roles and functions for both
hospital and community pharmacists, the clinical pharmacist
has emerged as a specially trained pharmacist engaged in
patient-oriented practice.
The movement toward a more patient-oriented, clinical
role for pharmacists may be viewed as the profession’s
response to structural changes and developments in
technology, social organization, the division of labor and
economics of health care, and represents a collective
reaction to a fear of displacement or down-grading of the
profession (Birenbaum, 1982).
The degree of support for the new clinical role is
unknown. Younger pharmacists appear to have rejected the
established norms which had governed the practice of
pharmacy, however, and have created new roles which greatly
expand the pharmacist’s area of expertise. Underlying each
of these new role activities is a concern with making the
profession more relevant to the pressing problems of
society, Bucher and Strauss (1961) suggested:
When an occupation seeks to change its position
in society it may be an unsettling experience,
challenging traditional beliefs held by those
inside the vocation and outside as well. . . .
Not all practitioners of the vocation seek
change, and elite groups or segments within the
occupation may be identified as the ’ ’carriers’ ’ of
the seeds of new roles.
Attempts at role change or redefinition place demands on
those within a profession who seek such changes. Those
interested in change must first seek to generate consensus
within their profession that such change is desirable and
necessary. They must also try to foster consensus for the
expanded role among members of other groups whose
expectations help to define the original role being
modified, and who are quite resistant if their own turf is
being threatened. Thus to generate consensus both within
and among groups is crucial for those who attempt to expand
their roles.
A study of the expansion of a professional role,
therefore, should include at least three assessments: 1)
social power of the professional membership, 2) consensus
on the proposed role changes, and 3) the degree to which
aspired changes are realistic.
An assessment of the power position of the group
promoting the change in relation to that of other relevant
groups should be made. The central role of power in
defining occupational territory has gained increasing
attention by many investigators. Kronus (1976) has
suggested that changes in an occupation’s role and power
position must be understood in the context of related
occupational and societal institutions.
Measurement of the degree of consensus about the
proposed change within the profession and between its
members and other professions functionally related to it
must be conducted. Role expansion and change can be viewed
as cyclic in nature (Ibid.), beginning with a blurring of
task role boundaries, legalization of new role activities,
and finally institutionalization of the new role
definition. It is at the point of institutionalization
that consensus between and among groups will be highest.
An estimation of the likelihood of success for the
proposed changes based on the first two components must be
made. This is necessary so that those group members
interested in promoting change can develop strategies to
overcome areas of resistance or barriers to proposed change
(Knapp, 1979).
This dissertation was designed to investigate the second
component (i.e. consensus) of the model identified above
and its implications for the other two components in
defining an appropriate and realistic role for pharmacists.
The major focus of this study was to assess the legitimacy
of expanded roles for pharmacists with different status
audiences. Specifically, this study compared the levels of
support for expanded, patient-oriented activities among
pharmacists, other health professionals (pharmacy school
faculty, physicians and nurses), and consumers.
The profession of pharmacy is a particularly fertile
field of study for medical sociology for several reasons:
(a) because of the relative neglect in the past; (b)
because of professional characteristics which appear to set
pharmacy apart from other health care professions; and (c)
because the profession has undergone significant
technological and social changes in the past 50 years.
1.2 PURPOSE OF THE STUDY
This study was undertaken to provide a better
understanding of selected aspects of the role of the
pharmacist. The major objectives of this study were to
determine :
1. the extent to which pharmacists, physicians, nurses,
pharmacy school faculty and consumers disagree in
their conceptualization of the role of the
pharmacist, particularly the extent of disagreement
for new clinical roles for pharmacists.
2. the extent to which pharmacists as a group disagree
in their conceptualization of the role of the
pharmacist, particularly for expanded, clinical
roles.
3. the background, situational or attitudinal variables
for pharmacists, physicians and nurses which are
associated with acceptance of expanded role
activities for pharmacists.
1.3 THEORETICAL FRAMEWORK
Both role theory and symbolic interactionism
perspectives traditionally have been proposed to explain
changes in social roles. These perspectives are useful in
understanding micro-level processes of role change and how
roles might evolve over time, but are less useful in:
I
explaining more macro-level role changes within an entirej
I
profession or social institution. j
In order to understand better the challenges faced by
pharmacy as it attempts to evolve into a
clinically-oriented profession, it is necessary to look
beyond the profession itself and focus instead on its
position within the hierarchical structure of the health
care system.
Because of the rapid changes within the health care
system, it is important to look at prevailing models of
professions and professionalization to assess how each
accounts for social role change. Of particular importance
is the central role of power in defining occupational
territory, and the most appropriate level of analysis in
studying occupational power is the systematic level where
power is based in the roles and positions defined as
occupational, rather than in the unique characteristics of
individuals in interaction with one another.
Relevant theoretical perspectives discussed in Chapter
III include process and power models of
professionalization, systems theory and stratification
theory.
1.4 HYPOTHESES
General hypotheses developed from the theoretical
perspectives discussed in Chapter III included:
1, Acceptance of a patient-oriented, clinical role for
pharmacists differs between health care
professionals and consumers. The predicted
direction of the differences was as follows:
pharmacists will be the most supportive group of an
expanded role for pharmacists, followed by nurses
and consumers; ‘physicians will be the group most
antagonistic toward expanded pharmacy roles.
2. Acceptance of a patient-oriented, clinical role for
pharmacists differs among pharmacists ; the most
supportive subgroups of pharmacists will be the
"elites" of pharmacy (i.e. pharmacy school faculty)
and recent graduates.
3. For each group, consensus will be higher for
traditional than for expanded role activities of
pharmacists.
1.5 PROCEDURES
Data for this study were collected as part of a larger,
multipurpose, cross-sectional survey of California
pharmacists, health care professionals and consumers. The
survey was conducted by the staff of the Community Pharmacy
Enhancement Project under the aegis of the USC Development
and Demonstration Center in Continuing Education for Health
Professionals, and funded by the W. K. Kellogg Foundation,
Three major issues were focused upon in that survey:
1. a marketing study to assess attitudes toward
traditional and innovative continuing education
programs for pharmacists;
2. assessment of the use of computers in pharmacy
practice, both for business and pa tient-oriented
activities, and
3. a multiperspective, interdisciplinary assessment of
professional and patient-oriented aspects of the
role of the pharmacist.
Data from this last component are used in this study.
Separate, self-report survey instruments were developed
for (a) pharmacists, (b) physicians and nurses, (c)
consumers, and (d) pharmacy school faculty. Each
instrument contained a core of common items to allow
comparison of attitudes across sample groups, as well as
relevant demographic information.
1.6 LIMITATIONS OF THE STUDY
The present study is limited in several ways. Since the
methodological procedures employed were dictated by the
demands of another project with considerations for
timeliness, project deadlines, and cost, certain
limitations were unavoidable. Because of the length of the
multipurpose survey developed, several variables of
10
interest to this study had to be eliminated. Also, because
of the expenses involved in doing a large, random sampling
of nurses and consumers, these samples were obtained in
more purposive ways. Although pharmacist and physician
samples were randomly selected, generalizations beyond the
non-random samples of nurses and consumers is not possible.
A final consideration has to do with non-responders,
particularly to the lengthy pharmacist survey. It is
difficult to determine the reasons that pharmacists who
responded were willing to take up to 45 minutes to complete
the mailed survey. It may be that pharmacists in general
are more traditional than the sample who responded who may
have done so because they were more highly motivated to
support the "new" role.
Pharmacists were given an opportunity to respond to a
wide variety of issues of acute interest to them in this
survey. Despite the length of the survey, several
pharmacists provided comments (both positive and negative)
at the end. It is possible that those who did not respond
were less likely to have strong feelings (either positive
or negative) toward the issues. This same argument may
also apply to physicians who did or did not respond to the
survey. Again, they were also given the opportunity to
respond to issues salient to physicians, and responders may
11
have been more interested in providing feedback concerning
expansion of the pharmacist role.
In an attempt to deal with these concerns about
potential response bias, pharmacists and health care
professionals were given an opportunity to enter a drawing
for $100. Pharmacists, physicians and nurses were informed
of this drawing and how to enter in the cover letter
included with the survey. Over 95 percent of the
respondents included their names and addresses with the
completed survey. The object of the drawing, of course,
was to motivate disinterested subjects to complete the
survey.
1.7 OUTLINE OF FOLLOWING CHAPTERS
Chapter II contains a review of the literature on two
major topics: relevant changes in health care in the United
States and in the profession of pharmacy. Chapter III
presents the theoretical framework for the study and the
specific hypotheses developed. Methodology used in this
study, including selection of relevant variables, is
included in Chapter IV. Findings of the study are
presented and discussed in Chapter V. Finally, Chapter VI
contains a summary of the study findings, conclusions and
recommendations for future research.
12
Chapter II
PHARMACY, A PROFESSION IN TRANSITION
In this chapter a brief discussion of recent changes and
trends in the profession of pharmacy is presented. In
order to look at where pharmacy is going and to assess
acceptance of changes in pharmacy practice, it is necessary
to look at where pharmacy has been and its position within
the social context of health care. In addition, recent
changes in health care roles and consumer attitudes toward
health care are discussed as they relate to changes in
pharmacy practice. Finally, previous studies of pharmacy
and perceptions of the pharmacist by role set members are
discussed.
2.1 CHANGES AND TRENDS IN HEALTH CARE
Although there is not space to delve into a lengthy
discussion of changes in the health care delivery system in
this chapter, a cursory discussion of such changes is
presented to help the reader appreciate pharmacy's
potential new status with reference to other broad changes
in health care.
13
Two rather different trends have emerged in recent years
within which lie the potentials for improvements in health
care services and in the provision of health care
information: 1) the trend toward ”a greater technocracy, a
dependency on scientific skills and expertise, and power
exercised over larger occupational groups in professional
territories as well as over consumers of the professional's
services," and 2) the trend toward "consumerism,
plebiscitary politics, participatory democracy, and open
entry into all previously closed groups; a demand by the
public and the public sector for greater involvement in
areas that affect the nature and quality of its life
(Newton, 1974, p39)."
Evidence of these trends can be seen in the rapid
development of new health care occupations and the
expansion of others (in particular the development of the
physician assistant role and the expansion of the nurse
role with the emergence of the nurse practitioner), and in
changes in the traditional practitioner-patient roles.
Somers (1974) discussed several paradoxes which existj
currently within health care: 1)increased longevity has led!
to an increase in chronic diseases, 2) physicians are
I
better trained today but the problem of maldistribution of
services still exists, 3) the hospital has emerged as the
14
logical center in health care but is prevented from playing
this role, and 4) reduction of financial barriers to health
care has resulted in outside intrusion into health care.
The average person today is better educated, will live
longer, has better health resources available, and is less
disease-ridden than ever before. At the same time, because
of this increased longevity, more concern with chronic
disease processes, and increasing expectations with respect
to health and health care, the individual needs and demands
more health care and health-related information than ever
before, and is increasingly critical of health care
delivery.
Although the new breed of physician is better trained
and more concerned with patients* emotional and social
needs, in addition to physiological needs, there still
exists a discrepancy between supply and demand, and
maldistribution. This has led to "increasing emotional and
financial pressure on the medical profession, resentment
and defensiveness, and public depreciation of the
profession (Ibid.)."
The hospital has emerged as the undisputed professional
and technological center of the health care system,I
i
I
although it has often been prevented from playing the
central coordinating role in health care which its position
15
would logically dictate. The unique internal structure of
the hospital often results in diffuse raanagraent and
conflicts between medical staff and lay administration.
External conflicts also exist as to what the hospital's
role should be. Meanwhile, hospital costs continue to
increase more rapidly than any other aspect of health care
(Freeland et al., 1980).
The financial barriers to health care have been reduced
or eliminated for most consumers with the tremendous
expansion of private and public third-party programs to
finance health care. However, these programs have resulted
in the erosion of physician autonomy in determining patient
care, with some types of services and some therapies not
being reimbursed. There is increasing intervention in the
traditional practitioner-patient interaction with resulting
dissatisfaction felt by both parties. Third-party coverage
of health care has increased both health practitioner
income and overall health care costs, to the point where
health care in the United States has been described as in
the midst of a crisis situation.
The redefinition of the pharmacist's role, therefore,
can be examined within the social context of a growing
demand by consumers for health care and health information,
health personnel shortages, the central but controversial
16
role of the hospital in health care, and the increasing
dependence on third-party financing of and intervention in
health care.
Two specific developments, the rise of physician
extenders and consumerism, are discussed in more detail
below as they are particularly relevant to the expansion of
the pharmacist's role. Finally, the increased dependence
of our society on drug therapy is discussed.
2.1.1 Physician Extenders
In recent years two physician extender health care roles
have emerged; 1) the nurse practitioner, and 2) the
physician assistant. The new role of physician assistant
developed in response to the physician shortages of the
1960's. The expansion of the nurse's role, although
influenced by the physician maldistribution problem, was
related to other factors both internal and external to the
profession. The discussion of the development of physician
extender roles, and particularly of the development of the
nurse practitioner role, is important in understanding the
current movement toward an expanded clinical role for
pharmacists. There are many parallels between the
movements toward expansion of the nursing role and
expansion of the role of the pharmacist.
17
2.1.1.1 Nurse Practitioner
One of the most exciting developments in nursing has
been the evolution of the nurse practitioner role. Nurses
working in ambulatory care settings have often performed a
wide range of primary care functions. In recent years,
however, there has been a surge of interest in training
1
nurses for "expanded" primary care roles. Although some
authors (Fink, 1975; Glen and Goldman, 1976; and Wood,
1976) classify both physician assistants and nurse
practitioners as physician extenders, viewing their role
primarily as that of a surrogate physician, the nursing
profession has generally rejected this view, emphasizing,
instead, the interdisciplinary and collaborative
relationships with other health care providers (Gimble,
1977; Lewis and Cheyovich, 1976; and Anderson et al.,
1974).
New professional roles have helped to elevate nursing to
greater professional status. This advancement has come
about because membership assumed more independent and
Weston (1975) provided a concise summary of the factors
behind the development of the nurse practitioner and
physician assistant programs and pointed out some of the
ambiguities inherent in these roles. Melosh (1982)
provided a somewhat different perspective on the history
of nursing and the development of the nurse practitioner.
She presented nursing history within the context of the
history of women, of labor, and of medicine within a
social power framework.
18
interdependent decision making, became more assertive, and
exhibited greater autonomy in providing health care.
Nurse practitioners provide accessible and readily
available health and illness care to communities without
other sources of professional health care, and assume major
responsibility for primary ambulatory health care of
patients at neighborhood clinics, in health maintenance
organizations, and in hospitals.
Generally, the nurse practitioner assesses a patient's
need for health care by interviewing the patient, doing
necessary physical examination, ordering laboratory tests,
and, if needed, consulting with a physician or other health
professional. All patient data are analyzed by such nurses
in determining whether to treat the patient using
established protocols, consult with a physician supervisor,
or refer the patient to other health professionals.
In the area of diagnosis and treatment, particularly in
prescribing drugs, nurse practitioners (and also physician
assistants) encounter medicolegal problems (Bergersen,
1977, p. 281). Diagnosis and drug prescription
traditionally have been the exclusive functions of
physicians, while nurses traditionally have administered
medications prescribed by physicians. In the majority of
states, nurse practitioners are not permitted to prescribe
19
independently and must do so by having the prescription
order signed by a supervising physician. Fourteen states,
however, presently grant limited prescriptive authority to
nurse practitioners (Bigbee, 1974).
Nurse practitioners currently are prepared for their
expanded role in several ways. Formal training may range
from 6-week certification programs to 2-year graduate
programs. The first training programs of the 1960's and
early 1970's prepared nurse practitioners to assist in
meeting primary care health needs (Barhydt-Wezenaar, 1981,
p. 111). These programs, which were generally supported by
the medical establishment, were originally developed (1) as
a means of controlling costs by introducing lower paid
health care providers into the system, and (2) as an answer
to distribution problems by training individuals who woulci
function in geographic areas that were short of physicians.
The role has further evolved to the point where many health
policy makers have projected that the nurse practitioner
may become the major group of primary care specialists
(Kalisch, 1978).
Although the provision of a formal academic education to
prepare nurses for their expanded role is somewhat new, thé
I
role itself has a long history. The public health nursej
the nurse midwife, the private duty nurse, the frontier
20
nurse of Kentucky, and the nur se-anesthetist have long
functioned well beyond the limits traditionally considérée
to constitute nursing practice, especially when physicians
were not readily available (Kirk et al., 1971). Despite
this, however, an aura of newness surrounds the expandec
role, leaving one with the impression that a revolutionary
process has taken place (Lees, 1973).
One positive result of the nurse practitioner movement
has been a move toward greater autonomy for all nurses.
With the passage of the Rural Health Clinics Act of 1977,
nurses for the first time could be reimbursed under
Medicare for their services through certified rural health
clinics (Sullivan et al., 1978). There are still barriers
to overcome, however, if nursing is to progress further.
The primary barrier is "attitudinal" (Kushner, 1973).
Probably physicians have been reluctant to relinquish
functions because of potential increased liability and loss
of autonomy and authority. The nurse often is reluctant to
take on increased responsibilities and accountabilityj
because of traditional male-female/doctor-nurse
relationships. Nurses have been making diagnostic
decisions for years but have protected themselves with
elaborate games, the object of which has been to make the
physician feel in control at all times (Stein, 1967;
21
Bullough, 1975). If the nurse practitioner is to function
effectively, this form of interaction must be given up and
replaced by a less power-dominated, more peer-like
relationship.
Physicians who work with nurse practitioners often
experience identity crises (Ibid.). As portions of their
conventional role are relinquished, difficulties are
experienced many times in trusting another health worker's
data base and decision-making (Bates, 1975). Relationships
may be strained if physicians do not accept the judgments
of self-assertive and competent nurse practitioners.
Physicians are often sensitive to the potential for
competition that the existence of nurse practitioners
implies (Burrows and Traver, 1974; Pickard, 1974, p. 114).
Although dissatisfied with their own professional roles,
nurses also have been reluctant to give up any professional
turf to others (Weiler, 1975).
There has been a widespread trend toward the development
of protocols for use by nurse practitioners and physician
assistants for diagnosis and treatment of routine or
uncomplicated acute diseases and other well-defined chronic
conditions. These protocols have limited value, however,
in that they do not always take into account every possible
variation and thus may have too rigid and binding an
approach (Barhydt-Wezenaar, 1981, p. 114).
22
The clinical work of various types of nurse
practitioners has been extensively evaluated, and in
general studies have found the quality of care by nurse
practitioners to be similar to that provided by physicians
(Sackett et al., 1974; Spitzer et al., 1974), noj
differences in morbidity or mortality (Lewis et al., 1969),
and in fact an increase in satisfaction of patients with:
nurse practitioner care (Lewis et al., 1969;
Barhydt-Wezenaar, 1981, p. 115).
Nursing as a profession has been able to organize and:
unite itself into a relatively cohesive unit to bring about
dramatic changes in practice in a fairly short period of
time. Nursing has traditionally been in a subordinate andj
conflicted position with reference to medicine. It has
successfully taken advantage of the physician shortages of
the last two decades, however, in challenging that
traditional relationship. The medical establishment has
generally been supportive of this role expansion and by
lending its support, has been able to "guide" the direction
of change.
2.1.1.2 Physician's Assistant
One alternative solution to the physician shortages of the'
1960's and early 1970's was the development of programs to
23
train physician's assistants or associates. Originally
these programs were designed to take advantage of and
provide continuing careers for medics returning from the
Vietnam War era. Although women are now being trained as
physician assistants, it is primarily a male-dominated
profession (as contrasted with nurse practitioners, a
majority of whom are women). The training varies even more
than that of the nurse practitioner, with programs lasting
from 8 weeks to 5 years (Barhydt-Wezenaar, 1981, p. 116).
The role of the physician assistant differs from that of
the nurse practitioner in that they do not do bedside
nursing and generally do not have separate licenses. Also,
physician assistants usually work for individual physicians
who assume responsibility for their work, and their role
and function is defined by the employing physician (Stead,
1966). Physician assistant programs have generally been
supported by physicians. Because physician assistants have
no separate license in most states and work directly with a
physician, and are dependent upon the physician forj
employment, there appears to be less conflict and animosity
between them and the physician "establishment" than is the
case with nurse practitioners, who have a separate license
and may work independently under certain circumstances.
Physician assistants are seen as subordinate to and
24
assisting physicians, and less of a threat to the
physician's power and autonomy than is the nurse
practitioner.
Studies have demonstrated that properly trained and
supervised physician assistants can deliver quality health}
care (Greenfield et al., 1974; Komaroff et al., 1974;
Spitzer et al., 1974; Charles et al., 1974), that they can
carry a significant patient load and free up physician time
(Golladay et al., 1973; Nelson et al., 1975), and that they
have good acceptance by patients (Lang, 1969; Dixon, 1970),
and by physicians (Murray, 1972; Borland et al., 1972).
Nurse practitioner and physician assistant roles are
involved in direct patient care. These roles developed to
some degree because of the health manpower shortages and
maldistribution of resources of the 1960's and 1970*s and
upwardly spiraling health care costs. In contrast, an
expanded clinical role for pharmacists will be shown in the
following section to be based not on physician shortage,
but on the need for accurate drug-related information.
I
With the expansion of physician surrogate roles the need'
for a health professional resource for drug information has
increased. Physicians do not receive as much education in
drugs and the pharmacokinetics of drugs as do pharmacists.
Nurse practitioners and physician assistants receive
25
significantly less information. Despite this wide
difference in level of drug knowledge, it was found in one
study that physicians were more favorable toward physician
assistants monitoring drug therapy and maintaining patients
on drugs for chronic diseases than they were toward
pharmacists (McKay and Jackson, 1976). A possible
explanation for this is the fact that while the physician
assistant is under the physician's direct supervision, the
pharmacist is not. It may be also that physicians are more
familiar with the role potential of the physician assistant
through their own medical literature, but not the
capabilities of the pharmacist. Several studies have shown
that despite the pharmacist's unique drug-related
knowledge, he is not the primary source of drug information
(Knapp, D. A. et al., 1969; Knapp, D. E. et al., 1969;
Smith and Mackewicz, 1972; Pitlick and Plein, 1973;
Bergersen, 1977; and McEvilla, 1977). The Physicians' Desk
Reference manual which is a compilation of reprints of FDA
approved package inserts provided by the drug manufacturers
was found to be the most used source of information by
nurses (Pitlick and Plein, 1973).
26
2.1,2 Rise of Consumerism
In the traditional view of the practitioner-patient'
relationship, the physician's diagnosis and treatment plans
are unquestioningly accepted by the patient. Attitude;^
have changed dramatically in recent years and "consumerism"
in general, and specifically in medicine is on the rise.
The health professions have become keenly aware of the
consumer movement within the last two decades. Although
this movement gained a renewed vigor in the turbulent 60*s,
organized consumer activities had been going on for some
time (Kilwein, 1981, p. 109).
Consumerism as a general concept is characterized as
"buyer's challenge of seller's claims" (Haug and Lavin,
1983, p. 16). Consumerism in medicine is defined by Haug
and Lavin as "challenging the physician's ability to make
unilateral decisions - demanding a share in reaching
closure on diagnosis and working out treatment plans" anc
is seen as a challenge to the physician's traditional
authority :
it focuses on purchaser's (patient's)
rights and seller's (physician's) obligations,
rather than on physician's rights (to direct) and
patient's obligations (to follow directions) . .
. In a consumer relationship, the seller has no
particular authority ; if anything, legitimated
power rests in the buyer, who can make the
decision to buy or not to buy, as he or she sees
fit (Haug and Lavin, 1981),
27
These authors see consumerism as a social movement and the
logical reaction to the increasing monopolization of
medical knowledge and practice that has occurred over the
past several decades.
The structural roots of contemporary consumerism in
health care lie in changes in the nature of illness,
advances in technology, the uncertainty inherent in medical
practice, and the social context of illness definition
(Ibid.). The decline in mortality from infectious diseases
in the last several decades has resulted in increased life
expectancy and concommitently an increase in chronic
diseases associated with aging. Many infectious diseases
can now be prevented by immunization or easily treated with
antibiotics. This is not true of chronic and aging-related
diseases. Patients with chronic diseases must over time
discover what helps to relieve symptoms and improve
functioning. Often these patients experience the confusion
and conflict within medicine about appropriate therapy for
their conditions. Many patients become disillusioned about
medicine's ability to treat their illnesses and may
question the wisdom of health professionals.
A second factor associated with the movement toward a
consumer perspective is the rapid technological advances in
medicine which have led to less personalized care by a
28
primary physician and increased dependence on specialists
and subspecialists. Because of the knowledge explosion in
medicine no physician can keep informed in all aspects.
Wide gaps exist in physician knowledge. The fragmentation
of the patient and resultant discontinuity of care have
seriously eroded patient trust in the physician.
Consumers today are better educated, have greater
expectations for quality health care, and are more willing
to question traditional authority relationships.
Literature catering to the public's concerns in health care
and offering guidelines for dealing with the health care
system has developed in recent years. The Peoples'
Pharmacy by Joe Graedon (1976), and The Pill Book (Stern et
al., 1982) are two examples of consumers' guides to drug
therapy which attempt to demystify medical j argon and
discuss drug therapy in practical, readable language. The
most logical source of drug information for consumers would
appear to be the pharmacist. However, in one national
study it was found that two-thirds of the consumers derived
their information on nonprescription drugs from advertising
or friends, and only 20 percent of the sample mentioned the
pharmacist as the source of information (Knapp et al.,
1976).
29
Consumers have also learned, with the growth of
physician extenders, that many physician services are
expendable and can be done as well by a nurse practitioner
or physician assistant. Much of the mystery and charisma
surrounding medicine has disappeared. A final factor in
the rise of consumerism is a return to and an appreciation
for self-care and increased personal responsibility for
health maintenance, an attitude encouraged by HMOs and
health insurance companies.
This discussion of changes in consumer attitudes and
values is included to point out the willingness of
consumers to try alternative modes of health care and
sources of health information. Patients desire information
and experience frustration when they do not get it. The
concept of patient advocate has emerged in recent years as
a way of helping patients deal with the complexity of the
health care system. As will be shown below, pharmacy has
changed from a product-oriented to a patient-oriented
system, and it may be that as a patient advocate the
pharmacist can provide the information desired by
consumers.
30
2.1.3 Increased Dependence on Drug Therapy
Drug therapy has been described as the key to modern
medicine (Amerson et al., 1978). Increasing attention has
been focused on the drug component of health care in recent
years, largely because of the effectiveness of
chemotherapeutic agents in treating a wide range of
diseases. Most of the advances in health care over the
past 50 years are traceable to the introduction of new
drugs. The discovery in the 1930* s of the sulfa drugs
opened the floodgates of research for other synthetic
antibacterial agents and led to the discovery and synthesis
of hundreds of other potent drugs such as penicillin and
other antibiotics, cortisone and other steroids, the
tranquilizers, potent diuretics and antihypertensive drugs,
antihistamines, anticoagulants, antidepressants, as well as
hormonal therapy and immunizations for disease prevention.
So rapidly have drugs been developed and progress in
research made that there has been an "information
explosion" in drug therapy (Francke, 1976). "Ninety
percent of the scientists of all times are living and
publishing today. Most of the scientific literature of the
world has been published during the past 20 years. Today
more than 90 percent of the drugs used were unknown 20
years ago (Ibid.)."
31
Use of medicinal drugs has increased more than use of
any other health resource. In the 25 year period from 1950
to 1975 the number of per capita prescriptions dispensed to
ambulatory patients had increased threefold, from 2.4 to
7.6 (Rabin, 1977). Use of nonprescription medicines also
increased greatly over the same 25 year period (Ibid.).
Reasons proposed for the rapid rise in the rate of
prescribed drug use include: 1) technological advances
which have made it easier to render more precise diagnosis
of many disease states for which new drug therapies have
been developed; 2) an increased proportion of elderly in
the population which has meant continuous drug therapy for
more patients with chronic diseases; 3) increased
prosperity has meant that more people are able to purchase
medical services and this includes prescription drugs; and
4) an increased proportion of the population with health
insurance has eased the financial barriers to seeking
medical care (Ibid.). Increases in personal income and
media advertising have been proposed as factors
contributing to the increased use of nonprescription,
"over-the-counter" (OTC) products.
32
2,1.3.1 Adverse Drug Reactions
The Commission on Drug Safety in a report issued in 1964|
noted that:
There is no way in which a drug can be made
completely safe, and it certainly cannot be made
so by law. Through legislation, a drug can be
surrounded by safeguards, but it can never be
made completely safe. In certain circumstances,
in certain dosages, any drug can be toxic. The
average American is not aware that a particular
drug which may be safe for many people may not be
safe or effective for him because of his
particular constitutional makeup or physiological
state (Gagnon, 1977).
The term "adverse drug reaction" has been defined as
"any noxious-pathologic and unintended change in the
structure (sign), function (symptom), and chemistry
(laboratory data) of the body that is not a part of the
disease and is linked with any substance used in thJ
prophylaxis, diagnosis, or therapy of disease or for the
modification of the physiologic state" (Ibid.). AdversJ
drug reactions can be categorized as: 1) drug interactions
(i.e. drug-drug, drug-food or drug-environment); 2)
secondary effects (i.e. side effects); 3) idiosyncrasies
(i.e. drug reactions that cannot be explained by the
inherent properties of drugs themselves but are due to some
altered characteristics within the patient taking it); and
4) hypersensitivities (i.e. drug allergies) (Maudlin,
1973). The incidence of adverse drug reactions has'
33
increased significantly over the past 10-15 years due, in
part, to the prescribing of more drugs for patients, the
use of more OTC products, and the development of more
potent drugs. Cluff, Caranasos and Stewart have stated:
Intensive epidemiologic surveillance of
hospitalized patients in the United States and
abroad has shown that 2 to 5 percent of patient
admissions to the medical and pediatric services
of general hospitals are attributable to
drug-induced disease. Five to 30 percent of
patients experience adverse reactions to drugs
during hospitalization. An unknown proportion of
fetal abnormalities may be attributable to drugs
taken by the mother during pregnancy or
administered during parturition. An undetermined
number of illnesses caused by drugs are
responsible for visits of patients to physicians *
offices. Conceivably, some diseases for which
causes have not been demonstrated or which are
widespread may have been induced by drugs (1975,
p. 10).
As drugs have become more effective, they also have
become more complex, and their inappropriate use, singly
and in combination, is now a significant cause of ill
health. This point has been illustrated by continued
reports in the literature that a significant number of
patients are hospitalized because of drug-related problems
(i.e. adverse drug reactions, patient non-compliance, and
medication errors).
Once in the hospital, the patient is still not immune to
I
drug-related complications. The problem of medication}
errors was first reported in the literature in 1962 by!
34
Barker and McConnell. The study reported one error in'
every six doses administered in the hospital setting.
Hynniman and co-workers (1970) reported medication error
rates from 8-20 percent in four hospitals. Also appearing
in the medical literature beginning in the mid 1960 * s were
epidemiologic studies of adverse drug reactions of patients
treated in hospitals (Seidl et al., 1966; Ogilvie and'
Ruedy, 1967; Schimmel, 1964) which found, in general, that
10-15 percent of hospitalized patients experienced an
adverse drug reaction during their hospital stay ; those
patients with adverse reactions stayed an average of nine
days longer than patients without reactions; as the number
of drugs a patient received increased, the incidence of
adverse reaction increased proportionately ; and finally,
the majority of reactions (81 %) were due to pharmacological
action of the drug and were, therefore, predictable and
preventable.
Traditionally drug distribution in the hospital setting
I
revolved around the nurse and her staff. Twenty-twoj
percent of total nursing time was devoted to medication
activities with the nurse practicing more pharmacy than did
the pharmacist (Smith and Mackewicz, 1972, p 71). During
the 1960 * s pharmacists in hospitals responded aggressively
to the problems associated with drug distribution and drug
35
therapy, and decentralized satellite pharmacies and unit
dose drug distribution systems were developed. Other
services developed included patient medication profiles,
drug information centers, participation of pharmacists in
patient care rounds, drug therapy conferences for
physicians and nurses, and patient drug monitoring services
(Ibid.).
If one were lulled into a false sense of security by
believing that medication errors are a thing of the past,
one needs only to read the daily newspaper. The January
19, 1984 issue of the Los Angeles Times (part I, page 2)
reported the following news brief abstracted from a recent
article in the New England Journal of Medicine (Steel et
al., 1981):
Doctors who investigated a fatal mixup in which
children were injected with the wrong drug say
such errors in hospitals are being reported "with
alarming regularity." One newborn died and five
others fell seriously ill two years ago when they
were mistakenly injected with a medicine that was
meant to be inhaled. Investigators blamed that
tragedy on nurses* failure to read look-alike
labels. Researchers said other reports show that
errors occur in as many as one in six doses of
medicine administered in hospitals, according to
a report in the New England Journal of Medicine.
Thus the relatively recent recognition of the complex!
I
interaction of many drugs which may "antagonize,!
potentiate, modify, inhibit, or destroy the action of
another drug" speaks to the need for increased knowledge
36
and expertise in this new area. The high incidence of
adverse drug reactions has been one factor in bringing the
pharmacist closer to the patient, the physician, and the
nurse (Francke, 1976).
2.1.3.2 Self-Care and Non-Compliance
As the array of drugs and other therapies has grown in
recent years, it becomes more obvious that the patient*s
conscious or unconscious decision not to comply with a
provider*s instructions for drug usage can render the most
efficacious regimen ineffective (Sackett and Haynes, 1977,
p. 335; Garrity, 1981). In a recent article in the Los
Angeles Times (4 Oct. 1983, Part I, p. 7), it was reported
that **30 percent of all prescriptions written are never
filled, and that only about 20 percent of those filled are
taken correctly.** Other estimates of the extent of
noncompliance are highly variable.
Francke and Smith (1972), in reviewing the literature on
patient compliance, found that from 15 to 93 percent of all
unsupervised patients were noncompliant with the
physician*s instructions in the use of medications. The
consumer himself often determines his own need for drugs
(prescription or OTC) and continues self-treatment until he
believes that his need no longer exists or until he seeks
37
professional assistance in determining his precise neec
(i.e. diagnosis). Even then he may be reluctant to follow
the recommendations of the health professional and may
ignore or alter the treatment plan individualized for him.
Much has been written about self-care in response to
illness (Dean, 1981; Barofsky, 1978), and self-care as a
"social movement" (Schiller and Levin, 1983). A recent
national survey reported by Maiman (1981) revealed that
from 25 to 75 percent, of a sample of adults would
self-medicate for more than 3 days for common ailments such!
as sore throat, cough, sinus congestion, head cold, hay
fever and skin problems; 12 percent would self-medicate for
longer than 2 weeks for one or more of these ailments.
Self-medication for chronic conditions occurred in about 25
percent of the sample experiencing asthma, allergies, or
hemorrhoids. Other studies reported by Maiman have found
that 75 percent of minor symptoms are treated by
self-initiated remedies and that 66 percent of the
population responds to symptoms of illness by
self-medication. Thus, self-diagnosis and self-medication
are common practices in our society: they are the first
responses to symptoms in almost half of all illness
episodes (Knapp and Knapp, 1972).
38
Because of the high reliance on self-medication,
pharmacists are in a key position to oversee a person's use
of proprietary drugs, and, when necessary, to advise these
persons to seek medical help. Two factors disturb the
relationship between pharmacists and consumers, however.
One is the consumer's concern over the price of drugs, and
the second is the stereotype of the pharmacist and of the
practice of pharmacy associated with popular images of the
typical drugstore, and particularly of the large chain
drugstore (Gagnon, 1977).
The drug-use process may be viewed as an interdependent
system in which physicians, pharmacists, nurses, and
consumers participate with each performing a particular
function; usually, however, each function is independent of
the other in both time and place (Brodie et al., 1980).
Through this process, either formally (via the
prescription) or informally (self-medication or
recommendation by others of appropriate OTC medication) the
consumer obtains biologically active substances (drugs)
(Ibid.). However, lack of effective health-related
communication between participants, and widespread misuse
(overuse, underuse, abuse) of drugs constitute major
problems in health care and severely limit the benefits
actually experienced by patients.
39
2.2 CHANGES AND TRENDS IN PHARMACY
2.2.1 Development of Pharmacy
American pharmacy has developed through three
discernable periods to its present state: 1) the early
compounding period, 2) the transitional counting and
pouring period, and 3) the emergence of clinical pharmacy
(Whitney and Archambault, 1981).
The first period ran from the early colonial days to
about the mid 1930* s and has been called the "compounding
and dispensing" era. This was the cottage pharmacy era and
pharmacists of the day (called "druggists") compounded and
dispensed prescription orders that were custom written,
often involving long and complicated recipes. These early
pharmacists were involved in a variety of professional
activities in the preparation of salves, spirits, elixirs
and pills. They also applied their drug knowledge and
skills in the treatment of common illnesses of the day.
When illnesses were encountered that exceeded their
ability, the patients were referred to local physicians for
examination. Often the pharmacist was the only "doc"
around, however, and did the best he could to see to the
health care needs of the community. *
The second period has been termed the "wandering and
floundering" period and lasted for about 40 years, from the
40
raid 1930*s to the early 1970*s (Ibid.). Industrialization
and the rapid development of the pharmaceutical industry
largely removed the compounding function from the
individual pharmacist and left him with only the dispensing
functions of "counting" and "pouring," and the sale of OTC
products. Paradoxically, during this same period the level
of education of the pharmacist more than doubled (from 2 to
5 years), and the quality of his scientific training
increased immeasurably (from a somewhat loose appreticeship
system to a sophisticated college-based program), resulting
in a well trained, educated dispenser of manufactured drugs
(Robbins, 1979). Although 80 percent of the prescriptionsj
still required the knowledge of compounding on the part of
the pharmacist in 1920, that percentage had dropped to 75j
percent by 1930, 26 percent by 1950, 4 percent by 1960j
(Kremers and Urdang, 1963), and by the mid 1970*s had
decreased to about one percent (Schumaker, 1977).
During the mid-twentieth century pharmacy was primarily
a product-oriented profession. There was widespread
confusion as to the roles to be played by thesJ
over-trained pharmacists. Pharmacy schools faced a realj
dilemma: what could they teach if practicing pharmacists no|
longer needed to know how to compound materia medica? The
schools moved into pharmaceutical chemistry areas to
41
provide students with "scientific" training, but this
knowledge was rarely used once the student entered
practice. By the end of this transitory era, pharmacy as a
profession was in the midst of a crisis of purpose.
2.2.2 Pressure for Change
The response of the profession of pharmacy to the loss
of function and the resultant stress and role ambiguity has
been a movement toward "reprofessionalization" (Birenbaum,
1982) which began in the 1960's and continues today.
Reprofessionalization has been advocated by the "elites" of
pharmacy (pharmacy leaders and educators) but has been met
with resistance from both inside and outside thJ
profession.
The goal of upgrading pharmacy into a patient-oriented,
clinical profession requires the acquisition of
qualitatively different roles from those performed by
pharmacists in the past. Birenbaum discusses the
structural changes in the organization and delivery of
pharmaceutical services which have encouraged this
collective response to the loss of power and status caused
by occupational displacement.
Birenbaum suggests that pressure to change pharmacy has
come from many sources: the decline in traditional
42
community pharmacy and the rise of large, discount drug
stores ; automation which has made individual compounding
unnecessary; the development of physician extender roles to
provide health care during the period of physician
shortages; changes in pharmacy education and recruitment of
more academically minded students ; and increased
opportunities for pharmacists to communicate with one
another and share their dissatisfactions and fears about
pharmacy practice. These socially sructured conditions
have promoted the development of the need and support for
dramatic changes in pharmacy practice. Thus, the third
period of American pharmacy will be known as the "clinical"
pharmacy era.
Birenbaum suggests that reprofessionalization represents
both a problem (loss of status and power) and an
opportunity (new roles and recognition) (Ibid.). Larson
(1977) considers professionalization a form of social
mobility and suggests that:
The professional project of social mobility is
considered as a collective project, because only
through a joint organizational effort could roles
be created - or redefined - that would bring the
desired social position to their occupants (p.
67) -
Birenbaum further suggests that pharmacy, unlike medicine,
is not seeking to enhance its status as much as it is
seeking to avoid being dispossessed :
43
The direction pharmacy is compelled to take is
away from the technical and business components
and toward the clinical service ideal.
Redefinitions of technical functions as clinical
services has occurred in the health care field in
the past. The specialties of anesthesiology,
radiology and pathology, which were once outside
of medicine, became defined as clinical services
and increased their prestige by joining it.
Pharmacy has no such goals at this time but does
demand more responsibility (1981),
A somewhat different look at the crisis in pharmacy is
presented by Mechanic:
The erosion of the pharmacist * s role is in no way
predetermined by the technical changes which have
occurred in medical care. To the contrary, the
changes which have taken place in the scientific
basis of medical care and its developing
technology demand a more rather than a less
central role for the pharmacist. The irrelevant
character of much that the pharmacist does today
is as much a result of the antiquated models of
medical care current today as it is a product of
the development of the pharmaceutical industries.
. . . important changes in medical care argue
for the substantial importance of the
pharmaceutical profession as part of the larger
health care approach. . . . Every medical team
should have a specially trained pharmacist who
is available for consultation and information. .
this would vastly improve the quality of
medical care and greatly contribute to the
integrity of the pharmacist role. The problem .
. . is not unique to pharmacy; all of the related
health professions are difficult to integrate
into current modes of outpatient practice. . . .
resistance to such change, both in pharmacy and
in medicine is based upon vested interests and
in part on certain stereotypes as to how the
other aspects of the health sector function
(1970).
The movement toward a more clinical role for pharmacists
which began in the 1960 * s can be viewed as a response to a
44
sequence of events which demanded the development of a new
role (Whitney and Archarabautt, 1981, p. 91): 1) recognition
of the importance of adverse drug reactions, drug
interactions and medication errors; 2) development of drug
information centers where health professionals could
consult with a pharmacist on drug-related problems ; 3)
creation of office-based pharmacy practice and the
development of the patient medication profile system ; 4)
adoption of the unit dose concept and satellite pharmacies
in the hospital drug distribution system; 5) establishment
of mandatory 5-year B.S. and optional 6-year Pharm.D.
degree programs of education ; and 6) changes in curriculum
and course content to increase the pharmacist*s knowledge
about patients and diseases,
2.2.3 Clinical Pharmacy
In essence, clinical pharmacy represents a reyolt by the
younger cohort against the way pharmacy as a profession has
deyeloped, the manner in which it has been practiced, the
nonreleyant isolation in which pharmacy students were
educated, the students* almost complete lack of contact
with patients, physicians and other health professionals
during pharmacy school, and the traditional role actiyities
assigned to pharmacists after completion of 5 or 6 years of
college leyel education.
45
The movement toward "clinical pharmacy" seeks to promote
a much stronger pharmacist-patient relationship and closer
interaction with physicians and other health professionals.
Llthough this movement defies strict definition, its
operational goals are to provide and integrate a
significant number of patient-oriented services. The
radition-bound patterns of pharmacy practice need to be
augmented for this movement to be successful.
Many developments in hospital pharmacy practice
contributed to the need for and acceptance of clinical
pharmacy. The acute shortage of nurses and other health
professionals of the sixties and seventies may also have
jbeen related to the need for pharmaceutical services to
become decentralized and move into the patient's
environment.
The Report of the Task Force on Pharmacists' Clinical
Role was published in 1971. This Task Force was appointed
to develop a set of working criteria for a clinical role
for the pharmacist, and was considered a preliminary step
toward the evaluation of the effectiveness and cost
feasibility of a clinical pharmacist role. Placing
emphasis on the pharmacist's role in the delivery of health
care and the professional functions that a pharmacist would
perform in a clinical role, the report discussed these
46
functions under the following categories: prescribing
drugs; dispensing and administering drugs ; documenting
professional activities; direct patient involvement;
reviewing drug utilization; education, and consultation
(Francke, 1972).
The development of a professional self-image is
extremely important for the clinical pharmacist. History
has demonstrated that when great social changes occur in a
profession they do not alter the attitudes and values of
its members until a significant number of them assume new
roles and perform successfully in them for two or three
generations. Thus, it will require considerable time for
pharmacy to transform itself and to change its patterns of
practice (Ibid*).
2.3 THE PRACTICE 0£ PHARMACY
Major changes in pharmacist characteristics, pharmacy
practice and salient aspects of the practice environment
are discussed to present a portrait of today's pharmacist.
2.3.1 Practice Setting
The practice of pharmacy differs from most other
professions in that its practitioners are identified more
often in terms of their physical settings than by the
47
nature of their professional activities. Thus while
physicians are identified by their specialities — OB/GYN,
internal medicine, dermatology, and so on, most pharmacists
are classified by practice setting — community pharmacist
(independent, chain or apothecary) or hospital pharmacist.
Clinical pharmacy represents a new orientation which is not
tied to a specific practice setting.
Each pharmacy practice setting, community retail or
hospital/institutional, is somewhat unique and differs from
the other in several ways. At the same time, pharmacists
in each setting perform essentially similar professional
tasks related to filling prescriptions, consulting with
patients and communicating with other health professionals.
Differences between pharmacists in these settings are
primarily a matter of differential time allocation to each
major type of activity. Major differences do exist in the
structural aspects of these settings, however, in terms of
position (employee versus owner), frequency of contact with
health team members, level of responsibility for patient
care, and preoccupation with making a profit to stay in
business (Robbins, 1979, p. 83).
Although hospital pharmacy has traditionally been
ancillary to medicine, community pharmacy has maintained a
unique tradition of entrepreneurial independence in
48
compounding and dispensing medicines and a high level of
autonomy in dispensing OTC products. In the hospital
setting the pharmacist had been wholly subordinate to the
physician and had even less patient contact than most other
ancillary health professionals. Hospital pharmacists, like
other members of the therapeutic team, must work within the
unique bureaucratic structure of the hospital which
provides fairly narrow definitions of health professional
roles. In contrast, the community pharmacist has been
fairly free to define his profession role in terms broader
than merely being ancillary to the physician. Often the
community pharmacist is the first health professional
contacted by a patient, which places him in a strategic
position to direct the patient to the appropriate level of
care. This autonomous "triage" function often approaches
medical diagnosis. Thus the community pharmacist is
already somewhat autonomous and independent relative to the
medical profession; he attracts his own clientele and is
not dependent on specific prescribers but rather
prescribers in general.
The term "clinical pharmacist" carries different role
implications depending on whether the pharmacist is in a
hospital or community setting. In the hospital setting the
pharmacist must remain ancillary to the physician and
49
subject both to his authority and that of the hospital
pharmacy administration. Expansion of the role to include
drug history taking, advising physicians on drugs,
monitoring for drug interactions, and consulting with'
patients on drug administration and reactions, encroaches
on the physician's or nurse's role and is permitted only
"by their leave" (Wardwell, 1974). If these new functions'
are not accepted by them, no real change in the
pharmacist's role can take place.
Even when a physician shares some of his functions with'
a pharmacist, he retains ultimate responsibility for their
joint patients, leaving the pharmacist with little real
autonomy. Recent legislation in California has changed
this somewhat, granting the pharmacist practicing in ah
institutional setting authority to take more responsibility
for patient care (Johnson, 1982; Stimmel, 1983).
In the community setting, the term "clinical" applies to
such activities as fitting surgical and medical appliances,
taking patients' blood pressure or other vital signs,
teaching patients how to test urine for glucose and
i
acetone, and to use serum glucose monitoring equipment; and
providing pharmacy services to home care patients. Concern
has been expressed about role boundary conflicts with otherj
I
ancillary health care professions and confusion for
50
patients who encounter the pharmacist in one of these new
roles (Wardwell, 1974).
The health maintenance organization (HMO) has been
suggested as a good setting for clinical pharmacy.
Complete health care is provided by a team, there is a
minimum of commercial orientation with fewer barriers to
the development of positive interprofessional interaction.
Once the team has been established, each professional
generally can do his own thing with minimal physician
supervision.
2.3.2 Changes in Socialization
As suggested previously, the pharmacist of today is
qualitatively different from the pharmacist of 20 years
ago. Major changes have occurred in the pharmacy school
curriculum which have brought about the recruitment of a
different breed of student. Salient differences between
these two cohorts (i.e. younger versus older pharmacists)
in terms of terminal degree, sex and ethnic distribution,
and preferred practice location will are discussed below.
2.3.2.1 Pharm.D. or B.S.?
Unlike medicine, which is a single terminal degree
profession (i.e. M.D. degree), pharmacy currently has two
51
""terminal degrees (and two levels of practice). Pharmacists
may be licensed after graduation from pharmacy schools that]
grant the baccalaureate degree (B.S.Pharm.) or the doctoral
degree (Pharm.D.). The emphasis in these two types of
degree programs is somewhat different, with the doctoral
level programs stressing patient-oriented, clinical
practice, and the B.S. level programs stressing more
traditional aspects of pharmacy practice.
A pharmacist holding the Doctor of Pharmacy degree has
been educated and trained as a drug specialist and can
legitimately be called a clinical pharmacist (Biles, 1983).
Currently 24 accredited schools of pharmacy offer the
Pharm.D. degree. These schools require a minimum of 2
years of prepharmacy education plus 4 years of pharmacy
school. Approximately half of the students admitted to
these schools have completed 4 or more years of college
level work; most of them hold a baccalaureate degree in
biology, biochemistry, chemistry, microbiology or
psychology (Ibid.).
Although graduates of B.S, in Pharmacy programs may gain
knowledge and expertise in clinical pharmacy through
postgraduate education programs or residency training, the
majority of these students enter traditional pharmacy
practice. Students from both types of programs are being
52
socialized similarly, however, in terms of the change in
values in pharmacy from a product- to a patient-oriented
profession. Courses have been added to both curricula to
provide students the necessary background to understand
patients' social and psychological needs and disease
processes. With these changes in educational content and
value orientation have come changes in the types of
students attracted to pharmacy.
2.3.2.2 New Recruits
Until quite recently, the overwhelming majority of
pharmacists were male and Caucasian. For the first time
the majority of students in some pharmacy schools are women
(Kronus, 1977). In a random survey of California
pharmacists, McGhan and Adamcik (1982) found that 20
percent of practicing pharmacists were women. Speedie
(1981) reported that 500 of 1132 (44.2%) students enrolled
in the three pharmacy schools in California were women.
Women graduates tend to settle into institutional pharmacy
practice, with fewer women pursuing careers in retail
pharmacy (McGhan and Adamcik, 1981, 1982).
A related change has been the rapid increase in number
of Asian-background pharmacy students, particularly in
California schools. Although no study has reported the
53
"ethnie distribution for California pharmacists, Speedie
(1981) did present a breakdown by ethnie group of students
enrolled in California pharmacy schools. Of the 1132
pharmacy students enrolled in the state, 448 (40%) were of
Asian background. There are still very few black,
Mexican-American, or other minority pharmacy students or
practicing pharmacists. Like women graduates, these
minority men and women are gravitating toward hospital
pharmacy practice (McGhan et al., 1983). The percentages
of female and Asian practicing pharmacists will continue to
rise rapidly in the next few years as students from these
groups enter the profession. The impact of these
demographic changes on the profession is not known at the
present time and will make an interesting study in the
future.
2.3.3 Levels of Practice
At the present time in pharmacy there are two levels of
practice. The rank and file pharmacist is still primarily
concerned with dispensing medications and providing some
degree of information and education to patients and health
care professionals in a variety of settings. The majority
of these pharmacists were educated at the baccalaureate
level, although many pharmacists with a Pharm.D. degree
54
also practice at this level. The second level of practice
is seen in the clinical pharmacist who generally practices
in health care institutions (although some are in private
co-practice with a physician) and provide a higher level of
patient care.
Most clinical pharmacists are trained at the doctoral
level as drug specialists and provide supportive services
to physicians, nurses and patients. In addition to
traditional compounding, dispensing and administering
drugs, these pharmacists are competent to compound
hyperalimentation therapy and intravenous admixtures as
well as to train patients and nurses in their use; elicit a
drug history from hospitalized and ambulant patients;
provide consultative services to health professionals on
generalized and patient-specific drug information ; review a
patient's total drug regimen for potential problems and
where appropriate make recommendations for alterations in
therapy to the prescriber; screen patients and direct them
to sources of appropriate care ; and provide education to
the community on drugs (Biles, 1983).
Whether the dual level of pharmacy practice will
continue remains to be seen. It seems likely that once
"unit-of-use" packaging is instituted in the community
pharmacy setting there will be little need to have a
55
pharmacist dispense. A pharmacy technician could just ring
up the sale.
2.3.4 Relevance of Changes in Pharmacy
Cantril (194*1) has noted that when structural changes
within a social system are rapid, the innovators and the
adherents of the changes are likely to be young. The older
person, in the face of these changes, may be unable to
adjust to novel arrangements because he has no role models
consistent with prior experience and values.
In view of the dynamic technological and social changes
which have occurred in the profession of pharmacy in the
past half-century, one would expect significant differences
between older versus younger pharmacists in attitudes
toward and acceptance of the new clinical pharmacist role.
Since the major changes in socialization and recruitment
occurred in the mid to late 1960»s, those pharmacists who
graduated in 1970 and later are considered the "younger"
cohort, and those who graduated prior to 1970, the "older"
cohort. Because recent pharmacy graduates appear to
gravitate toward hospital or institutional pharmacy
practice, one would also expect there to be significant
differences based on practice location.
56
2.4 MAJOR ISSUES IN STUDIES OF PHARMACY
An analysis of the limited studies of pharmacy and
pharmacists reveals several major issues which have been
dealt with in the past and which continue to be of
interest: 1) the dualistic nature of the pharmacist's role,
i.e. the professional versus business orientation in
community pharmacy practice; 2) the degree of role stress
and resultant psychological strain experienced by
pharmacists as a result of this role conflict; 3) the
preferred and actual role activities of pharmacists ; 4)
attitudes about pharmacists and pharmacy ; 5) acceptance of
an expanded pharmacy role ; and 6) barriers to changes which
would move pharmacy toward optimal pharmaceutical care of
patients. The literature has been reviewed in several of
these areas.
2.4.1 Continuing Role Conflict
The sociological study of pharmacy began with Thorner
(1942) who first focused on the unique business and
professional elements inherent in the practice of retail
pharmacy. He defined the pharmacist's social function as
that of the preparation and distribution of drugs, which
involved a professionally skilled service, and pointed out
the conflicting nature of the pharmacist's role when
57
distribution occurs in the commercial environment. At the
time of Thorner*s study, over 80 percent of pharmacists
worked in "drug stores," and hospital pharmacy had not yet
begun to develop.
This theme was further elaborated upon by McCormack
(1956) who went so far as to define pharmacy as a marginal
occupation because of the conflict between the professional
and business roles :
Pharmacy is of special interest because, unlike
new or anti-social occupations, its marginality
is of degree rather than kind. Its structure is
sufficiently undefined so that it may attract
persons who are marginal in the social structure
and who impose the concomitants of the ambiguous
status on the occupation. Its functions are
sufficiently unclear that the problems of
acquiring sanction and legitimacy persist.
The goal of McCormack's study of first year pharmacy
students was to "assess how persons entering a marginal
occupation handle their special status subjectively; their
ideological frame of reference; projected image; and
orientation toward professional or business goals." He
felt the study of marginal occupations to be important to
the development of theories of social stratification and
suggested that "the processes of change and adjustment in
occupations would be more visible in those which lie along
the edges of any given classification system than
elsewhere."
58
McCormack described the marginal role of the pharmacist
in both functionalist and interactionist frameworks.
Because of changes in the compounding of drugs which begar
in the 1950* s, the marginality of the pharmacist* s role
matched the changing definition of the occupation's
function (with increased focus on distribution of
manufactured products). Marginality was also seen in the
resultant discrepancy between pharmacy students'
self-perceptions and the perceptions by others concerning
pharmacy's status (i.e. loss of). He found that pharmacy
students tended to view their own prestige as being much
higher than did the general population.
The marginality of pharmacy was further elaborated upon
by Quinney (1963, 1964) who explored the adaptation of
pharmacists to "occupational role organization" which he
defined as "the relative orientation of retail pharmacists
to both the professional and business roles." Quinney
pointed out that some occupations incorporate two or more
roles, rather than a single, well-defined role, and when
these multiple roles are to some degree contradictory and
incompatible, the individual must act to adjust to the
conflict. He found pharmacists to be aware of the duality
of their roles, with the majority experiencing some role
conflict. He classified pharmacists on the basis of their
adherence to both business as well as professional roles.
59
Because of the existence of the two divergent roles,
Quinney hypothesized that pharmacists would choose either
one of the roles (i.e. business orientation or professional
orientation) while abandoning the other, would attempt some
compromise of the two (mixed orientation), or would attempt
to avoid both sets of expectations (indifferent
orientation). He found that pharmacists adjusted to the
"occupational role strain" by orienting themselves in
varying degrees to both roles, and used this typology to
study level of prescription violations by pharmacists.
Thus it has been shown repeatedly that pharmacy is a
profession in conflict. As pharmacy has progressed,
loyalties and commitments have developed in two separate
and sometimes antagonistic areas. Each orientation
(professional versus business/commercial) tends to
perpetuate its own values which has led to long-term]
conflict within the profession, with
professionally-oriented pharmacists often viewing
business-oriented pharmacists with disdain (Kapnick et al.,
1970). Professionally-oriented pharmacists are generally
interested in "intellectual pursuits, health care,
preventive services and treatment proceses," whereas a
business orientation leads to interest in "products,
practical problem solving and profit-making" (Ibid.),
60
2.4.1.1 Role Stress
There is much indirect evidence of the stress inherent
in the profession of pharmacy, despite the lack of direct
investigation, such as a high suicide rate for pharmacists
(Rose and Rosow, 1973; Murray, 1974), significant turnover
problems (Powell, 1972), and a high rate of attrition from
pharmacy practice (Thurlow, 1974). Curtiss has dealt
extensively with this issue of role stress and role strain
in looking at the quality of "fit" between expectations of
pharmacists (based on education) and reality (actual
practice environment) (Curtiss et al., 1978a; Curtiss et
al., 1978b). It is not surprising that with the higher
levels of pharmacist education there would be increased
frustration and dissatisfaction when the new cohort of
pharmacists becomes employed.
2.4.1.2 Ideal versus Actual
As early as 1965 Knapp et al. demonstrated a discrepancy
between pharmacists' perceptions of the "ideal" and
"actual" in pharmacy practice. The ideal pharmacist was
seen as performing mainly professional functions, while the
actual pharmacist was found to be performing mainly
business functions.
61
Shaw (1972), in analyzing pharmacy's lack of social
acceptance as a true profession, suggested that the retail
pharmacist was generally alienated from a professional
orientation due in part to his training, the structure of
interpersonal relations in the pharmacy, economics,
restrictive government laws, lack of ego-autonomy and the
professional organizations. He suggested that the dual
role in retail pharmacy engendered ego-straining problems
for the pharmacist since a major difference between
professions and other occupations is norms of service which
supposedly govern the professions. He further suggested
that the degree of alienation in pharmacy was dependent
upon the lack of ego-autonomy available over the
pharmacist's practice.
Linn and Davis (1971) were the first researchers to
investigate empirically what retail pharmacists actually
did. In addition to identifying how much time pharmacists
spent in professional versus nonprofessional services and
activities, and how much time pharmacists would prefer to
spend in those activities, they were interested in
determining the demographic, social and environmental
characteristics associated with the difference between
actual and preferred.
62
Linn and Davis found that strong professional interests
and involvements were most likely among pharmacists just
entering the profession and less likely among older
professionals. They also suggested that the business
environment of a pharmacy significantly affected both the
activity and the orientation of the pharmacists it
employed. They found that professional interests and
activities were highest in those pharmacists who worked in
fiscally sound pharmacies (i.e. stores where business had
been increasing over the previous 3 years), and in
pharmacies in minority group neighborhoods, where the
demands placed upon the pharmacist may be different from
those in predominantly white neighborhoods.
Wilson (1974) has noted that in low income areas, the
pharmacist often is "the health professional in closest
contact with the people. Public health facilities are
often far away. There is usually a paucity of physicians
and dentists, and self-medication is the rule rather than
the exception. ”
2.4.2 Perceptions of the Role of the Pharmacist
In 1970 Mechanic stated that "we know little about how
pharmacists view themselves, how they see their place in
medical care, how they relate to other health
63
professionals, or how they view their responsibilities."
Although there are abundant data on other health workers,
I
i the literature is sparse on studies of pharmacists. There
! have been a limited number of studies comparing the
perceptions of different medical occupational groups, both
of themselves, each other, and their clients, but pharmacy
has systematically been excluded from most of these studies
(Burkett et al., 1978; Westbrook, 1978; Shorten, 1974;
Nunnally and Kiltross, 1958; Furnham et al., 1981).
Possibly because of the lack of attention paid to
pharmacy in studies of health professions, pharmacy has, in
recent years, begun to study itself (Smith, 1968).
Although no study has examined each significant member of
the pharmacist's role set simultaneously, several studies
have looked at one or more groups in relation to specific
aspects of the pharmacist's role (Belasco and Arbeit, 1969;
Davis et al., 1976; Yellin and Norwood, 1974; Knapp and
Knapp, 1970).
Knapp, Knapp and Edwards (1969), concerned with the:
perceived occupational roles of pharmacists, conducted a
study to assess attitudes toward pharmacists held by
pharmacists, consumers and physicians. They found that all
groups, including pharmacists, placed the pharmacist closer
to the concept of technician than that of professional.
64
Most of the subject groups did not appear to hold the
pharmacist in very high regard. The major exception to
this finding was the strong, positive attitude toward the
role held by pharmacy leaders. Knapp and co-workers
concluded that there would have to be significant attitude
changes on the part of all concerned. They also suggested
that pharmacists believed physicians to be more negative
and critical than they actually were, and that if
pharmacists were aware of the willingness of some
physicians to accept them on a more equal level, they might
be less hesitant in offering more professional services.
Lambert and co-workers (1977) surveyed physicians,
social workers, osteopaths, nurses and other health
professionals of the Minnesota Public Health Association
and found that efforts to incorporate clinical pharmacy
services into practice had not been entirely successful.
These researchers suggested that possibly pharmacists were
not aware of their full range of possible activities and
were not sufficiently aggressive to cultivate new areas.
A substantial amount of research has been conducted on
attitudes of physicians and others toward clinical pharmacy
(Anderson and Winship, 1971; Bernstein et al., 1978; Knapp
et al., 1969; Lambert et al., 1977; McKay and Jackson,
1978; Pitliok and Plein, 1973; Ritchey and Raney, 1981 A;
Ritchey and Raney, 1981B). There have been mixed findings.
65
Although generally physicians have been found to be
somewhat negative toward most clinical services, Ritchey
and Raney (1981 A), in looking at factors associated with
physicians' acceptance of pharmacy services, found that
physicians were least supportive of tasks that allowed the
pharmacist to make independent technical-therapy decisions
such as choice of drug, and most favorable toward
traditional clerical tasks such as maintaining patient drug
profiles. They found young physicians to be more favorable
toward pharmacists becoming involved in direct patient
care, but only in terms of adjunct tasks which facilitate
the physician's role. In addition to the age factor, they
also found that physicians who spent a large part of their
time in the hospital setting, and those with past working
experience with a clinical pharmacist were the most
supportive.
In a second study by Ritchey and Raney on the effect of
exposure to clinical pharmacists on physicians' attitudes
toward clinical pharmacy, a positive effect was
demonstrated (I98IB). The survey measured the extent to
which physicians felt pharmacists in the hospital setting
should maintain drug profiles, monitor prescribing patterns
of physicians to prevent adverse reactions, counsel
patients at the bedside, determine the frequency of use and
66
dosage form of drugs prescribed by the physician, and
independently select the drug to be prescribed based on the
physician's diagnosis. While all physicians were
unfavorable to pharmacists independently choosing drugs,
those physicians exposed to a clinical pharmacist were
significantly more positive toward pharmacists counseling
patients and determining frequency of use and dosage form
of prescribed drugs. Over 90 percent of physicians exposed
to a clinical pharmacist ranked their quality of work as
good or excellent.
Bernstein et al. (1978) categorized the type of
physician most likely to use and have a positive attitude
toward clinical pharmacy services, and suggested that the
optimal situation occurs when the physician is young, group
practice oriented, writes a large number of prescriptions,
and has been exposed to the services of a clinical
pharmacist.
As reported previously, McKay and Jackson (1978) found
that physicians in their study were more favorable toward
the physician assistant, compared to the pharmacist,
performing the tasks of drug therapy monitoring and chronic
disease maintenance.
A majority of attitudinal studies have focused on
factors influencing consumer patronage of pharmacies. Only
67
a few studies have been done of consumers* attitudes toward
expanded pharmacy practice. Gagnon (1977) found that
consumers wanted personalized, professional contact with
their pharmacists, desired assurance of having the
pharmacist available when they need him, and felt it
important for the pharmacist to keep patient records.
Patients in a family care practice were asked to evaluate
the quality of health care received both with and without
pharmacist consultation. Those patients who had pharmacist
contact were significantly more satisfied with their health
care than those who did not (Helling et al., 1979).
Wertheimer et al. (1975), utilizing a consumer panel,
found that consumers "want to converse directly with the
pharmacist and want to know their pharmacist." Norwood et
al. (1976) examined the attitudes of rural consumers and
physicians and concluded that enthusiasm for greatly
enlarged pharmacy roles (i.e. preliminary diagnosis,
screening, and treatment) is not shared by the rural
consumers or physicians. Both groups, however, did support
provision of health information and treatment in
emergencies by the pharmacist. Galloway and Eby (1971)
assessed the attitudes of poverty area consumers toward
various pharmacy roles and found that such persons tended
to view expanded pharmacy roles more favorably than did
higher income consumers.
68
2.5 SUMMARY
It is difficult to draw any conclusions from this review
of studies of attitudes toward pharmacy. Because of the
rapid changes occurring in the profession over the past 10
to 20 years, it is' inappropriate to assume that earlier
attitudes still prevail. Several major limitations of
these studies make it difficult to tell where pharmacy
stands. First, no study assessed the attitudes of
physicians, nurses, consumers, practicing pharmacists, and
pharmacy leaders using the same instruments. This makes it
impossible to compare across groups. Second, in most
studies of attitudes of health professionals, pharmacy has
systematically been excluded.
69
Chapter III
THEORY
From the preceeding review of the literature on
pharmacy, it is apparent that pharmacy as a profession
finds itself in the midst of a crisis of purpose. The
response to this crisis over the past 10 to 15 years has
been a restructuring of pharmacy from essentially a
product-oriented to a patient-oriented health profession.
It has been suggested that when a profession seeks to
change its position in society, it may be an unsettling
experience, challenging traditional beliefs held by those
inside as well as outside the occupation (Bucher and
Strauss, 1961). Not surprising, support for increased
education and new responsibilities may vary within an
occupational community. Not all practitioners seek change,
and elite groups or segments within a profession may be
identified as the "initiators" of new roles. In addition,
those seeking change must contend with resistance from
those outside the profession who have a vested interest in
maintaining the status quo.
70
In this chapter, the theoretical background for the
present study is explored. In order to understand the
challenges faced by this evolving profession, it .is
necessary to look beyond the profession itself and focus on
pharmacy*s position within the hierarchical structure of
the health care system. Relevant theoretical perspectives
to be discussed in the development of hypotheses include
role theory and symbolic interactionism, process and power
models of professionalization, systems theory and
stratification theory.
As outlined in Chapter I, this study is concerned with
both inter-group and intra-group perceptions of the role of
the pharmacist and acceptance of a new clinical role.
Hypotheses were developed to address both of these major
areas of inquiry.
3.1 ASSESSMENT OF SOCIAL ROLES
Few studies have been designed to assess social roles
empirically. Often the nature of a social role is merely
assumed and other, more interesting aspects of a role such
as role ambiguity or conflict are focused upon. Until the
seminal study of Gross, Mason and McEachern in 1958 on the
role of the school superintendent, role consensus was not a
salient vari able to be considered, and most theoretical
positions merely assume that role consensus existed.
71
Social roles may be defined in three ways: 1) role
incumbents may be questioned directly concerning the
expectations (i.e. rights and duties) of their position. 2)
; Roles may be inferred from an examination of the behaviors
of a person occupying a particular role (i.e. what the
person actually does). And finally, 3) roles may be
assessed by reviewing written documents where the
expectations, behaviors and attitudes that define a social
role may be stated formally or informally (e.g. literaturq
review, formal "standards of practice," codes of ethics,
and legal statures). The role of the pharmacist is ir
transition. It is not clearly defined and there is much
ambiguity associated with the role. Data from all three
resource areas have been utilized in the development of s
definition for this study.
It is important to assess how an emerging or changing
profession is perceived for a number of reasons. First,
such information gives those within the profession a
measure of how adequately services are being provided and
whether or not those services are reaching the groups for
ft
which they were intended. Second, by assessing the views
of other members of a profession* s role set, the accuracy]
with which a professional role is perceived can be gauged.
Finally, since each person relates to other role set!
72:
members according the way he thinks they are being
perceived, it is important to have a clear idea of how one
is in fact perceived. Kilwein (1981), for example, has
suggested that pharmacists tend to minimize the esteem in
which they are held by consumers and other health
professionals alike, and that this underestimation may
result in a lowering of professional assertiveness. This
study is an attempt to understand how pharmacists
themselves, consumers and other health professionals view
the profession of pharmacy in general, and specifically,
how the new pa tient-oriented role is perceived and
accepted.
3.2 SOCIAL ROLES AND CHANGE
In general the term "role" is used to represent the
behavior(s) expected of the occupant of a given position
and status in a social pattern, system or subsystem
(Sarbin, 1943). Position is the place occupied in that
pattern or system, and status is the rank or importance of
that place.
I^ classic role theory, society is viewed as a network
of interrelated positions in which individuals enact social
roles. Each position has associated with it a set of
expectations (norms) which specify how the incumbent of a
73
position is to behave. Individuals in society are viewed
as occupying clearcut positions and conforming to norms.
The individual is seen as assessing and interpreting what
is expected of him by others, and has the option of
deciding how to respond to these perceived expectations. A
major focus of role theorists has been how the role
incumbent adjusts and adapts to these perceived demands of
others. Role theory takes note of potential strain in the
social structure and defines it as role conflict
(contradictions among expectations), role strain (inability
to meet all expectations), or role ambiguity (lack of
clearcut expectations) (Hardy, 1978). Such strain and
srife, however defined, is generally viewed as "deviance, "
and potentially conflicting roles are viewed as normally
non-overlapping and separated in time and/or context
(Ibid.).
Three aspects are involved in role playing. First, the
individual must have accurate knowledge of the status(es)
to which he has been assigned by members of his role set.
Second, he must be involved in a continuous process to
ascertain the behaviors that are expected of him by role
set members. Finally, he must comply with the perceived
expectations. If the expectations of others cannot be met
or are in conflict with the individual * s other roles or
74
values, then he must take action to reduce the stress
resulting from non-compliance. This is seen as a
continuous and cyclic process. The individual * s
self-concept determines how roles are perceived and
ultimately carried out, and in turn is affected by
enactment of his roles (Turner, 1978).
Role theory is useful in examining behavior in terms of
social status and roles, as a person*s knowledge of his own
identity in terms of role or social position is seen as a
powerful index of his behavior. The reciprocal of this is
also true, that is, knowledge of another individual * s role
identity is a powerful determinant of one’s own attitudes
and behaviors. One’s dominant perception of another’s role
influences greatly what is expected from the other person.
For example, if the pharmacist is seen as primarily a
retailer of drugs or a businessman, then individuals who
hold this view will develop a particular set of
expectations for the pharmacist’s role. On the other hand,
if the pharmacist is seen in a more professional light, as
an autonomous health care professional, a drug therapy
expert, then a different set of expectations will develop
among individuals who so perceive the pharmacist’s role.
Therefore, differing orientations to a particular social
position would be expected to result in differing sets of
75
expectations for behavior of incumbents of that focal
position.
In contrast to role theory which views interactions as
structured by expectations, symbolic interactionism
conceptualizes interaction as reciprocal social exchange
and focuses on the strategic adjustments and readjustments
of players in a "game" (Maykovich, 1980). A symbolic
interactionist interpretation of roles and role behavior is
concerned with the meaning which the acts and symbols of
actors in the process of interaction have for each other.
Thus actors are viewed as continually negotiating and
renegotiating their social roles vis-a-vis one another. In
this process "role-making" may occur where role
modification is consciously entered into (Conway, 1978, p.
24). Both role-taking and role-making involve taking the
attitudes of others who are involved in an interaction.
The health care system is one of the most rapidly
expanding and complex systems within society. Scientific
knowledge has grown markedly in recent years and the field
of health care has experienced a proliferation of new roles
and rapid modification of established roles. The attempt*
i
to cope with demands related to the exponential increase in
technology and medical knowledge, and the expanding healthl
care system itself, have been identified as major sources
76
of role stress. Health professionals are faced with the
continuing need to redefine and realign their roles in
relationships of professional to professional, and
professional to consumer. It is within this impetus toward
role redefinition and realignment that the above
theoretical perspectives can be used to understand the
process of role change and how roles evolve over time. In
addition, it suggests means by which present role patterns
could intentionally be altered. These perspectives,
however, are less useful in explaining more macro level
role changes.
Of primary concern to this study are the expectations
held for an actor by others in the role set, and the
actor’s perceptions of those expectations. It is useful to
break down the separate components of a role and evaluate
expectations component by component. Turner (1978) has
suggested that the normative components of most roles are
ordered in importance from mandatory to discretional.
Pharmacy practice, regardless of the setting, generally
calls for a number of key role-related activities. These
include filling prescriptions, consulting with patients on
prescription-related matters, consulting with patients on
nonprescription medications, communicating with physicians
and other health professionals on drug-related matters, and
77
the administrative and managerial aspects of pharmacy
practice. Each of these major areas of activity is
composed of a number of specific role behaviors which are
also ordered from mandatory to discretional. Therefore,
those role activities which are considered "mandatory" tend
to be deeply internalized, and difficulties in conforming
to them tend to be more stressful than with the more
discretionary activities.
Those activities of pharmacists that are considered
"mandatory" are more critical to the actor’s and role set
members’ primary expectations and are expected to be
weighted more heavily that discretional activities.
Therefore, more consensus concerning those activities which
could be defined as traditional "core" activities of
pharmacists is expected than for the newer "clinical"
activities which are performed by a segment of the
profession. Greater role taking ability of pharmacists for
core (versus clinical) activities is also expected. That
is, pharmacists are expected to be more accurate in their
perceptions of role set members’ attitudes toward core
activities than toward clinical activities. In turn, those
pharmacists who perceive the appropriateness of role
activities similar to the way groups of role set members do
would experience the least amount of role strain and
stress, and greatest level of job satisfaction.
78
From the discussion above, the following hypotheses are
proposed ;
1. Consensus will be higher for traditional "core" role
activities of pharmacists than for expanded
"clinical" role activities among pharmacists.
2. Consensus will be higher for traditional "core" role
activities for pharmacists than for expanded
"clinical" role activities among role set groups
(pharmacy faculty, physicians, nurses and consumers)
whose expectations help to define the pharmacist’s
role.
3.3 MODELS OF PROFESSIONALIZATION AND CHANGE
Conflict and consensus are often reflected in the
structure of roles. Role norms and expectations are
complex in that they are often partly defined in formal
fashion and partly developed informally in the work place
by the individual in interactions with other members of the
role set. The emergent nature of roles adds further
complexity, for while the incumbent of a role may hold one
set of expectations for his own behavior, his peers and
other members of his role set may have a different set of
expectations. The problem of defining just what a role is
then becomes difficult.
79
Because of the rapid changes within the health care
system, it is important to look at prevailing models of
professions and professionalization to assess how each
accounts for social role change, and the processes by which
"emerging" professions strain toward more professional
status. Three perspectives are discussed: a conventional
or functional model based on consensus and equilibrium, and
two conflict models— a process model which focuses on
conflict within a profession, and a power or political
model which focuses on conflict between professions.
3.3.1 Functional Model
This traditional perspective, which focuses on system
integration and consensus, defines professional behavior in
terms of four essential attributes : 1) a high degree of
generalized and systematic knowledge ; 2) primary
orientation to the community interest rather than to
individual self-interest; 3) a high degree of self-control
of behavior manifest in codes of ethics internalized in the
socialization process and in voluntary professional
organizations ; and 4) a system of social rewards (income,
prestige, honor, or other symbols of work achievement)
which become ends in themselves, and not simply means to
some end of individual self-interest (Barber, 1963, p. 24).
80
The four essential attributes discussed in the
preceeding paragraph define a scale of professionalism, and
a way of assessing the extent to which it is present in
different forms of occupational performance. From these
attributes other traits of the professions can be derived.
First, since consumers and other non-professionals cannot
evaluate professional knowledge, a profession acquires
autonomy in determining its own standards of training and
practice, and in evaluating and sanctioning the behavior of
its practitioners. Second, the professions provide a more
far-reaching, intense socialization and training experience
than do other occupations. Often the amount of learning
required to enter an occupation can be used as a rough
measure of the knowledge base upon which professional
status is granted. Finally, as stated above, the
professional organizations serve to control the conduct of
their members. Another, even more important function,
however, is to protect the professions from external
control through legal and political mechanisms (Denzin and
Mettlin, 1968; Goode, 1969; Pavalko, 1972).
The functional approach assumes the importance of
internal changes within an occupation, the maintenance of
equilibrium within the process, and the professions’
improved adaptive capacity.
81
In rather simplistic terms, the functional perspective
views a profession largely as a relatively homogeneous
community whose members share identity, values, role
definitions and interests (Goode, 1957). Socialization of
recruits consists of induction into the common core which
defines the profession.
The study of social change is difficult within this
framework. The major difficulty in this approach to
professionalization lies in its failure to appreciate the
external forces operating upon occupations, such as
industrialization and bureaucratization, and the
conflicting nature of interaction among various systems and
institutions (Maykovich, 1980, p. 270).
The major type of social change which can be explained
by this perspective is the process of differentiation. For
example, in the early history of medicine, physicians
dispensed medicine and operated drug stores. Later, the
preparation of medicaments became the specialized function
of the pharmacist, who did not have the same level of
training as the physician. Differentiation has also
occurred within the nursing role and it may be that the
physician’s role is being differentiated with routine care
being provided by physician extender roles (i.e. physician
assistants and nurse practitioners).
82
The functional perspective portrays professions as thei
legitimate domains of expertise. Members of professions
have extended theoretical knowledge in a body of esoteric
and highly prized knowledge. They share a special altruism;
or commitment to service. The professionals* unusual
autonomy in work is acknowledged and this independence is
deemed appropriate, even essential. Because of the
possession of special knowledge, professionals alone are
fully equipped to judge and direct its application. The
profession’s clientele can grant this broad license with
confidence because of the altruism that distinguishes thej
professions from other occupations.
Freed from most external supervision, professionals
develop their own codes of ethics to ensure the responsible
use of their knowledge. Mechanisms of peer review to
monitor and regulate practitioners are often set up. In
addition, professions carefully control access to their
special privileges, setting standards for the education and
certification of new practitioners to guarantee their;
competence and worthiness. Often professionals develop a
special orientation to work which permeates their
personalities. This perspective assumes the hierarchical
organization of knowledge to be necessary and desirable,
and that a profession’s power is derived primarily from the]
support of a broad social consensus.
83
The extensive discussion of the functional model of
professionalization was included to provide a baseline and
background for the discussion that follows of conflict
models of professionalization which developed to explain
more macro level change within the professions. The
functional model, although the dominant perspective in
sociology for many years, does not allow for the
development of hypotheses concerning rapidly occurring
changes in the health care professions. Models based on
conflict and power differentials within and between
professions have emerged recently and provide a more useful
theoretical perspective for understanding major social role
changes in the health professions.
3.3.2 Process Model
A process approach to professions and
professionalization focuses upon the diversity and conflict
of interest within a profession and the implications of
this for change. This model posits the existence of a
number of groups or segments within a profession which tend
to take on the characteristics of a social movement (Bucher
and Strauss, 1961; Bucher, 1962; Coe, 1970). The notion of
segments refers to organized identities and not simply
differentiation along certain issues, Bucher and Strauss
(1961) suggest that;
84
Segments are not fixed, perpetually defined parts
of the body professional. They tend to be more
or less continually undergoing change. They take
form and develop, they are modified and they
disappear. Movement is forced upon them by
changes in their conceptual and technical
apparatus, in the institutional conditions of
work, and in their relationship to other segments
and occupations. Each generation engages in
spelling out, again, what it is about and where
it is going. In this process, boundaries become
diffuse as generations overlap and different loci
of professional activity articulate somewhat
different definitions of the work situation. Out
of this fluidity new groupings may emerge.
Thus segments are seen as developing distinctive
identities and a sense of the past and goals for the
future. They organize activities which will secure an
institutional position and implement their distinctive
goals. It is in the competition and conflict of segments
in movement that the organization of a profession shifts.
The process approach focuses on structural heterogeneity
and value diversity in the professions. It views
professions as composed of many interests or segments
pursuing different objectives, at times coming into
conflict, and at other times forming loose coalitions to
resist or overwhelm other more powerful interests. This
model also considers the role of dominant professions in
the larger institutional complex within which other
professions operate (i.e. health care, welfare or legal
systems) (Bucher and Strauss, 1962; Friedson, 1970A;
Ladinsky, 1971).
85
The professional attributes discussed previously in
terms of occupational self-control (e.g. codes of ethics,
licensure, and control over who may enter the profession)
are viewed in this model as "mechanisms for domination and
control manipulated by certain segments to the exclusion of
others, or by certain professions in an institutional arena
to the disadvantage of other professions in that arena"
(Ladinsky, 1971).
The process model addresses issues of differentiation,
conflict and change in professions which are not very well
" * I
addressed by a functional or consensus model; however, with
its emphasis on intra-professional diversity, the
importance of shared values within a profession is not^
focused upon. Members of a profession usually agree on a
large number of issues and disagree on others. Segments
within a profession generally do not develop ideologies or
organizations which radically oppose the mainstream of the
profession. |
i
Within the profession of pharmacy, the movement toward
I
clinical practice is clea'rly a case of a special interest
group striving for "its place in the sun" as the dominant
value orientation and future professional role.j
Differences in level of support for this new role are
I
expected within the profession, with the elites of pharmacy
86
(i.e. pharmacy school faculty and those involved in
organizational activities and politics) and recent
graduates who have been socialized in this new orientation
to practice being more supportive of a clinical role than
the rank and file practicing pharmacist, particularly those
in a retail setting where the competition between a
professional and business orientation is greatest.
From the above discussion of the process model of
professionalization, it was expected that segments within
the profession of pharmacy would exhibit differing levels
of support for expanded role activities. Specific
hypotheses tested included:
1. Pharmacy school faculty members will be more
supportive of expanded role activities for
pharmacists than will practicing pharmacists.
2. Younger pharmacists (who graduated in 1970 or
later), will be more supportive of expanded role
activities for pharmacists than will pharmacists who
graduated prior to 1970.
3. Pharmacists practicing in the hospital setting will
be more supportive of expanded role activities for
pharmacists than will pharmacists practicing in the
community setting.
87
3.3.3 Power Model
The central role of power in defining occupational
territory has gained increasing importance in recent years,
and has led to the emergence of a third model of the
professions based on political power (Gilb, 1966; Jamous
and Peloille, 1970; Johnson, 1972; Friedson, 1970A, 1970B).
Friedson proposes that professions are distinguished from
other occupations by their ability to control their own
work activities. This autonomy from extra-occupational
authority or interference, he contends, results from
superior power. This model rejects the value or normative
foundation of professions inherent in a functional
perspective ; it rejects the service ideal as a central
driving force in the professions ; and views professions as
simply monopolistic occupations which have succeeded in
using the symbols of professionalism to gain exclusive
power and control over their work environment (Ladinsky,
1971). Ethical codes and control over licensure are seen
as important mechanisms to restrict the services available,
limit the encroachment of other occupations on professional
turf, and generally provide the legitimacy to control
professional behavior independent of public need or
government control (Ruane, 1975).
88
Ladinsky (1981) has suggested that two critical
occupational-organizational conditions must exist in order
for a market monopoly such as is found in medicine, law,
dentistry, architecture and engineering to exist: first,
the professional elites must be able to "coordinate members
and minimize internal dissent;" and second, they must
"successfully regulate external competition, primarily by
establishing close ties with government so as to protect
the profession*s boundaries through exclusive control over
work and over who enters the profession."
The most appropriate level of analysis in studying
occupational power is the systemic level where power is
based in the roles and positions defined as occupational,
rather than in unique characteristics of individuals qua
individuals, or in dyadic relationships between two people
(Clark, 1968). By focusing on power at the systemic level,
the conceptual level can be held constant and
interrelationships between major social units (e.g. between
medicine and government, medicine and nursing, or medicine
and pharmacy) can be understood as intersystem exchanges.
A basic assumption of this approach is that changes in the
structure and activities of a system are intimately tied to
the dynamics of other systems that share bonds of
2
This approach is consistent with the open systems model
of Buckley et al. (1967).
89
dependence.
Kronus (1975) has defined occupational power as an
occupation * s ability to establish and maintain barriers
around its task domain, and suggests that the more
resources a system controls, the greater its potential
power to influence other units. The relative ability of an
occupation to protect its task domain from encroachment,
and/or to encroach on others, is considered a central
measure of power. Boundary defense is seen as a system
goal, hence, one of the most important activities of an
occupation is to build and maintain boundaries around its
operating activities or tasks.
It would be expected that when an occupation attempts to
expand its role domain to include activities which have
traditionally been performed by another occupation,
particularly if traditional "core" activities are being
threatened, it will be met with fierce resistance. For an
occupation to succeed in extending its boundaries into
"foreign turf," it must have at its disposal unique
resources which can be used to create a shift in the power
relationship between the two occupations. Generally, this
power struggle is overt, with the encroacher attempting to
gather legal and consumer support for its role expansion.
At other times, however, the occupation being encroached
90
upon appears to give up some of its responsibility without
much struggle. A closer look at these instances suggests
that in fact this is a clever manuver by a threatened
occupation or profession to gain control over the direction
of the invasion.
Friedenberg (1970) has suggested that the process of
adoption and adaptation of a threatening movement*s goals
is one of **co-optation, * * where selected aspects are
modified so as to make them less threatening to a group* s
autonomy and power. . Flacks ( 1970) has observed the same
process in inter-generational conflict:
A generational movement may be understood as a
movement of cultural and social innovation whose
impact has been contained within the framework of
existing society. For agencies of social
control, the ideal circumstance would be the
opportunity to eliminate those elements in the
movement that are most disruptive and
destructive, while putting into effect some of
the cultural, social and political innovations
and reforms the movement advocates. Accordingly,
you put Yippies in jail but work out some means
to legalize the use of marijuana. You put draft
resisters in jail or into exile while abolishing
conscription. You expel SDS from the campus
while admitting student representatives to the
board of trustees . . .
To bring the power model into the health care arena, one
need only look to the movement toward professionalization
in nursing. Nursing has traditionally been subordinate to
medicine. In the 1960*s a unified attempt at gaining
increased autonomy and professional status resulted in the
91
development of the clinical nurse practitioner role, and
increased input of nursing into health care decisions
concerning patients. Although nursing was granted limited
authority and autonomy in patient care by medicine, it
still remains under the supervision of and subordinate to
the physician. The nurse practitioner was granted the
right to provide care to routine and chronic disease
patients, and to do physical assessment. In most states,
however, she must work with a physician and cannot
prescribe legend drugs without a prescription signed by a
physician. By negotiating with nursing in defining areas
of role expansion, medicine has maintained its power
position. It will be interesting to look at this issue in
the future in the case of clinical pharmacy, particularly
in the hospital setting where the physician has the most
control.
The discussion of the power model of professionalization
lends support to the expectation for differing levels of
support for expanded roles for pharmacists among physicians
and nurses. Any attempt at role expansion which threatens
the "turf" of another profession or challenges the autonomy
of another health professional will be met with resistance
in one form or another. This would lead to the expectation
that :
92
1. Physicians will be the most antagonistic group
toward expanded clinical role activities for
pharmacists, particularly those activities which
directly threaten their role domain,
2. Physicians will be more antagonistic toward expanded
clinical role activities for pharmacists in the
community setting than in the hospital setting.
Since nursing has successfully challenged physician
autonomy and role domain in many areas, nurses would be
expected to welcome an "ally" in the fight to "chip away"
portions of the physician * s traditional role domain. This
alliance would lead to the expectation that:
1. Nurses will be moderately supportive of expanded
clinical role activities for pharmacists which do
not directly threaten their own role domain.
The point of much current theoretical work, as discussed
above, is that roles are not static parts of the structure
of organizations, but rather dynamic and evolving
reflections of diverse sets of group interests and power
relations. A conflict perspective as exemplified in the
process and power models of the professions, focuses on the
possibilities for disagreement between incumbents of
different roles and to the use of power to expand or
redefine role boundaries. The stratification of health
93
care is a reflection of the power resources of the various
groups of health care workers and will be discussed in more
detail in a later section of this chapter. Bucher and
Strauss (1961) suggest that:
The work situation and the institution itself are
not simply places where people of various
occupations and professions come together and
enact standard occupational roles, either
complementary or conflicting. These locales
constitute the arenas wherein such roles are
forged and developed. Work situation and
institution must be regarded in the light of the
particular professional segments represented
there: where the segments are moving and what
effect these arenas have on their future
development. Since professions are in movement,
work situations and institutions inevitably throw
people into new relationships.
3.3.4 Role Change in Medicine - Some Examples
There are numerous examples from the history of the
health professions where role change has been sought by one
occupational group and opposed by others. In the early
1900 * s physicians began a systematic campaign to redefine
the medical practitioner *s role. The newly created AMA
rejected early models of medical training and practice
(i.e. proprietary medical schools, short training, and
divergent schools of medical theory) and endeavored to
generate consensus for these changes from within the
medical profession and encourage acceptance by the public
of the proposed changes. In a subsequent role change, by
94
ithe 1920 * 8 specialist groups had started a successful push
1
for definition of separate, expanded positions for
themselves as direct providers of medical care to patients.
The particular circumstances surrounding each of these
examples of role change differ somewhat. The establishment
of "regular" medicine under the AMA and its acceptance as
the single legitimate branch of medical practice was a case
of one faction * s winning out in a struggle among several to
define the proper role of the physician. The development
of medical specialist roles was a case of differentiation
within an already established professional group, a case
based on claims of specialized knowledge and technique.
The development of the nurse practitioner role is a good
example of role change taken from the nursing profession.
Nurse*s organizations by the 1960*s were pressing to
establish a broader, more professional role for their
members as primary providers of medical care. Nurses,
whose role had traditionally been subservient to that of
physicians, attempted to redefine and expand their own role
in the hospital * s organization.
These diverse instances of role change all placed a dual
demand upon those within the occupational group who sought
to promote the changed role. First, those interested in
change had to generate consensus within their group that
95
such change was desirable and necessary. Second, those
concerned with change also had to try to gain consensus for
the expanded role among members of other groups whose
expectations helped to define the original role in
question. To generate consensus both within and among
groups was thus critical for those who attempted to expand
their roles.
A key difference exists, however, between the examples
from medicine and nursing— one of differential power. In
the first two instances cited earlier, physicians redefined
their roles vis-a-vis one another in a context of rough
power equality, and while one group might be said to have
prevailed, concessions were made on both sides (e.g. the
continued semi-legitimate status granted chiropractors, and
incorporation of specialist boards within the structure of
the AMA). In the case of nurses, however, various
observers have noted constraints that will likely prevent
nurses* full attainment of co-equal professional status
with physicians in hospitals. Physicians both have far!
I
superior power resources and are willing to use that power
to prevent any erosion in what they regard as their own
sphere of occupational operation. Nurses may need to focus
on areas not of interest to physicians.
96
Kronus (1976) has traced the evolution of the
physician*s and pharmacist*s roles in terms of occupational
power in England and the United States. She proposes a
cycle of role expansion in which the same strategies and
ploys recur. First, there is role expansion by some
members of an occupational group who take on activities
beyond the boundaries defined for them by superordinates
(in the case of the English apothecary, it was physicians).
This results in a blurring of the traditional boundaries,
and, if the expansion is to be successful, the development
of a client base. The next step is legalization of the new
role which legitimates the expanded role activities as part
of an encroacher* s turf and changes the boundaries between
the two conflicting professions. Legal action may be
instituted by either occupation.
In the case of English apothecaries, it was the
threatened group (physicians) who instituted legal action
which resulted in an unexpected outcome and the
legitimation of the new apothecary role. In other cases,
the threatening group may solidify its resources and
initiate legislation. Once legal action is taken to
protect the newly expanded role, recruits may then be
socialized into the new role, the client base expands, and
the new role becomes institutionalized.
97
Kronus suggests that task boundary maintenance is
dependent upon the resources of power available to an
occupation. Such resources include an economic monopoly,
patronage of clients, control over esoteric knowledge, and
influence with political elites. It has only been within
the past 60 years or so that a clear-cut boundary between
drug prescribing and drug dispensing has existed between
pharmacists and physicians. Physicians were given
exclusive jurisdiction over treatment decisions based on
their expanded medical knowledge.
3.4 POWER AND STRATIFICATION WITHIN THE HEALTH CARE
SYSTEM
Status defines a position within society, fixes the
identity and expectations of those individuals who occupy a
defined status level, and strongly influences interactions
among individuals. In health care occupations, status
strongly influences intergroup interactions with a net
effect of these interactions resulting in a rigid status
hierarchy (Georgopoulos and Mann, 1972). Therefore,
stratification within the health care delivery system is a
major variable in determining the roles or behavior
patterns of the occupants of the system.
There are at least two major stratification hierarchies
within the health care system. First, there is the
98
stratification patterns of the health care workers
themselves. Second, there is the stratification system
which links these workers with their patients. These forms
of stratification within the institution of medicine affect
the organization of services, relationships among health
workers, and the interactions between physician and
patient.
The study of stratification is essentially a study of
the levels of power, social class and wealth within a given
structure. To these three attributes we may add a fourth:
functional importance. Pellegrin and Bates (1959) define a
functionally important position as one upon which other
positions are dependent:
Usually, a functionally important position is at
a focal point in decision making and
communication; the roles of the position involve
control over resources and services vital to
incumbents of other positions ; the
responsibilities of the position are such that
they can be performed correctly only by persons
of exceptional training, experience, and/or
ability; and the function performed is highly
valued by members of society and believed to be
important.
Within the health care professions, the most salient
attribute seems to be power, which is, in part, based on
functional importance.
Several reasons have been put forward to explain why the
stratification system within the health care industry is so
99
broad and pervasive. First, the industry is large and
rapidly expanding. And although size and complexity do not
always go together, they often do. The rapid growth in the
number of workers in health care has paralleled the
increased complexity of the system (Bullough, 1978, p.
164). The emergence of the professionalization process
discussed earlier has been proposed as a second factor in
stratification.
The scientific revolution has given primacy to knowledge
as the basis of stratification, and the learned professions
have emerged as the most powerful occupations.
Professionalization, however defined, is a process
whereby an occupation gains greater power and prestige
because it commands greater resources (e.g. unique body of
knowledge and political clout). Depending on one's
perspective, the public willingly grants, or is forced to
give up, more control to a profession because of this
increased knowledge base.
The labor-intensive nature of the health care industry
is a third factor involved in the expansion of the
stratification of medicine. As the cost of labor has
risen, health care costs have risen dramatically. In order
to deal with increasing labor costs, many professional
roles have been broken down into component parts and the
100
simpler tasks have been assigned to workers with less
training. Over the years this rationalization of the
system has led to a proliferation of worker roles. While a
few of these roles had their origins in the nursing role
(e.g. physiotherapist and inhalation therapist), most of
the laboratory and engineering specialties have grown out
of the traditional role of the physician (Ibid.). The
major thrust in the differentiation of the nursing role
occurred in the years following World War II, when nursing
split into the three levels of registered, practical and
aide, with concomittent levels of responsibility and
authority. The physician * s role has been more resistant to
differentiation than that of the nurse, but recently the
development of the physician extender roles may be a
similar process.
In addition to the size and complexity of the health
care industry, the professionaliz ation of the top
occupations, and the economic realities that stimulate role
differentiation, two additional factors seem to be related
to health care stratification. One of the most obvious
characteristics of health occupations is their marked sex
segregation. Most jobs can be classified as either male or
9
Rationalizing the system has been defined as the process
of breaking a role into its component parts and
allocating the parts to individual workers in order to
maximize efficiency (Ibid., p. 173).
101
female and deviations in role allocation are duly noted
when they occur (i.e. we talk about the "male nurse" or the
"woman doctor" in qualifying each noun).
The health professions accorded both highest status and
income include physicians, dentists, pharmacists,
veterinarians, optometrists, and chiropractors, and this
group was over 90 percent male in 1970 (Ibid.) (Table 1).
TABLE 1
Demographic Distribution of Health Care Workers.
OCCUPATIONAL GROUP SEX
%M %F
ETHNICITY
%W % Non—W
Physicians, dentists,
optometrists, veterinarians,
pharmacists, chiropractors 92% 8% 98% 2%
Health administrators
55 45 94 6
Technologists, technicians 30 70
91 9
Nurses, dietitians, therapitst 5 95 92 8
Health service workers. 14 86 78 22
orderlies
Bullough, 1978. Summary of 1970 Census data.
102
The group composed of nurses, dietitians an'a~therapi“ ^ts was
over 90 percent female. Similar stratification patterns
were noted in terms of ethinc background. Only two percent
in the top health care professions were classified as
nonwhite, whereas 22 percent of health services workers
were nonwhite.
The dramatic shifts in the demographic distributions of
pharmacists over the past 10 years, with rapid increases in
the percentages of women and Asian pharmacists, may have a
significant impact on the future status of the profession.
This will be an issue to watch in the coming years. Since
women and Asian pharmacists may be considered as upwardly
mobile segments, one would expect these groups to embrace a
professional "clinical" role for pharmacists. Therefore,
it was predicted that :
1. Women pharmacists will be more supportive of
expanded clinical role activities for pharmacists
than will men pharmacists.
2* Asian pharmacists will be more supportive of
expanded clinical role activities for pharmcists
than will Caucasian pharmacists.
Much has been written about stratification within thé
hospital system. Hospitals are powerful bureaucracies with
the unique complication of the development of two
103
hierarchical structures which often are in competition for
the loyalty of the health worker. In most other major
social institutions, bureaucracies tend to be built upon
clear lines of authority, written rules, and a single
hierarchical structure in which lower levels report to
higher levels. Physicians complicate the structure of the
hospital because they are neither part of its structure
nor clearly clients of it. Smith (1978) has described the
hospital as "an organization at cross purposes with
itself." Nurses in particular are often placed in a
conflicted position with respect to the two lines of
authority represented by physicians and nursing
administration (Croog and Versteeg, 1972).
Clinical pharmacists in hospitals must now also be
concerned with both physician and pharmacy administration
authority hierarchies. This would lend support to the
expectation of more support for expanded clinical role
activities by hospital pharmacists than by community
pharmacists. The clinical pharmacist performs tasks which
provide for increased autonomy and sharing of authority for
patient care with the physician.
Finally, it seems appropriate to look at the
implications of the stratification of health care. The
differentiation of the primary roles of the nurse and the
104
physician, and the development of multiple medical
technicians has fragmented and depersonalized hospital
care. The discriminatory aspects resulting in both gender
and ethnic segregation have created serious barriers to
communication between health team members.
Duff and Hollingshead (1968), in a study of a community
hospital, concluded that poor patient care resulted to a
significant degree from a lack of effective communication
between team members, particularly between nurses and
physicians. The communication gap that existed between
these two professions was not the normal one which occurs
in complex occupations with multiple levels of workers,
rather it was an exaggerated one resulting from sex
segreation with a peculiar stylized pattern which Bullough
(1978) has called the doctor-nurse game. It had its roots
in the traditional power differential between men and women
and was seen as a mechanism whereby relatively powerless
females gained power over men by manipulation. This
pattern of communication was not efficient and crucial
information was lost or distorted, resulting in poor
patient care and decreased interprofessional respect. A
similar sort of "game" may occur in the communication
patterns between lower status minority and higher status
white health care workers.
105
The professionalization of the high status health
occupations and the increasing stratification of the health
care system are significant factors in the current wave of
consumer discontent and the movement toward more lay
control and initiative of health care. Friedson (1970)
suggested a more appropriate model of the patient role in
light of the current state of affairs, and suggested that
patients and providers may be seen as occupying different
positions in the social system which may lead to clashes at
times.
How consumers will react toward expanded pharmacy roles
is not known. Preliminary hunches, however, can be
ventured. Because of the disillusionment of consumers with
traditional health care, and the rise of physician
assistants and nurse practitioners in primary health care,
it was expected that there would be moderate support for
other's attempt at role expansion, particularly if it is
perceived as beneficial to the consumer. Many reasons can
be proposed for consumer support. Younger and better
educated consumers are more informed about health care
issues and drugs and demand more information. Older
consumers may remember the pharmacist of their youth and
young adulthood as a health professional in whom they could
confide and seek advice. Pharmacists are often closer in
106
social class origin to consumers than are physicians, and
this often facilitates communication. Consumers suffer
from more chronic diseases and utilize pharmacy services
more frequently as they age, and the pharmacist becomes a
more salient health care professional because of this. So
for several reasons at least a moderate level of support
for an expanded role for pharmacists is expected by
consumers. The survey of consumers was only exploratory in
this study and further investigation is planned. It was
expected that;
1. Consumers will be moderate in level of support for
expanded role activities for pharmacists.
The question to be considered in this review of health
care stratification is where does pharmacy fit in all this?
Where pharmacy fits within this hierarchy is rather unclear
(Manasse, 1977). In looking at the traditional role the
pharmacist plays in the delivery of health care services,
an important difference emerges in comparison to other
health care roles which would indicate the pharmacist's
status to be defined quite differently from other health
professionals.
The pharmacist generally does not physically perform a
"laying on of hands" or make decisions about the future
course or expected outcomes of the patient's therapeutic
107
regimen, although this does not hold for the emerging role
of clinical pharmacist. Not performing these types of
activities has in the past separated the pharmacist from
other health care professionals and resulted in a
differential level of status (Manasse, 1977). The autonomy
of the professional, exemplified in its most extreme form
by physicians, is limited for the pharmacist by his
functional dependence on the physician's opinion and
ultimate authority in decision making with regard to
patient care. Thus the lack of functional autonomy and the
close meshing of merchandising business practices in the
community setting have led to a number of status
constraints for pharmacists (Shuval and Gilbert, 1978).
Within the hospital setting the clinically oriented
pharmacist finds himself in a conflicted position similar
to the nurse with respect to the dual lines of authority.
The pharmacist must answer to both the physician and the
hospital pharmacy administration.
It has been suggested that the recent history of
medicine can be viewed as a series of struggles among
certain group alliances over the definition and treatment
of illness (Johnson, 1972; Friedson, 1970B; Furnham et al.,
1981). Historical dominance by physicians has meant that
health occupations which have more recently developed have
108
been forced to seek their mandate of operation not only
from their clients and the state, but also from the
physician organizations.
Groups seeking to establish a unique diagnostic
role have encountered greatest opposition from
those which have been prepared to purchase a
limited form of autonomy by recognition of the
physician's superior role. This issue may be
summed up by a distinction between those
professions to whom physicians have devolved
jurisdiction and those who are thought of as
having appropriated it (Furnham et al., 1981).
The technological and scientific knowledge revolution of
this century has seen the rise of a number of largely
hospital-based sub- or para-professional occupations which
have all attempted to establish control over a particular
category or aspect of illness and its treatment and over a
particular technological apparatus or process. Each has a
history of conflict and compromise, and of cooperation with
the other professional or para-professional groups. Each
group has attempted to achieve the status of a profession
in order to establish their autonomy and self-regulatory
ability. The degree of conflict between these groups is
therefore likely to be a function of the similarity between
those groups in terms of training, their clientele and the
services they offer. Friedson (1970A) has argued:
One of the major variables mediating
interoccupational relations in the health
services seems to be functional autonomy - the
degree to which work can be carried out
independently of organizational or medical
109
supervision and the degree to which it can be
sustained by attracting its own clientele
independently of organizational referral or
referral by other occupations, including
physicians. On the whole the more autonomous the
occupation, and the greater the overlap of its
work with that of the physician, the greater is
the potential for conflict, legal or otherwise
(p. 53).
The above discussion of functional autonomy in
interprofessional relations supports the expectation of
more conflict between pharmacists and physicians over the
appropriateness of clinical pharmacy activities.
Traditionally, pharmacy has been viewed as a relatively
autonomous health profession, not dependent on individual
physicians for its clientele. This has been particularly
true in the community setting, which further supports the
prediction that physicians will be more antagonistic toward
clinical pharmacy in the community pharmacy (compared to
the hospital). Hospital pharmacists experience less
autonomy, are more visible to physicians, and are more
directly dependent on physicians for involvement in patient
care.
Various professions have been studied within a politics
of occupations or division of labor perspective (Furnham etj
al., 1981), including physicians, nurses, midwives and
dentists (Berlant, 1975; Reeder and Mauksch, 1977; Larkin,
1980), as well as other para-professions (Alaszewski and
110
Meltzer, 1979; Wardwell, 1979). A number of theoretical
studies have also attempted to compare various health
groups in terms of their professionalism, which has been
defined in a number of ways (Goode, 1957; Maddison, 1980;
Wilensky, 1964). Thus from the sociological perspective
there appears to be a number of reasons to expect
differences in the perceptions of various medical
professions. That is, the conflict between groups is
likely to be manifest in their intergroup perceptions - and
expectations.
There have been a limited number of studies comparing
the perceptions of different medical occupational groups
both of themselves, each other and their clients.
Differences in occupational perceptions appear to be as
true of newly emerging professionals as of the older more
established professions. Studies of interprofessional role
perceptions, particularly of physicians' perceptions of and
attitudes toward other health care workers, suggest that
the conflict between physicians and these groups of workers
over new or expanded professional roles may decline as
younger physicians, and those with previous experience with
the roles develop more favorable attitudes toward them
(Burkett et al., 1978; Westbrook, 1978; Shorten, 1974;
Nunnally and Kittross, 1958).
Ill
The study of interpersonal perceptions is particularly
interesting within the medical profession because of the
notion of the health care team. Whereas much work or
inter-occupational perceptions has been done using people's
perceptions of other professions they have little or no
direct contact with, most medical professionals would be
expected to have regular experience of other professionals
in a team. These team work experiences could lead either
to a reduction of conflict and stereotyping, or an increase
of it, depending on the structure and functioning of the
team (Furnham et al., 1981).
A team effort of any magnitude requires a minimization
of status differentiation and a maximization of power-free
interaction. The basic premise upon which the team concept
of care is founded is the fact that a variety of health
care practitioners demonstrate various levels of specific
skills which can be used to meet the patient's unique
health needs. The pharmacist's contribution to such a team
is his expertise in the drug use process,
A critical variable in this discussion of the health
care team is the perception of each professional's area of
expertise. If the pharmacist is perceived as the drug
therapy expert by other team members, then it would be
expected that those team members would be more supportive
112
of a clinical pharmacist role which relates directly to
drug use in patients. On the other hand, if the physician
is viewed as the drug therapy expert by health team
members, then a lower level of support for a clinical
pharmacist role would be expected.
The opportunity to work with a clinical pharmacist
provides health care team members a chance to observe and
learn about this new role, and to replace stereotypes about
pharmacists. This would be expected to lead to more
support for a clinical role for pharmacists. The
relationship between clinical pharmacy experiences and
level of support for expanded clinical roles for
pharmacists may be further modified by the individual's
evaluation of those experiences, so that as long as they
were felt to be good, experience would lead to favorable
attitude. If the experiences were rated as poor, then a
negative attitude toward expanded clinical roles may
result.
Whether the health care team in actuality is functioning!
is open to debate. Manasse (1977) has suggested that the
"health care team is a sociological, psychological,
economic and political myth." Most limiting to the|
creation of a health care team is the factor of economics.
No economic incentives presently exist for a team to form.
113
Mechanisms of payment to the various team members for the
variety of services rendered have not been designed. The
team concept obviously requires greater risk in loss of
status from the prescribers of drugs and greatest gain in
status for the pharmacist.
3-5 RESEARCH HYPOTHESES
From the extensive discussion of theoretical issues
relevant to the practice of pharmacy, the following
hypotheses were proposed and tested by the data.
1 . A differential level of acceptance of a
patient-oriented, clinical role for pharmacists will
be demonstrated among pharmacists, physicians,
nurses and consumers. Specifically, it is predicted
that :
a) Pharmacists will be more supportive of a clinical
role for pharmacists than physicians, nurses or
consumers.
b) Nurses will be the next most supportive
professional group (after pharmacists) of a
clinical role for pharmacists.
c) Physicians will be the profession most
antagonistic toward a clinical role for
pharmacists.
114
d) Physicians will be more antagonistic toward a
clinical role for pharmacists in the community
setting than in the hospital setting.
e) Consumers will be intermediate in level of
support for a clinical role for pharmacists.
2. For each group there will be higher consensus on
traditional role activities of pharmacists than on
expanded, clinical role activities.
3. A differential level of acceptance of a
patient-oriented, clinical role for pharmacists will
be demonstrated among pharmacists. Specifically, it
is predicted that:
a) Pharmacists who are faculty members of a school
of pharmacy will be the most supportive of all
pharmacists of a clinical role for pharmacists.
b) Pharmacists who have graduated since 1970 (the
younger cohort) will be more supportive of a
clinical role for pharmacists than will
pharmacists who graduated before 1970.
c) Upwardly mobile, expanding pharmacist segments
(women and Asians) will be more supportive of a
clinical role for pharmcists than will more
stable segments ( men and Caucasians
respectively).
115
d) Hospital pharmacists will be more supportive of a
clinical role for pharmacists than will community
pharmacists.
4. Specific background and attitudinal variables will
be related to support for expanded roles for
pharmacists. Specifically,
a) Pharmacists and health professionals who perceive
the pharmacist primarily as a "clinician" will be
more supportive of a clinical role for
pharmacists than those professionals who perceive
the pharmacist primarily as a "businessman."
b) Physicians and nurses who have had experiences in
working with a clinical pharmacist will be more
supportive of a clinical role for pharmacists
than those professionals who have not had such
experiences.
c) Physicians and nurses who perceive the pharmacist
as the "drug expert" will be more supportive of a
clinical role for pharmacists than those
professionals who perceive the physician as "drug
expert."
116
Chapter IV
METHOD
Data for this study of the role of the pharmacist were
collected as part of a larger, multipurpose cross-sectional
survey of California pharmacists, health care
professionals, and consumers conducted by the staff of the
Community Pharmacy Enhancement Project (Eagan et al.,
1982), under the aegis of the University of Southern
California Development and Demonstration Center in
Continuing Education for Health Professionals, and funded
by the W.K. Kellogg Foundation. Three major issues were
focused upon in that survey: (1) a marketing study to
assess attitudes toward traditional and innovative
continuing education programs for pharmacists; (2)
assessment of the use of the computer in pharmacy practice,
both for business- and patient-oriented activities, and (3)
a multiperspective, interdisciplinary assessment of|
professional and patient-oriented aspects of the role of|
the pharmacist. Data from this last component has been
utilized in this dissertation.
117
4-1 OVERVIEW ^ THIS CHAPTER
The procedures used in this study are discussed in this
chapter, including: development of four self-report survejj
instruments, sampling procedures, methods of administration
and statistical analyses. Response rates and demographic
profiles are presented for each group. Finally, results of
two factor analyses performed on responses of thes
pharmacists group are presented.
4.2 DESCRIPTION OF RESEARCH DESIGN
This cross-sectional survey research was designed to
assess attitudes toward pharmacy practice and traditional
and expanded role activities of pharmacists.
Separate self-report survey instruments were developed
for (a) pharmacists, (b) physicians and nurses, (c)
consumers, and (d) pharmacy school faculty members. Each
instrument contained relevant demographic information and a
core of common items which allowed comparison of attitudes
across sample groups.
118
4.3 DEVELOPMENT OE SURVEY INSTRUMENTS
Survey instruments were prepared from a collection of
potential items, both content and demographic, amassed from
a review of relevant literature, through a process of item
by item consideration to assess worth and relevance. ThJ
preliminary instruments thereby developed were pretested
with small groups of pharmacists and interdisciplinary
staff members for clarity, content and phrasing. Because
of the multi-purpose nature of the survey developed for
pharmacists, the final product was quite long. The other
three surveys, however, were shorter and more focused.
4.3.1 Pharmacist Survey
This survey was designed to collect data for three major
studies of pharmacy practice. Only those aspects relevant!
to this dissertation will be discussed. However, the:
complete questionnaire is included in Appendix A.
4.3.1.1 Demographic Data
Relevant demographic data from this survey included the;
following variables: age, sex, ethnic background, year of
graduation from pharmacy school ("cohort"), pharmacy
degree, practice location (hospital, community-independent,
community-chain, pharmaceutical industry, pharmacy school,
119
or other), and work position (owner/co-owner]
director/manager, assistant director/manager, supervisor,
staff pharmacist, clinical pharmacist, or other),
4.3.1.2 Role Consensus
Twenty role-related activities were selected from à
review of the literature on pharmacist roles and the joint
American Pharmaceutical Association (APhA) and American
Association of Colleges of Pharmacy (AACP) National Study
of the Practice of Pharmacy (Rosenfeld et al., 1978).
Items were selected to represent the range of activities
associated with pharmacy practice (e.g. administration and
management, dispensing, and professional and
patient-oriented activities), with an emphasis on specific
aspects of an expanded, clinical role for pharmacists.
Equal numbers of traditional (T) and expanded (E) role
activities were included in the surveys;
1. The pharmacist serves as a drug information resource
and/or drug therapy consultant to physicians and
other health care professionals (T).
2. The pharmacist prepares special drug formulations,
fills drug orders/prescriptions, and dispenses drugs
(T).
120
3. The pharmacist teaches pharmacology to health care
professionals and students in the health care
professions (E).
4. The pharmacist selects the source of supply
(manufacturer) of drug products ordered by
prescribers (T).
5. The pharmacist manages and controls pharmacy
supplies and/or pharmacy personnel (T).
6. The pharmacist counsels patients about the
prescription drugs they take (e.g. discuss
directions, side effects, interactions,
contraindications) to promote compliance (T).
7. The pharmacist consults with patients to properly
identify symptoms in order to advise and assist inj
the selection of non-prescription (OTC) products for
self-medication (T).
8. The pharmacist serves as an important entry point to|
the health care system by talking with patients
about their health care concerns, assessment of
non-emergency conditions and referral to appropriate
health professional when necessary (T).
9. The pharmacist maintains medication profiles for
patients to prevent harmful drug interactions,
minimize abuse, detect compliance problems and
prescribing errors (T).
121
10. Using protocols established with prescriber, the
pharmacist makes adjustments in a patient's drug;
therapy (e.g. change dosage, substitute drug, etc.)
(E).
11. Using protocols established with prescriber, the!
pharmacist prescribes drug therapy for patients with;
acute, uncomplicated disease states (E).
12. The pharmacist advises patients in personal health
matters (e.g. smoking, drug abuse, nutrition, etc.)
(T).
13. The pharmacist serves as a consumer educator,
counselor and advisor on drug- and health-related
concerns and participates in education and screenin
programs for chronic diseases (T).
14. Using protocols established with prescriber, the
pharmacist provides training of and services to home
care patients (e.g. oxygen therapy, total parenteral
nutrition, intravenous admixtures, etc.) (E).
15. The pharmacist provides and instructs patients in
the use of durable medical equipment, and medical
and surgical supplies (E).
16. The pharmacist takes patient's blood pressure,
interprets reading(s) to patient, and makes referral
to health care professional when necessary (E).
122
17. Using protocols established with prescriber, the
pharmacist orders drug therapy-related laboratory
tests necessary to monitor patient's therapy
response (E).
18. Using protocols established with prescriber, the
pharmacist assumes primary responsibility for
long-term care of patients requiring continuous drug
therapy (E).
19. The pharmacist provides drug consultation services^
to home health agencies, skilled nursing facilities,
mental health clinics and other institutions (E).
20. Under the supervision of a physician, the pharmacist
administers injectable drugs and biologicals,
including immunizations (E).
Each of the twenty role activities can legally be
performed under certain conditions by pharmacists in
California. Several of these activities overlap with the
role domain of physicians or other health care
professionals, particularly those in a physician extender
role (i.e. nurse practitioners or physician assistants).
Respondents were asked to indicate for each activity (a)
whether they felt it to be an appropriate role for a!
hospital pharmacist; (b) for a community pharmacist; and
(c) whether they felt pharmacists were competent to do it.
123
Five response categories were included for each question:
definitely yes, probably yes, not sure, probably no, and
definitely no.
These 20 role activities and questions a-c for each
comprise the items used to assess intra-role and inter-role
consensus and serve as the basis for comparison of
attitudes between pharmacists and members of their role
set. These items represent a range of activities from
traditional, core to expanded, clinical aspects of the
pharmacist's role.
4.3.1#3 What is a Pharmacist?
This question was included to assess respondent's
dominant orientation toward pharmacists. Respondents were
asked to rank from 1 to 8 the following "roles" often
associated with pharmacy practice: health care
professional, health educator, clinician, manager,
businessman, scientist, technician, and craftsman. The
list of possible "roles" was included to assess how the
respondent perceived the pharmacist— as primarily a
businessman, a clinician, and so on. It was assumed that
this dominant perspective would influence attitudes toward
the appropriateness of role activities. It was further
assumed that by providing logical boundaries to the list of
124
"roles" a more meaningful ranking of "roles" within these
boundaries would result. It was expected that most
respondents would indicate "health care professional" as
first in importance, and "craftsman" as last. "Health care
professional" is a rather ambiguous buzz word in common
usage today, and it would be hard to deny that a pharmacist*
is, in fact, a health care professional. "Craftsman" was
predicted to be the lower boundary of the list because,
although the pharmacist of centuries ago was considered a
craftsman, today's pharmacist is not.
4.3.2 Health Care Professionals Survey
This survey was developed to assess how physicians and
nurses utilize the professional services of pharmacists and
to assess their attitudes toward pharmacists and pharmacy.
Common items from the pharmacist survey to assess role
consensus and dominant orientation toward pharmacists were
also included in the survey of physicians and nurses.
Relevant demographic variables included in this survey
were: age, sex, ethnic background, education, profession
(physician, nurse, nurse practitioner, physician
assistant), number of years in the profession ("cohort"),
primary work location (hospital, HMO, clinic, private/group
practice office), and area(s) of specialization. In
125
addition, these health care professionals were asked if any
member of their family was a pharmacist. This was includec
as a measure of direct knowledge of the role.
Respondents were also asked to indicate whict
professional (physician, nurse or pharmacist) they
considered to be the "expert" on drug therapy relatec
matters.
Because experience often affects attitudes, witf
positive experiences often leading to improved attitudes
towards the object of experience, an item was included to
assess whether health care professionals have ever workec
with a clinical pharmacist in the hospital setting.
Respondents also were asked to evaluate that experience on
a 5-point scale (excellent to poor).
4.3.3 Consumer Survev
Consumers of pharmacy services, the patients, represent
the third component of the drug therapy triad of
physi cian-patient-pharmacist. Patients are free to select
the pharmacy they use. Physicians generally do noJ
recommend a particular pharmacy, as they do a laboratory or|
radiology facility. Patients, therefore, generally form
opinions and attitudes based on their experiences with the
various pharmacists with whom they come in contact.
126
Without the endorsement of a high status professional (i.e.
the physician), patients must rely on their own evaluation
of each situation. This survey was developed to assess
consumers' attitudes toward pharmacists' role activities.
It also contained the common items from the other surveys.
Relevant demographic variables included in the consumers
survey were: age, sex, ethnic background, marital status,
level of education, respondent's occupation, spouse's
occupation; family income level, number of children at home:
(under 5 years, 5-12, 13-17, and over 17 years), and if any
family member is a pharmacist.
4.3.4 Pharmacv School Faculty Members Survey
Because pharmacy school faculty members are often the
innovators in change, it was felt important to obtain
responses from pharmacists who are full-time,
non-practicing members of their profession.
In addition to the items common to all surveys, the
following demographic variables were included in this
survey : age, sex, ethnic background, degree, year first
licensed to practice pharmacy ("cohort"), faculty position
or rank, major area(s) of teaching responsibility, and
whether s/he is involved in pharmacy practice in addition
to teaching.
127
4.4 lüE SAMPLES
Five populations were sampled (practicing pharmacists,
pharmacy school faculty members, physicians, nurses, and
consumers). Whenever economically feasible, random
sampling was used. However, it was not possible to sample
nurses or consumers randomly.
Because of the length of the surveys it was felt that a
suitable, non-biased incentive should be offered for
completing the survey. In the cover letter included with
the surveys for practicing pharmacists, physicians and
nurses, respondents were informed that there would be a
drawing for $100 to be awarded to someone who returned a
survey. Each respondent was given the opportunity to enter
the drawing by filling out his name and address on a
separate sheet of paper to be returned with the survey.
The surveys for faculty members and consumers were much'
shorter and it was felt inappropriate to offer such ar
incentive to these groups.
Details of the selection of samples and the sampling
procedures used are discussed below for each population.
128
4.4.1 California Pharmacists
Pharmacists to be included in this study were randomly
selected from a mailing list of all pharmacists licensed to
practice in California, purchased from the California Board
of Pharmacy. There were 14,304 pharmacists listed with
home addresses in California (also included in the list
were pharmacists who maintain their California license but
practice out of state). From this list, 500 names were
randomly selected as follows. A number (i.e. "60") was
selected from a table of random numbers as the starting
point, then every 29th name on the list was selected to be
included in the sample. As the mailing list was ordered by
zip code, more pharmacists were sampled from urban than
rural areas, thus roughly representing the actual
distribution of pharmacists in California.
Pharmacists were surveyed by mail. Each pharmacist was
sent a copy of the survey with a cover letter explaining
the purpose of the study, information on the $100 drawing,
and instructions for returning the survey. Also included
was a pre-addressed, stamped return envelope. Three weeks
after the initial mailing reminder postcards were sent to
those pharmacists not known to have returned a survey
(Appendix B). Because of the drawing, nearly every
respondent included his name and address with his completed
129
survey so it was possible to check off those who had
returned the questionnaire.
4.4.2 Health Care Professionals
4.4.2,1 Los Angeles County Physicians
A sample of 250 physicians was randomly selected from
the 1982-1983 Directory of the Los Angeles County Medica].
Association. Physicians are listed alphabetically in this
directory and information is included on their area(s) of
specialty. Physicians practicing in areas which would have
little contact with pharmacy (e.g. pathology, radiology, or
orthopedic surgery) were not included in the sample. There
were 8372 names listed in the Directory. Beginning with
the 7th name, every 28th name was selected for inclusion in
the sample. If the 28th name was a physician in one of the
excluded specialties or over the age of 75, the next name
on the list was selected.
Although not all practicing physicians belong to the Los
Angeles County Medical Association, and therefore are not
listed, a majority of practicing physicians in the Los
Angeles area do. Using this directory was the most
feasible and least expensive way to sample area physicians.
Although it would have been desirable to sample from all
California physicians, funds were not available to purchase
the mailing list or to process a larger number of surveys.
13d
A survey with attached cover letter similar to that sent
to pharmacists (Appendix C), plus a pre-addressed stamped
return envelope were sent to each physician selected from
the list. Because of the limited budget, no followup
postcards were sent to this group.
4.4.2.2 Southern California Area Nurses
A non-random sample of 300 Southern California area
nurses and physician extenders was selected from three
separate lists of nurses who had attended continuing
education courses sponsored by the University of Southern
California Health Sciences Campus Postgraduate Education
Department within the past 12 months. One list included
nurses and physician extenders who had attended a sexually
transmitted diseases clinician training course, the second
list was from nurses attending courses of general interest
to nurses, and the third list was of nurses attending a
licensing review course and included many nurses who were
recent graduates from two-year community college nursing
programs. Thus, although not a random sample of area
nurses, the sample includes nurses from all levels of
nursing— clinical nurse practitioners, hospital nurses,
office nurses, and recent graduates. One advantage of this
sample was that a larger number of nurse practitioners (and
131
physician assistants) could be selected than would probably
have been obtained by systematic sampling of a list of
nurses. Only a small percentage of California nurses are
in these physician extender roles and a small random
sampling of nurses might have missed selecting any nurse
practitioners. Limited funding prevented obtaining a
large, random sampling of California nurses.
The same surveying procedures used with physicians were
used with nurses. Nurses were sent a survey, cover letter,
and stamped return envelope. No followup postcard was
sent.
4.4.3 Los Angeles Area Consumers
The survey of consumers was non-random and
non-systematic. It represented only a preliminary sampling
to pilot test the instrument. A full-scale random sampling
of consumers is planned for the future. In this
preliminary consumer panel, staff members distributed
surveys to members of their work and social networks.
Surveys were given to a wide range of individuals,
including library personnel, engineers, therapists,
clerical and secretarial personnel, lawyers, graduate
students, and family members. Surveys were given to 120
individuals with a cover letter explaining the purpose of
132
the study and a pre-addressed, stampled return envelope
(Appendix D). Since there was no financial incentive
offered to this group, no records were maintained of to
whom the surveys were given. A major problem with this
sample is, of course, that it was not representative of any
specific population. There was an under-representation of
working class and blue collar workers and an
over-representation of college-educated, middle class
professionals. It is often this latter group, however, who
demands more professional services from health care workers
and is least likely to settle for less. This group is
probably most knowledgeable and supportive of the
consumerism movement.
4.4.4 use School of Pharmacv Full-Time Faculty
Health care professionals working in the academic
setting are often the innovators of change. These "elites”
of the professions are involved in the socialization of
students in the health care professions and promote new
ideas and new expectations for practice of a profession.
All full-time pharmacy school faculty members who have
"mail boxes" at the school were surveyed. Fifty surveys
with cover letters and instructions for returning them via
internal mail system were placed in faculty boxes (Appendix
133
E). No incentive was offered, and no followup reminder was
sent. This group was surveyed two weeks before the end of
the Spring semister.
4.5 STATISTICAL ANALYSES
Frequencies, means and standard deviations were computed
for the relevant demographic, situational and attitudinal
variables.
The 20 role-related activities included to assess role
consensus were subjected to factor analysis to determine if
major categories of role activities exist for hospital and
community pharmacy practice. Analysis of variance was used
to evaluate within- and between-groups consensus on
categories of role items. The degree of variance in
responses to stimulus items was used as a measure of
consensus. Means and variances for each of the 20 items
are presented to allow comparisons between groups.
4.6 LIMITATIONS
Results from the surveys of California pharmacists and
Los Angeles County Medical Association physicians are
probably generalizable to these two populations. It would
not be feasible to generalize the results of the surveys of
nurses or consumers beyond the sample groups because of the
134
haphazard way the samples were obtained. Faculty members
at use may or may not be similar in attitudes to faculty
members at the other two schools of pharmacy in California,
and results cannot be generalized beyond the USC faculty.
Despite these limitations in external validity, this
study is a first attempt to use the same role-specific
items to assess attitudes, opinions and beliefs of
significant groups of persons in the role set of the
pharmacist. This attempt at "role triangulation" to
address the questions of what is a pharmacist, what should
he do, what can he do, is a beginning. Future studies need
to be developed which use better sampling methods.
Another area of concern is the possible difference
between those individuals who completed the survey and
returned it and those who chose not to. Most of the
surveys were quite long, with the survey of pharmacists
taking about 45 minutes to complete. As will be discussed
in the next section, however, the response rates were
comparable to those reported in other surveys of these
groups.
135
4.7 RESPONSE RATES AND DEMOGRAPHIC DATA OF RESPONDENTS
Response rates in mail surveys are often low, and
caution should be exercised in interpreting findings which
include fewer responses than the original sample (Ellis et
al., 1970). Filion (1976) has suggested that low response
rates are biased in favor of those segments of the samples
more actively involved in the subject matter under
investigation. With these cautions in mind, the response
rates of the groups sampled in this study are discussed
(Table 2).
TABLE 2
Response Rates for Populations Sampled.
Group Sampled:
Surveys
Distri
buted
Surveys
Incorrect
Address
Surveys
Com
pleted
Rate of
Response
Pharmacists 500 55 201 45%
Pharmacy Faculty 50 - 18 36%
Physicians 250
3
61 25%
Nurses 300 - 82 34%
Consumers 120 -
43
36%
136
A useable response rate of 45% (n=201 ) for the
pharmacists group was quite satisfactory considering the
extreme length and multipurpose nature of the survey. A
recent national survey of pharmacists, for example, yielded
a usable response rate of only 16 percent (Gagnon, 1976),
and a "local" survey in Illinois employing a brief, 25-item
instrument, generated a response rate of 54 percent (Gold
and Nelson, 1976).
The response rate for pharmacy school faculty members
(36%, n=18) was lower than expected. As pharmacists who
supposedly represent the "elites" of the profession and for
whom the issues addressed in the questionnaire should be
quite salient, this relatively low response was quite
surprising. Factors which may have affected the response
rate include the time of year when the questionnaire was
sent (two weeks before the end of the Spring semister) and
its length, requiring over 30 minutes to complete. Also,
there was no reminder postcard sent to non-responders in
this group.
The response rates for physicians (25%, n=61) and nurses
(34%, n=82), although not as high as pharmacists, were
considered typical for these health professionals and
within the ranges found in other studies (McKay and
Jackson, 1978; Norwood et al., 1976; Ritchey and Raney,
137
1981 A; Shortel, 1973; and Shearer et al., 1978). Likewise
the response rate for consumers (36%, n=43) was less than
expected but consistent with that found in other studies
(Davis et al., 1976; and Yellin and Norwood, 1974).
138
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4.7.1 Pharmacists
Table 3 presents a breakdown of demographic data for the
pharmacists group as a whole and by practice setting. Mean
age for the group was 44.3 ± 13.8 years. Pharmacists
practicing in the hospital setting had the youngest mean
age (37.4 ± 10.7), followed by pharmacists practicing in
the chain store (44.0 ± 12.5) and independently owned (47.2
± 12.4) community settings.
Seventy-four percent (n=149) of the pharmacists were
male and 26% (n=51) were female. A higher percentage of
women pharmacists were employed in the hospital setting
(32%) than in the community settings (22-25%).
Seventy-six percent (n=152) of the pharmacists were
Caucasian, 21% (n=42) were of Asian background, and the
remaining 3% (n=7) were of other minority group membership.
The highest proportion of Caucasian pharmacists was
employed in the community settings (85-88%). Asian and
other minority pharmacists made up 48% of pharmacists
practicing in the hospital setting.
The majority of the pharmacists surveyed held as their
highest pharmacy degree the B.S. in Pharmacy (62%, n=114).
Thirty-eight percent (n=69) of the pharmacists held the
doctorate degree (Pharm.D.). Significant variations in
distribution by degree among the three practice settings
141
existed. The majority of hospital pharmacists held the
doctorate degree (60%), while the reverse was true in the
community setting. Sixty-eight percent of pharmacists
working in independently owned pharmacies, and 85% of
pharmacists working in chain store pharmacies held the B.S.
degree in Pharmacy.
Slightly over half (51%,. n=69) of the pharmacists
surveyed graduated from a pharmacy school not located in
California. Significantly more community pharmacists
(60-66%) compared to hospital pharmacists (38%) belonged to
this group, with the majority of graduates of California
schools practicing in the hospital setting (62%).
In looking at position titles, the majority of
respondents worked in a staff level position (42%).
Forty-four percent of hospital and 69% of chain store
pharmacists listed their position as "staff." This is in
contrast to pharmacists working in independently owned
community pharmacies where only 27% listed themselves as
"staff," and the majority (60%) reported themselves as
owners of their pharmacies. Ten hospital pharmacists (18%)
listed themselves as "clinical" pharmacists.
Other variables of interest included work status: 74% of
the pharmacists worked full-time, 14% worked part-time
(less than 30 hours/week), and 10% were retired; and number
142
of years employed in present position: 8.3 ± 7.3 years for
the whole group, with the shortest mean years of employment
in the hospital setting (6.5 ± 5.0) followed by chain store
(7.2 + 6.2) and independently owned pharmacies (11.2 ± 9.2
years),
Pharmacists who graduated prior to 1970 represent the
"older" cohort and make up 57% of the respondents. Those
who graduated in 1970 or later, the "younger" cohort, were
43% of the pharmacists sampled. The majority of hospital
pharmacists (65%) were from the "younger" cohort, and the
majority of community pharmacists (67-72%) were from the
"older" cohort.
To summarize the demographic profile of pharmacists in
this sample, it was shown that, as expected, pharmacists in
the younger cohort (i.e. who graduated since 1970) were
significantly more likely to have entered hospital pharmacy
practice than were those pharmacists who graduated prior to
1970. In addition to being younger, this cohort
represented a higher proportion of women and minority
pharmacists and pharmacists holding the doctorate degree in
pharmacy. Although not reported in Table 3, the ten
"clinical" pharmacists were from this cohort. Thus there
is some basis demonstrated in the differing demographic
makeup of these two cohorts for the expectation of
143
differences in attitudes and values predicted in the
hypotheses developed.
TABLE 4
Demographic Profile of Respondents to Versions 1 and 2 of
Pharmacist Survey.
Survey 1
("expanded")
Survey 2
("standard")
Test of
Significance
N;
75
126
Age (Mean) 46 .4 yrs. 43 .0 yrs. t = 1 .66
Sex ;
Male
Female
55
19
(74%)
(26%)
94
32
(75%)
(25%) = 0.002
Ethnic Background
White
Minority
62
13
(83%)
(17%)
90
36
(71%)
(29%)
x2 =
2.64
Practice Setting:
Hospital
Community
20
39
(34%)
(66%)
40
59
(40%)
(60%) y? = 0.42
Degree :
B.S.Pharm.
Pharm.D.
49
21
(70%)
(30%)
65
48
(58%)
(42%) = 3.66
p=NS for all tests of significance
Two versions of the instrument were used in the survey
of pharmacists. Survey 1 , the expanded instrument,
contained several additional questions relevant to each of
144
the 20 role activities. Other sections of the two surveys,
however, were identical in format and content. A
comparison of significant demographic characteristics of
respondents to each survey was done to determine if any
response bias was present (Table 4). No significant
differences were found between respondents to the two
instruments in terms of age, sex, ethnic background,
practice setting, or pharmacy degree. Therefore, it was
felt appropriate to combine responses of the two subgroups
to all questions common to both instruments.
145
TABLE 5
Demographic Profile of Pharmacy Faculty Sample,
N 18
Age (Mean ± S.D,) 40 ± 11.2
Sex :
Male 94%
Female 6%
Ethnic Background:
Caucasian 72%
Black -
Hispanic
Asian 28%
Other
—
Degree(s):
B.S.Pharm. 6%
Pharm.D. 83%
Ph.D. 6%
Other 6%
Years Licensed (Mean ± S.D.) 16 ± 8.5
Work Status:
Full-time 89%
Part-time (<30 hr/wk) 11%
Involved in Pharmacy Practice?
Yes 11%
4.7.2 Pharmacy School Faculty Members
Mean age of faculty members was 40.1 + 11.2 (Table 5),
slightly younger than the practicing pharmacists group.
The overwhelming majority of faculty members were male
146
(94%). It would apear that fewer women graduates are
entering academia. Ethnic distribution of faculty members
approximates that of practicing pharmacists with 12%
Caucasian and 28% Asian. As expected, the majority of
faculty members hold the doctorate degree in Pharmacy
(83%), and one faculty member surveyed had a Ph.D. The
mean years since licensure was 16. Eleven percent were
also involved in pharmacy practice in addition to their
academic duties.
Because of the small number of respondents (n=l8) and
low response rate of this group (36%), it is difficult to
determine if this group is even representative of the USC
Pharmacy School faculty as a whole. All responses of this
group will be considered preliminary at best and no
inferences to the USC faculty or pharmacy school faculty
members in general will be made.
147
Demographic Profile
TABLE 6
of Health Professional Sample.
Physicians Nurses
N: 61 82
Age (Mean ± S.D.) 50.5 ± 10.2 41.4 ± 12.3
Sex :
Male 80% 1%
Female 20%
99%
Ethnic Background:
Caucasian 97% 67%
Black 2
19
Hispanic - 4
Asian 2
9
Other - 2
Years in Profession
22.3 ± 10.5 19.8 ± 13.1
Primary Work Location :
Hospital . 3%
56%
HMO
—
1
Clinic
7
12
Private/Group Practice 76 6
Other 14 25
Board Certified :
Yes 70%
Family Member a Pharmacist?
Yes 5% 8%
148
4.7.3 Physicians
Mean age of physician respondents was 50.5 ± 10.2 years
(Table 6). Eighty percent of physicians responding were
male, 20% were female. Nearly all physicians were
Caucasian (97%), with one black and one Asian background
physician. Respondents had been in their profession for an
average of 22.3 years. The majority of physicians worked
primarily in private or group practice (76%), and were
Board certified (70%). Three physicians (5%) had a close
family member who was a pharmacist.
4.7.4 Nurses
Mean age of the 82 nurses in this sample was 41.4 ± 12.3
years (Table 6). All but one of the nurses were female;
67% were Caucasian, 19% black, 4% hispanic, 9% Asian and 2%
other minority. Nurses had been in their profession an
average of 19.8 years. Over half of the nurses (56%)
worked primarily in the hospital setting. Seven nurses had
a close family member who is a pharmacist. Although not
reported in Table 6, six nurse practitioners and one
physician assistant were captured in this sample.
149
TABLE 7
Demographic Profile of Consumer Panel.
N 42
Age (Mean ± S.D.)
46.9 ± 12.7 yrs.
Sex :
Male 28%
Female 72%
Ethnic Background:
Caucasian 95%
Black
-
Hispanic 2
Asian 2
Other -
Marital Status:
Married
71%
Education (Mean ± S.D.) 16.8 ±2.7 yrs.
Family Member a Pharmacist?
Yes 7%
4.7.5 Consumers
Mean age of the 42 consumers in this panel was 46.9 ±
12.7 years (Table 7). Consumers in this panel were
predominantly female (72%), and Caucasian (95%).
Seventy-one percent were married. Highly educated
consumers were over-represented in this panel. The mean
number of years of education was 16.8 ± 2.7. Three
150
respondents in this panel had a close family member who is
a pharmacist.
151
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152
4.8 FACTOR ANALYSIS OF 20 ROLE TASKS
Exploratory factor analysis was performed using
responses of the pharmacists sample to the twenty role
tasks as a means of reducing the large number of items to a
more manageable and meaningful number of logically
consistent role components or segments upon which
comparisons between groups could be made. Separate factor
analyses were performed for the set of 20 items for the two
questions concerning appropriateness of role tasks for (a)
community pharmacists and (b) hospital pharmacists. A
principal factoring method with iteration (PA2), and
varimax rotation was used (Nie et al., 1975) and the
resulting correlation matrices and varimax rotated factor
matrices are included in Appendices F and G.
4.8.1 Role Segments - Community Pharmacy
Five factors were revealed for both appropriateness of
tasks for community pharmacists and for hospital
pharmacists. A summary and reorganization of the factors
for both groups is presented in Table 8.
The items loading heaviest on the first factor for
community pharmacists included; task 11 - prescribing for
acute illness (.76), task 17 - order lab tests (.76), task
18 “ primary care of chronic patients (.72), task 10 -
153
dosage adjustments (.68), task 20 - administer injectable
drugs (.54), and task 3 - teach pharmacology (.46). These
items all clearly represent role tasks which may be defined
as "clinical" or "expanded" and require a high level of
training, knowledge and expertise on the part of the
pharmacist. This role segment was labelled "Clinical"
activities.
Items loading heaviest on the second factor included:
task 7 - counsel patients on OTC drugs (.59), task 6 -
counsel patients on legend drugs (.59), task 4 - select
source of supply (.48), task 8 - entry point to system
(.45), task 9 - medication profiles (.36), task 5 - manage
pharmacy (.32), and task 2 - fill prescriptions (.32).
This cluster of items represent role tasks which have been
part of the traditional role of the community pharmacist
for a long time and the minimum that a pharmacist should do
in community practice. This role segment was labelled
"Core" activities.
Factor three was composed of the following items: task
13 - consumer education (.71), and task 12 - advise on
personal health matters (.60). These two items have
traditionally been part of the pharmacist’s role in
community health education and advisement, and most
pharmacists are competent to perform this role. This
154
segment was labelled "General Patient Advisement"
activities.
The four items which loaded heaviest on factor four
were: task 19 - institutional consulting (.58), task 14 -
training home care patients (.58), task 15 - training
patients using medical equipment (.43), and task 16 - blood
pressure monitoring (.42). These items also represent
patient advisement, education or monitoring but differ from
items in factor three in that they generally require
additional training of the pharmacist and therefore call
for a higher level of knowledge, skill and expertise. In
addition, the pharmacist generally takes on more patient
care responsibilities in performing these activities. For
some pharmacists these activities may be income generating
and reimbursable by third-party payors. For these reasons
this role segment was labelled "Specialized Patient
Advisement" activities.
The final factor was composed of only one item, task 1 -
drug information resource (.62), and was labelled as such.
This is a relatively new role activity for pharmacists in'
the community setting and represents a rather specialized
function requiring advanced knowledge and skill.
155
4.8.2 Role Segments - Hospital Pharmacy
Five of the items which loaded heaviest on the first
factor for community pharmacists were found for hospital
pharmacists : task 17 (.82), task 11 (.75), task 10 (.73),
task 18 (,55) and task 20 (.54). Task 3 did not load high
on any factor but rather at about the same value (.25-.29)
on three factors. Therefore, this item was omitted for
hospital pharmacists. This role segment was also labelled
"Clinical" activities.
Items loading highest on the second factor included the
same four items of the fourth factor for community
pharmacists: task 19 (.68), task 16 (.55), task 14 (.54),
and task 15 (.51). These items were also labelled
"Specialized Patient Advisement" activities, as additional
training and education generally is required by hospital
pharmacists in performing these activities.
The third factor for hospital pharmacists included the
two items from the third factor for community pharmacists,
task 13 (.59) and task 12 (.58), as well as two items from
the second factor for community pharmacists, task 6 (.57)
and task 9 (.50). Although this role segment contains two
additional items, it was also labelled "General Patient
Advisement". The two items added to this component which
were part of the "core" activities of the community
156
pharmacist, would appear to fit better here.
Traditionally, hospital pharmacists rarely counselled
patients directly. In addition, most patient data was
contained in the patient’s hospital chart. Therefore,
these two tasks rarely were part of the traditional core
activities of the hospital pharmacist. When these
activities do occur in the hospital setting they are
generally considered aspects of patient advisement and
logically fit within this role segment. They are not
integral components of the core functions as they are in
community practice.
Items in the fourth factor are two tasks which were
contained within the ’’core’’ segment for community
pharmacists but represent a unique segment for hospital
pharmacists and included: task 7 (.82) and task 8 (.53).
These two activities are not generally part of the hospital
pharmacist’s usual activities. To the extent that they do
occur, they probably represent a ’’triage’ ’ type of function
where the pharmacist would help the patient decide the next
step to take when concerned with symptoms (i.e. try a
nonprescription remedy or seek other medical assistance).
These two activities are part of the usual routine of
pharmacists in the community setting, however. Therefore,
this separate role segment for hospital pharmacists was
labelled ’’Triage’’ activities.
157
Finally, factor five for hospital pharmacists contains
the remaining items which can be construed as the "core"
activities for hospital practice. Items in this cluster
include: task 5 (.64), task 2 (.49), task 4 (.45), and task
1 (.37). The first three tasks are also found in the
"core" segment for community pharmacists. The final item,
drug information resource, is a well-integrated and
accepted component of traditional hospital pharmacy
practice.
In comparing the five role segments for each practice
setting, it is apparent that the clustering is essentially
the same. Where differences exist they may be explained
easily. The results of this rather solid delineation of
role segments or clusters of role activities was used to
make comparisons across sample groups and to determine
patterns of consensus toward more traditional core and
patient advisement activities, versus expanded clinical and
specialized patient advisement activities.
158
Chapter V
FINDINGS
The findings of the study are presented in this chapter,
which is organized into three main sections plus a summary.
The first section presents the findings relevant to the
first set of hypotheses concerned with comparisons across
groups for levels of support and consensus for expanded
roles for pharmacists. Findings relevant to the second set
of hypotheses concerned with the delineation of different
levels of support for expanded pharmacy roles among
pharmacists is presented in the second section. In the
final section, the findings for the third set of hypotheses
in the delineation of the effects of relevant background,
situational and attitudinal variables on support for
expanded roles are presented.
5.1 INTER-GROUP CONSENSUS FOR THE ROLE QF THE PHARMACIST
Two separate concerns are addressed in this section: 1)
the degree of favorableness or level of support for
individual and categories of role activities as appropriate
for hospital and community pharmacists to perform in their
159
practices, and 2) the strength of agreement or consensus
within each group. The appropriateness of role segments
for a particular practice setting, and the strength of the
agreement among groups were the issues addressed.
5.1.1 Measurement of Support and Consensus
An index of central tendency, whether it be the mean,
mode or median, summarizes only one aspect of a
distribution of responses or observations (Hays, 1973, p.
236). The variance (and its square root, the standard
deviation) summarizes a second aspect, the tendency for
observations to be unlike the mean (Ibid.).
The variance reflects the degree of spread or dispersion
of observations in a distribution, and the more the
observations differ from the mean, the larger the variance
will be. The variance also summarizes how different the
observations are from each other, and is "directly
proportional to the average squared difference between all
pairs of observations" (Ibid., p. 240). The variance,
therefore, may be used as a measure of consensus. A low
variance value would indicate a high degree of agreement
among members of a group; a high value, on the other hand,|
would indicte a high level of dissensus among group:
members.
160
Just as hypotheses about two population means can be
tested using sample means, hypotheses about two population
variances can be tested using sample variances. The F
distribution is used to determine if the ratio of two
sample variances is significant given some selected value
for alpha (Ibid., p. 449). Hays emphasizes the importance
of the normal distribution assumption in using the F
distribution in testing hypotheses about two sample
variances. Unless the population distribution is normal or
the sample sizes quite large, inferences about the
population variances should be made with caution (Ibid., p.
451 ).
5.1.2 Inter-Group Comparisons of Support for Expanded
Roles
The first set of hypotheses tested by the data were
concerned with comparisons of levels of support and
consensus for expanded role activities for pharmacists
across groups. Specifically, it was predicted that:
1 . Pharmacists will be more supportive of a clinical
role for pharmacists than physicians, nurses or
consumers.
2. Nurses will be the next most supportive professional
group (after pharmacists) of a clinical role for
pharmacists.
161
3. Physicians will be the profession most antagonistic
toward a clinical role for pharmacists.
4. Physicians will be more antagonistic toward a
clinical role for pharmacists in the community
setting than in the hospital setting.
5. Consumers will be intermediate in level of support
for a clinical role for pharmacists.
6. For each group there will be higher consensus on
traditional role activities of pharmacists than on
expanded, clinical role activities.
162
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The final hypothesis in this set was concerned with the
level of consensus among group members for traditional and
expanded role activities. It was predicted that level of
agreement would be higher for traditional role segments
(core activities and general advisement) compared to
expanded role segments (specialized advisement and clinical
activities).
Table 10 presents the variances for role segments by
group. Two F tests were computed for each group. First,
the ratio of the variance for the clinical role segment to
the variance for the core role segment was computed.
Second, the variance for each role segment was compared to
the variance for the pharmacists group. These F ratios
were computed to test the null hypothesis of no difference
in group variances.
Results of the F tests of sample variances indicate
support for the hypothesis of higher consensus for
"mandatory" core activities compared to more
"discretionary" clinical activities within each group for
both practice settings (p <.001).
Highest consensus (most agreement) within each group was
exhibited for the core activities, as was expected. The
triage role segment for hospital practice exhibited the
most variance within groups, indicating very littlej
agreement on level of support for these activities.
170
Levels of consensus for the two advisement role segments
for hospital practice were quite similar in each group.
There was much less consensus on the general advisement
segment compared to the specialized advisement segment for
community practice among all groups except pharmacists*
This finding was somewhat puzzling, however. The role
activities which make up the general advisement segment
have been traditionally performed by community pharmacists,
and, in fact, a community pharmacist who avoids these
activities may be negligent. Even pharmacy faculty were
less agreed on the general advisement segment than the
specialized advisement segment in the community setting.
This relatively large discrepancy in consensus is difficult
to explain, since overall level of support for general
advisement in the community setting was fairly high.
The second set of comparisons dealt with level of
consensus of other groups relative to pharmacists.
Although level of consensus was high for all groups on core
activities, pharmacists were significantly more tightly
clustered in level of support for the community core
activities segment compared to physicians, nurses and
consumers (p <.0001). This was also true for the community
general advisement segment with pharmacists exhibiting
significantly more consensus on level of support than
171
faculty (p <.04), physicians (p <.0001), nurses (p <.002)
or consumers (p <.002). Physicians were in less agreement
on level of support compared to pharmacists for both
expanded role segments (specialized advisement and clinical
activities) in the community setting (p <.05).
Compared to the wide variations in consensus exhibited
across groups for community practice role segments, the
lack of significant variations in consensus for hospital
practice role segments across groups was noteworthy.
Except for significant differences in concensus between
pharmacists and physicians on the two advisement segments,
there appeared to be remarkable consensus on level of
support for all hospital role segments across groups.
Certainly this would indicate that regardless of whether or
not a particular group was supportive of a role segment for
hospital practice, members of each sample group were
relatively equally united in their opinions.
The importance of looking at level of consensus across
groups to the development of strategies for purposeful
social role change is discussed more fully in the next
chapter. However, it should be apparent that regardless of
differences in level of support (i.e. group means) for a
role activity (or cluster of role activities), how "united"
a front (i.e. level of consensus) a group presents will be
172
important information in trying to change attitudes and
increase level of support for social role change.
173
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In order to more closely examine the patterns of support
for the role segments and to determine if specific items
were responsible for differences noted between groups in
support for role segments, the twenty items which make up
the role segments were subjected to analysis of variance to
determine overall difference. Group means for pharmacists
were compared to each of the other group means for each
item.
Table 11 presents a breakdown of the ten traditional
role activities by groups. The only activity which was
supported equally by all groups was the filling of
prescriptions in both practice settings. This represents
an extremely narrow definition of the pharmacist's role.
For most of the traditional activities the pattern
observed for each role segment was also seen for the
individual items (i.e. pharmacists most supportive,
consumers intermediate, and nurses and physicians least
supportive). Exceptions to this pattern were noted for
item 5, "manage pharmacy," where physicians were
significantly more supportive of this activity compared to
pharmacists for both the community (1.17 vs. 1.32, p <.05)
and hospital settings (1.17 vs. 1.52, p <.0001). For item
1, "drug information consultant," nurses were significantly
more supportive of this activity for hospital pharmacy
compared to the pharmacist group (1.15 vs. 1.27, p <.04).
177
All activities which require independent judgment or
autonomous action relevant to patient care (e.g. counsel
patients on legend or OTC drugs, select source of supply,
maintain medication profiles, advise patients on personal
health concerns, serve as entry point to health care system
or consumer educator) demonstrate a significant difference'
in level of support between pharmacists and the nurses and
physicians groups.
178
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Table 13 provides a summary of the patterns of support
for traditional and expanded role activities and indicates
by the coding of pluses and minuses the modal categories of
responses, and therefore level of support, for each item.
This table provides a graphic picture of the different
levels of support between traditional and expanded role
activities for each group. For example, over 70 percent of
the pharmacists felt the community pharmacist should fill
prescriptions, counsel patients on legend and OTC drugs,
select the source of supply, and manage the pharmacy. The
majority of pharmacists, however, felt it inappropriate for
a community pharmacist to prescribe, order lab tests or
administer drugs.
Physicians were the most supportive of the community
pharmacist filling prescriptions and managing the pharmacy,
and least supportive of the community pharmacist monitoring
blood pressure, making dosage adjustments, training home
care patients, prescribing, providing primary care to
chronic disease patients, ordering lab tests or
administering drugs. Similar patterns were observed for
nurses. Faculty members were clearly shown to be the most
supportive group of these activities for pharmacists.
187
5.2 INTRA-GROUP COMPARISONS OF SUPPORT FOR EXPANDED ROLES
The second set of hypotheses examined with the data were
concerned with differences in level of support for expanded
role activities among pharmacists:
1. Pharmacists who are faculty members of a school of
pharmacy will be the most supportive of all
pharmacists of a clinical role for pharmacists.
2. Pharmacists who have graduated since 1970 (the
younger cohort) will be more supportive of a
clinical role for pharmacists than will pharmacists
who graduated before 1970.
3. Upwardly mobile, expanding pharmacist segments
(women and Asians) will be more supportive of a
clinical role for pharmacists than will more stable
segments (men and Caucasians respectively).
4. Hospital pharmacists will be more supportive of a
clinical role for pharmacists than will community
pharmacists.
Each hypothesis was examined separately.
The first hypothesis was concerned with differences in
level of support for a clinical pharmacy role between
practicing pharmacists and the "elites" of the profession,
the pharmacy school faculty, who as a group have great
influence on the direction the profession will take in the
future.
188
TABLE 14
Comparison Between Practicing Pharmacists and Pharmacy
Faculty on Role Segments.
PHARMACY
PHARMACISTS FACULTY
(Mean ± SD) (Mean + SD)
COMMUNITY PRACTICE ROLE SEGMENTS
Core Activities
1 .30 ±
0.36 1 .43 ± 0.48
General Advisement 1 .61 ± 0.71 1 .41 ± 1 .00
Drug Information 1 .61 ± 0.83 1 .71 ± 0.99
Specialized
Advisement
2.04 ± 0.80 1 .66
± 0.73
Clinical Activities 3.00 ± 0.95 2.48 ± 0.88
HOSPITAL PRACTICE ROLE SEGMENTS
Core Activities
1.33 ±
0.40 1 .28
±
0.36
General Advisement
1 .75 ±
0.40
1 .73 ±
0.78
Triage
2.43 ± 1.11 2.47
± 0.14
Specialized
Advisement
2.18 ± 0.79 1 .84
+ 0.79
Clinical Activities 2.20 ± 0.80 1 .89 ± 0.68
* p <.05
189
The data presented in Table 14 partially support the
above hypothesis. Pharmacy faculty members were more
supportive of both expanded role segments (specialized
advisement and clinical activities) for the two practice
settings compared to practicing pharmacists. However, only
the difference for clinical activities in the community
setting reached statistical significance (2.48 vs. 3.00, p
<.05) .
The pharmacy faculty group was more supportive of all 10
expanded role activities than practicing pharmacists for
both practice settings (Table 12). The differences between
these two groups were significant for three activities for
community practice; primary care of patients with chronic
diseases (1.94 vs. 2.73, p <.02), ordering lab tests (2.53
vs. 3.42, p <.005), and administering injectable drugs
(2.59 vs. 3.32, p <.03); and three activities for hospital
practice: institutional drug consulting (1.47 vs. 1.93, p
<.004), making dosage adjustments (1.47 vs. 1.85, p <.03)
and primary care of patients with chronic diseases (1.82
vs. 2.57, p <.02).
190
TABLE 15
Comparison Between Pharmacists Who Graduated Prior to 1970
and 1970 or Later on Role Segments.
OLDER YOUNGER
COHORT COHORT
(Mean ± SD) (Mean + SD)
COMMUNITY PRACTICE ROLE SEGMENTS
Core Activities 1 .36
±
0.40 1 .23 ±
0.30*
General Advisement 1 .59 ± 0.71 1 .63 ±
0.72
Drug Information 1 .67 ±
0.86 1 .54
±
0.78
Specialized
Advisement
2.13 ±
0.82 1 .92
+ 0.77
Clinical Activities
3.09 ± 0.99 2.89 ±
0.90
HOSPITAL PRACTICE ROLE SEGMENTS
Core Activities 1 .32
±
0.36 1 .34
±
0.44
General Advisement
1 .77 ± 0.75 1 .73 ± 0.67
Triage 2.55 ± 1.17 2.30
± 1 .03
Specialized
Adv isement
2.16
±
0.81 2.20
±
0.78
Clinical Activities 2.26
± 0.77 2.13 + 0.83
* p <.05
191
The second hypothesis of differences between the two
cohorts of pharmacists is related to the first. The
influence exerted by pharmacy faculty on the profession is
often directly manifested in the socialization experiences
of pharmacy students. Values are transmitted from faculty
to students during this process. Pharmacists who graduated
since 1970 have received a qualitatively different
socialization to the profession compared to pharmacists who
graduated earlier. Therefore, differences between these
subgroups in level of support for clinical activities was
expected.
The trend for higher levels of support for clinical
activities in the community and hospital settings by the
younger cohort compared to the older cohort was supported
by the data (Table 15).
192
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193
An examination of support for the 10 expanded role items
by cohort revealed the same general trend of higher support
by the younger cohort (Table 16). Significant differences
between the younger and older cohorts were found on only
three items for community practice: institutional
consulting (1.62 vs. 1.96, p <.05), blood pressure
monitoring (1.72 vs. 2.07, P <.05), and primary care of
patients with chronic diseases (2.51 vs. 2.91, P <.05).
None of the differences between cohorts for hospital
practice were statistically significant.
The third hypothesis predicted higher levels of support
for clinical activities by upwardly mobile segments In the
profession. Women pharmacists were expected to be more
supportive of clinical activities than men pharmacists;
Asian-background pharmacists were predicted to be more
supportive than Caucasian pharmacists. Tables 17 and 18
examined the differences between pharmacists by sex.
Tables 19 and 20 examined differences by ethnic background.
194
TABLE 17
Comparison Between Male and Female
Segments.
Pharmacists on Role
MALE
PHARMACISTS
FEMALE
PHARMACISTS
(Mean ± SD) (Mean + SD)
COMMUNITY PRACTICE ROLE SEGMENTS
Core Activities 1.34 ± 0.38 1 .20
± 0.27*
General Advisement 1.65 ± 0.72 1 .48
+
0.68
Drug Information 1.70 ± 0.86 1.36
± 0.67*
Specialized
Advisement
2.06 ± 0.80
1 .99 + 0.83
Clinical Activities 3.09 + 0.94 2.77 ±
0.98
HOSPITAL PRACTICE ROLE SEGMENTS
Core Activities 1.36 ± 0.42 1 .24
±
0.32*
General Advisement 1.79 ± 0.72 1 .64
±
0.68
Triage 2.49 ± 1.15 2.28
±
1 .01
Specialized
Adv isement
2.23 + 0.80 2.02
±
0.76
Clinical Activities 2.23 ± 0.80 2.11 ± 0.80
* p <.05
195
Women pharmacists were more supportive of clinical
activities for both practice settings compared to men.
This trend lends support to the hypothesis but the
differences were not statistically significant (Table 17).
Further examination of Table 17 revealed that women
pharmacists tended to be more supportive of all role
segments for both settings. This may indicate response
bias, with women rating all segments more highly than men.
Except for significant differences in both means and
variance ratios for core activities between men and women
pharmacists, comparisons of variances (F tests) indicate no
significant differences in dispersion. This may support
the contention of a tendency to respond more positively on
all activities. An alternative explanation, however, would
be that women view the role as more all-encompassing than
do men.
196
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197
Table 18 presents the 20 role activities by sex. This
table allows for further exploration of the response
patterns. In general, women tended to be more supportive
of most role activities. Women were significantly more
supportive of many role tasks which require good
interpersonal skills: counsel patients on legend drugs in
the community setting (1.08 vs. 1.27, p <.005) and hospital
setting (1.31 vs. 1.68, p. <.005); serve as entry point for
patients to the health care system in the community setting
(1.17 vs. 1.45, p <.005); serve as drug information
consultant to health care professionals in the community
(1.36 vs. 1.70, p <.05) and hospital settings (1.00 vs.
1.33, p <.0001); consumer educator in the community setting
(1.6Ô vs. 1.93, P <.05); and train home care patients in
the hospital setting (1.67 vs. 1.98, p <.05). Women were
also significantly more supportive of making dosage
adjustments by community pharmacists (2.27 vs. 2.89, p
<.005) and community pharmacists teaching pharmacology to
health care professionals (2.44 vs. 2.88, p <.05).
198
TABLE 19
Comparison Between White and Asian
Segments.
Pharmacists on Role
WHITE
PHARMACISTS
ASIAN
PHARMACISTS
(Mean ± SD) (Mean + SD)
COMMUNITY PRACTICE ROLE SEGMENTS
Core Activities 1.30 ±
0.35 1 .31 ±
0.38
General Advisement 1.60 +
0.71
1 .66
±
0.74
Drug Information
1 .63 ± 0.86 1 .55 ± 0.73
Specialized
Advisement
2.06 ± 0.82
1 .99 ± 0.75
Clinical Activities
3.03 ± 0.98 2.91 ± 0.87
HOSPITAL PRACTICE ROLE SEGMENTS
Core Activities 1.34 ± 0.40 1 .30
± 0.39
General Advisement 1 .72 ± 0.71 1 .85 ±
0.72
Triage
2.49 ± 1.15 2.27 ± 0.99
Specialized
Advisement
2.13 ± 0.79
2.32
±
0.81
Clinical Activities 2.24 + 0.84
2.09 ±
0.66
p = N.S. for all comparisons.
199
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Asian-background pharmacists were more supportive of the
clinical activities segments for both practice settings
compared to Caucasian pharmacists, but the differences did
not reach statistical significance (Table 19). Asian and
white pharmacists were about equally supportive of most
other role segments. Although the difference was not
statistically significant, Asian pharmacists were less
supportive of the specialized advisement segment for
hospital pharmacy compared to white pharmacists (2.32 vs.
2.13, t=1.42, N.S.).
When responses to the 20 items are examined, no
significant patterns emerge between pharmacists by ethnic
background (Table 20). A truly mixed pattern of responses
is evident, with Asian pharmacists more supportive on some
activities (both traditional and expanded) and less
supportive on others compared to white pharmacists.
The data examined in Tables 17 to 20 provide mixed
support for the hypothesis of more support for clinical
activities by women and Asian pharmacists. There is
moderate support for the hypothesis by sex, with women
tending to be more supportive of all clinical role
activities compared to men. Most of these differences,
however, were not statistically significant.
201
There was little support for the expectation of
differences by ethnic background. Although
Asian-background pharmacists, overall, were more supportive
of the clinical role segments than white pharmacists, when
the individual role activities were examined, no clearcut
pattern of support for clinical activities emerged.
The last hypothesis in this set of intra-group
comparisons dealt with differences by practice setting of
respondents. Only pharmacists practicing in the hospital
or community setting were included in this analysis.
Different practice locations call for different role
activities beyond a small core of activities common to both
settings. Differences also exist within these two practice
settings in terms of the pharmacist * s position in the
status hierarchies, and the relative focus on
revenue-generating activities. For these reasons it was
predicted that hospital pharmacists would be more
supportive of clinical activities compared to community
pharmacists. Tables 21 and 22 present the data for
pharmacists by practice settings.
202
TABLE 21
Comparison Between Hospital and Community Pharmacists on
Role Segments.
HOSPITAL
PHARMACISTS
COMMUNITY
PHARMACISTS
(Mean + SD) (Mean ± SD)
COMMUNITY PRACTICE ROLE SEGMENTS
1 .30 + 0.38 Core Activities
0.72 General Advisement
1.62 ± 0.78 Drug Information
0.83 Specialized
Advisement
2.98 ± 0.90 3.08 ± 0.92 Clinical Activities
HOSPITAL PRACTICE ROLE SEGMENTS
0.40 1 .34 Core Activities
1 .85 General Advisement
2.25 ± 0.89 2.60 1 .21 Triage
0.84 Specialized
Advisement
0.78 Clinical Activities
203
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204
No significant differences were noted between hospital
and community pharmacists on comunity practice role
segments, or hospital practice role segments with the
exception of the triage segment (Table 21). The data do
support the expectation of more support for clinical
activities by hospital pharmacists, but the differences did
not reach statistical significance.
Differences by practice setting for the 20 role items
are presented in Table 22. No clearcut pattern emerged
between hospital and community pharmacists* levels of
support for expanded role activities.
The data do not support the hypothesis of more support
for clinical role activities by hospital pharmacists
compared to community pharmacists.
In summary, there was moderate support for the second
set of hypotheses concerning differences among pharmacists.
Certainly pharmacy school faculty members were
significantly more supportive of expanded role activities
for pharmacists than the **rank and file*' practitioners.
The data do suggest that this "elite" group of pharmacists
hold values which are different from the majority of
pharmacists.
A trend exists toward higher levels of support for
clinical activities among pharmacists in the younger cohort
205
(vs. older cohort), women pharmacists (vs. men
pharmacists), Asian background pharmacists (vs. Caucasian
pharmacists), and pharmacists practicing in a hospital
setting (vs. a community setting), but the differences were
not statistically significant.
5.3 DELINEATION OE VARIABLES ASSOCIATED WITH SUPPORT FOR
EXPANDED ROLES
The third set of hypotheses tested were concerned with a
delineation of the background, situational or attitudinal
variables associated with support for a clinical role for
pharmacists. This aspect of the dissertation was somewhat
exploratory in nature. The following hypotheses were
proposed and are examined separately :
1. Pharmacists and health professionals who perceive
the pharmacists primarily as a "clinician" will be
more supportive of a clinical role for pharmacists
than those professionals who perceive the pharmacist
primarily as a "businessman."
2. Physicians and nurses who have had experiences in
working with a clinical pharmacist will be more
supportive of a clinical role for pharmacists than
those professionals who have not had such
experiences.
206
Physicians and nurses who perceive the pharmacist as
the "drug expert
clinical role for those pharmacists than
professionals who perceive the physician as the
drug expert
207
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208
Respondents were asked to rank eight possible "roles" or
"hats" for pharmacists. This question was included in the
survey to ascertain respondents* dominant orientation
toward pharmacists. Table 23 presents the rankings by
pharmacists, pharmacy faculty, physicians, nurses and
consumers. Analyses of variance revealed significant
differences across groups on all eight items. As
predicted, "health care professional" was ranked first by
all groups, and "craftsman" was ranked seventh or eighth by
all groups. These two "roles" acted as boundaries for the
set. "Health Educator" was ranked second by all groups
except physicians, who ranked it third. "Clinician" was
ranked third by pharmacists, pharmacy faculty, nurses and
consumers, and eighth by physicians. Clearly, physicians
do not wish to think of the pharmacist as a clinician.
Physicians ranked "businessman" as second, and "technician"
as fourth. The remaining groups were rather consistent in
their rankings of the items. The data in this table
indicate wide differences between physicians and the
remaining groups in dominant orientation toward
pharmacists.
The two perceptions of interest to this study were
"clinician" and "businessman." These two items represent
very divergent orientations. Respondents in each group who
209
TABLE 24
Clinical Versus Business Orientation By Group.
Dominant Orientation Toward Pharmacists
Clinician Businessman
% (N) % (H)
Pharmacists 63% (115) 37% (67)
Faculty
67%
(12)
33%
(6)
Physicians
37%
(20)
63% (34)
Nurses 83% (66) 17%
(14)
Consumers 72% (28) 28% (11)
T? = 30 .23 (p <•00001 )
ranked "clinician" higher than "businessman" were defined
as having a clinical orientation toward pharmacy, those
respondents who ranked "businessman" higher than
"clinician" a business orientation. Table 24 presents a
breakdown of groups by orientation. The majority of all
groups except physicians hold a clinical orientation toward
pharmacy. Eighty-three percent of the nurses held a
clinical orientation. This was higher than pharmacists or
pharmacy faculty. Sixty-three percent of physicians, on
210
the other hand, ranked businessman higher than clinician.
Chi-square was 30.23 (p <.00001).
Significant differences also were demonstrated among the
pharmacy group. Table 25 presents a breakdown by dominant
orientation by the following demographic variables of
pharmcists; sex, ethnic background, cohort, practice
setting and pharmacy degree.
211
TABLE 25
Dominant Orientation Among Pharmacists.
Dominant Orientation:
Clinical Business
% (N) % (N)
ALL PHARMACISTS:
SEX:
Male
Femali
X'
64% (115)
= 10.60 (p
ETHNIC BACKGROUND:
White
Asian-
X'^ = 5.18 (p
COHORT:
Older
Younger
X^ = 18.81 (p
PRACTICE SETTING:
Hospital
Community
X^ = 26.32 (p
PHARMACY DEGREE:
B.S.Pharm.
Pharm-D.
^ = 8.73 (p
56%
84%
<.001 )
58%
78%
<.02)
(74)
(41 )
(79)
(36)
48%
81%
<.00001 )
(48)
(67)
91%
46%
<.00001 )
(48)
(42)
54%
78%
<.003)
(57)
(50)
36% (6 6)
44% (58)
16% (8)
42%
22%
52%
19%
54%
22%
(57)
(10)
(51 )
(16)
(5)
(49)
(48)
(14)
212
All separate comparisons of dominant orientation by
demographic variables were significant. Women pharmacists
were significantly more likely to hold a clinical
orientation compared to men (84% vs. 56%, p <.001).
Significantly more Asian pharmacists compared to white
pharmcists expressed a clinical orientation (78% vs. 58%, p
<.02). Eighty-one percent of the younger cohort versus 48
percent of the older cohort held a clinical orientation
toward pharmacists. Nearly all (91%) hospital pharmacists
expressed a clinical orientation toward pharmacists, while
only 46 percent of community pharmacists did (p <.00001).
Finally, 78 percent of pharmacists with a doctorate degree
versus 54 percent of baccaleaurate level pharmacists held a
clinical orientation (p <.003).
It appears from Tables 24 and 25 that dominant
orientation toward pharmacists is a rather salient variable
both across groups and within the pharmacists group.
213
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214
The effect of dominant value orientation on support for
pharmacy role segments is presented in Table 26. Separate
t-tests were computed for pharmacists, physicians and
nurses. There were no differences among the three groups
between clinical and business orientations for core
jactivities or specialized advisement segments for community
or hospital practice settings. Pharmacists with a clinical
orientation were significantly more supportive of general
advisment in the hospital setting (p <.03), and the triage
segment for hospital practice (p <.05) compared to those
with a business orientation. A similar pattern was
observed for physicians and nurses, with those respondents
with a clinical orientation expressing significantly more
support for general advisement and triage segments in the
hospital setting compared to respondents in these groups
with a business orientation.
Significant differences were noted in each group between
respondents holding clinical orientations compared to
business orientations for the clinical activities segments
for both practice settings. The second hypothesis in this
set is well supported by the data.
Dominant value orientation appears to be a significant
variable associated with support for a clinical role for
pharmacists. Although it is not possible to determine the
215
direction of causality between these variables, at least
within the survey instrument respondents were required to
rank the eight "roles" for pharmacists before responding to
questions about the appropriateness of role activities. By
forcing respondents to think about "What is a pharmacist?"
it is possible that this activity influenced the responses
to the rest of the instrument.
TABLE 27
Experiences with Clinical Pharmacists.
Physicians Nurses
%
(N) % (N)
CLINICAL PHARMACIST
EXPERIENCE?
Yes 58%
(34)
64% (51 )
No 42% (25) 36% (20)
= 0.31 (p=NS)
It was predicted that experience in working with a
clinical pharmacist would lead to a more positive attitude
toward pharmacists and more support for clinical rol
216
activities. Table 27 shows the percentages of physicians
and nurses who indicated that they had worked with a
clinical pharmacists. The majority of both groups had
experience with a clinical pharmacist (p=NS).
Physicians and nurses were also asked to evaluate their
experiences with clinical pharmacists. Fifty-five percent
of the physicians and 57 percent of the nurses rated their
experiences as "excellent".
217
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218
The effect of clinical pharmacist experiences on support
for role segments is presented in Table 28. There were no
significant differences between respondents who did and did
not have such experience except as follows. For
physicians, those with experience in working with a
clinical pharmacist were somewhat more likely to support
clinical role activities in the community setting (p <.03)
but the level of support was still negative. For nurses,
those with experience were significantly more supportive of
core functions (1.35 vs. 1.54, p <.04) and clinical
activities in the hospital setting (2.74 vs. 3.28, p <.01 ),
and slightly more supportive of community clinical
activities.
It appears that for this group of physicians and nurses,
experience, overall, has little effect on attitudes toward
the appropriateness of role activities for pharmacists,
although there was a tendency for those with experience to
be more supportive of clinical activities. Thus, there is
weak support for the hypothesis.
The third hypothesis in the set was concerned with the
effect of perception of the pharmacist versus the physician
as the legitimate "drug expert. " Seventy-eight percent of
the physicians indicated the physician as drug expert.
Only 26 percent of the nurses felt the physician to be the
219
drug expert, and 72 percent indicated the drug expert to be
the pharmacist (X^ = 33.7, P <.0001).
TABLE 29
Effect of Clinical Pharmacist Experience on Perception of
Pharmacist as Drug Expert.
PHYSICIANS NURSES
MD RPH MD RPH
Drug Drug Drug Drug
Expert Expert Expert Expert
% (N) % (N) % (N) % (N)
CLINICAL RPH
EXPERIENCE?
Yes 79% (27) 21% (7) 18% (9) 82% (40)
No 76% (19) 24% (6) 41% (12) 59% (17)
X^’ 0.01 (p=NS) 3.80 (p <.05)
When perception of physician or pharmacist as drug
expert was compared with experience with clinical
pharmacist for physicians (Table 29) no significant
differences were observed (p=NS). However, when the same
comparison was made for nurses, it was observed that 82
percent of nurses with clinical pharmacy experience felt
220
the pharmacist to be the drug expert compared to 59 percent
3.80 of the nurses without such experiences (X
Experience in working with a clinical pharmacist is related
to perception of the pharmacist as drug expert for nurses
but not for physician
221
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222
Table 30 presents analysis of level of support for role
segments by perception of physician versus pharmacist as
drug expert for the physicians group and nurses group. No
significant differences were noted between physicians who
indicated the physician as drug expert compared to those
who indicated the pharmacist as drug expert. There was a
tendency for physicians who felt the pharmacist to be the
drug expert to be more supportive of drug information
resource segment in community practice, and clinical
activities segments in both practice settings, but the
differences did not reach statistical significance. Nurses
who felt the pharmacist to be the drug expert were somewhat
more supportive of clinical role activities in the
community setting (p=NS) and in the hospital setting (p
<.04).
In summary, of the three conditional variables analyzed
above, the most significant appears to be dominant value
orientation toward pharmacists. Significant differences
were demonstrated between respondents who felt the
pharmacist to be primarily a clinician compared to those
who felt him to be more of a businessman. It makes
intuitive sense that one's major orientation to another
person's role position would greatly affect one's
perceptions of appropriate role activities.
223
Although other researchers have found that the
opportunity to work with a clinical pharmacist led to a
more positive attitude and acceptance of clinical
pharmacist activities, the data only demonstrate a trend in
the predicted direction. This was a more influential
variable for nurses than physicians in this study.
Finally, the finding that the majority of nurses felt
the pharmacist to be the drug expert was somewhat
surprising. In addition, the effect of clinical pharmacist
experiences on this relationship was significant. It
appears that nurses who have an opportunity to examine
stereotypes about pharmacists are more willing to accept
the pharmacist as the expert on drug-related matters. Why
this effect was not noted in the physicians group is open
to speculation. It may be that physicians experience the
clinical pharmacist as a direct threat to their autonomy
and devalue the clinical pharmacist as a way to "keep him
in his place."
5.4 SUMMARY
This chapter was devoted to the presentation of the
empirical data that constitute the findings of this study.
Three sets of hypotheses were presented, tested and
discussed.
224
The first set of hypotheses predicted differences in
levels of support for expanded roles for pharmacists. As
predicted, pharmacists were the most supportive group of a
clinical role; and physicians were the group most
antagonistic toward these roles. Both nurses and
physicians were more negative toward the clinical
activities role segment in the community pharmacy practice
setting than in the hospital pharmacy setting. For each
group, consensus on level of support was higher for core
activities than for clinical activities, confirming the
prediction that there was more consensus for the mandatory
aspects of the role than for the discretionary activities.
An examination of the 20 individual role items from which
the five role segments for each practice setting were
derived revealed a similar pattern of more support and
higher consensus for core versus clinical activities.
The second set of hypotheses predicted that specific
segments within the profession of pharmacy would be more
supportive of a clinical role. Pharmacy faculty, who
represent the "elites" and trend-setters of the profession,
were the most supportive sub-group of expanded role
activities for pharmacists. There was partial support for
the hypotheses concerning other segments within the
profession. The trend for higher levels of support for
225
clinical activities was observed for women pharmacists (vs.
men), Asian pharmacists (vs. Caucasians), pharmacists in
the younger cohort (vs. older cohort), and hospital
pharmacists (vs. community pharmacists). The differences
between these sub-groups did not reach statistical
significance, however.
The final set of hypotheses was concerned with the
effect of three variables on level of support for clinical
role activities: dominant orientation toward pharmacists
(clinical vs. business), prior experience in working with a
clinical pharmacist, and perception of the pharmacist as
the health care professional who is the "expert" on
drug-related matters. Pharmacists, nurses and physicians
who held a "clinical" orientation toward pharmacists were
significantly more supportive of expanded role activities
compared to members of those groups with a "business"
orientation toward pharmacy. Nurses and physicians who
have had an opportunity to work with a clinical pharmacist
were more supportive of a clinical role for pharmacists
compared to those group members who did not have such
experience. Finally, nurses and physicians who indicated
the pharmacist as "drug expert" were more supportive of
clinical activities than than those respondents who
indicated the physician as the "drug expert." An
226
interesting interaction was noted between clinical
pharmacist experience and perception of the pharmacist as
drug expert among the nurses group.
TABLE 31
Conclusions Relevant to Hypotheses About Level of Support
for a Clinical Role for Pharmacists.
HYPOTHESES (from pages 114-116) CONFIRMED?
SET I: INTER-GROUP COMPARISONS
a.
b.
c.
d.
e.
f.
SET
b.
c.
d.
e .
Pharmacists most supportive profess
Nurses next most supportive profess
Physicians least supportive profess
Physicians more antagonistic toward
role in the community vs. hospital
Consumers intermediate in level of
All groups demonstrate higher conse
traditional vs. expanded role activ
ional group
ional group
ional group
clinical
setting
support
nsus for
ities
II: INTRA-GROUP COMPARISONS (Pharmacists* Group)
Faculty members more supportive than other
pharmacists
Younger cohort more supportive than older cohort
Women more supportive than men pharmacists
Asians more supportive than Caucasians
Hospital pharmacists more supportive than
community pharmacists
Yes
Yes
Yes
Yes
Yes
Yes
Yes
?
Yes
?
No
SET III: CONDITIONAL VARIABLES
a. Respondents with "professional” orientations more Yes
supportive than those with "business" orientations
b. Respondents with clinical pharmacist experiences Yes
more supportive than those without such experiences
c. Respondents who perceive the pharmacist as "drug Yes
expert" more supportive than those who perceive
the physician as "drug expert"
227
Chapter VI
CONCLUSIONS AND RECOMMENDATIONS
Conclusions relative to the three sets of hypotheses and
the theoretical perspectives from which they were developed
are presented in this chapter. There is also a brief
discussion of the application of the findings to social
role change. Finally, areas for future research are
discussed.
6.1 CONCLUSIONS: INTER-GROUP COMPARISONS
The first set of hypotheses predicting differences in
levels of support for expanded roles for pharmacists
between pharmacists, physicians, nurses and consumers was
supported by the data. As predicted pharmacists were the
most supportive group of expanded roles, consumers and
nurses were intermediate in levels of support, and
physicians were the least supportive group (Tables 9 and
13).
This set of hypotheses was derived from the discussion
of the power model of professions, which posits the central
role of power in defining occupational territory. Conflict
228
between professions occurs when boundaries are challenged.
Therefore, it was expected that professions most threatened
by expansion of the pharmacist*s role, physicians and
nurses, would be the most negative toward role activities
which directly challenged autonomy, authority, status or
economic security.
The findings of lack of support for the clinical role
segments by nurses and by physicians, in particular, and
specifically the lack of support for clinical role
Lctivities which directly threatened the role domains of
these professionals confirm the usefulness of the power
model in predicting support for role activities. Further,
it was found that clinical activities which required
independent judgment or autonomous action by the pharmacist
relevant to patient care were not supported by physicians
and nurses, particularly in the community setting where the
pharmacist is relatively autonomous and not supervised.
The finding that nurses were supportive of the
pharmacist teaching pharmacology, ordering laboratory tests
to monitor patients* drug responses, and making dosage
adjustments in the hospital setting may be interpreted as a
clear signal of support for pharmacists* challenge of
physicians’ power in these areas. Nurses were only
moderately supportive of expanded role activities in the
229
community setting. It may be that nurses perceive some of
these activities to be the role domain of the nurse
practitioner. If this is so, then it may indicate that
ethnocentric concerns take precedent over alliance with
pharmacists in the erosion of physicians* power.
A different interpretation may be made concerning the
support by physicians for the pharmacist teaching
pharmacology and making dosage adjustments in the hospital
setting— one of **co-optation. ** If physicians can steer
clinical pharmacists away from the most threatening aspects
of an expanded role (i.e. prescribing, primary care and
laboratory monitoring) and toward more subordinate, yet
clearly defined areas of expertise (drug information
consultant, teaching pharmacology to other health care
professionalS--probably defined as not physicians, or even
making minor adjustments in dosages), then they will have
succeeded in boundary maintenance.
Because of the rapid increase in knowledge about and
awareness of adverse drug reactions (the majority of which
are based on human error and not idiosy ncracies of the
patients), pharmacists * superior knowledge and training in
drug-related areas can be viewed as a unique resource which
may be used to bring about a shift in the power
relationship between pharmacists and other health care
230
professionals. Selection of the pharmacist as "drug
expert" by a majority of the nurses group also supports
this conclusion.
Lack of support by physicians and nurses of expanded
activities in the community setting may be related to
several factors relevant to the power model. First, the
community pharmacist functions in a situation that is
relatively isolated from other health professionals and
generally the pharmacist can control the amount of
supervision that he receives. In addition, several of the
proposed expanded role activities may directly threaten the
physician’s economic security by depriving him of office
visits by the "walking well." The idea that a consumer can
walk into his neighborhood pharmacy and talk over symptoms
and health concerns with the pharmacist, maybe have his
blood pressure taken, or purchase an OTC product is
threatening to many physicians.
In conclusion, the power model of professional relations
appears to be a useful approach for looking at differences
between groups in levels of support for both traditional
and non-traditional, expanded roles.
231
6.2 CONCLUSIONS: INTRA-GROUP COMPARISONS
The second set of hypotheses tested differences between
segments within the profession of pharmacy on levels of
support for expanded role activities.
The process model of professionalization posits
differences within professions and emphasizes
intra-professional diversity and conflict of interest.
This model predicts the development of segments within
professions which are in competition with one another for
control over the direction the profession will take on
major issues of interest to them.
Clearly the elites of the profession are represented by
the pharmacy faculty, who were found to be significantly
more supportive of expanded roles than practicing
pharmacists. These academic pharmacists generally are
non-practicing, do not have to deal with the day-to-day
stresses associated with economic survival in the community
setting, nor with interpersonal conflicts with higher
status prescribers.^ They are charged with responsibility
to take the "helm" and guide the profession toward the
future through the socialization of the students. In
addition, they are often involved in the politics of the
professional organizations and exert their influence there
as well.
232
The process perspective was of moderate usefulness in
predicting the tendency for higher levels of support for
expanded roles among the other segments examined in this
study by cohort, sex, ethnic background and practice
setting. These four sub-groups are highly interrelated,
however. The cohort of pharmacists who graduated in 1970
or later was composed of a higher proportion of women and
Asian pharmacists, and pharmacists practicing in the
hospital setting compared to the cohort who graduated prior
to 1970. There was a strong tendency for pharmacists in
this younger cohort to be more supportive of the expanded
role activities, although for many items the differences
did not reach statistical significance. Women pharmacists,
in particular, were more supportive than men of all role
segments. This may indicate that women pharmacists have a
broader definition of the role of the pharmacist than do
men.
The most consistent differences were noted for women.
In order to examine this finding further, t-tests were
computed to compare means for the role segments by both sex
and cohort (not reported here). No differences were found
in means between older and younger male pharmacists, or
between older cohort men and women pharmacists.
Significant differences were noted, however, between older
233
and younger women pharmacists for clinical activities in
the community (3.38 ± 0.81 vs. 2,52 ± 0.94, p <.006) and
hospital settings (2.50 ± 0.83 vs. 1.96 ± 0.75, p <.04).
In addition, in comparing means for younger cohort men and
women pharmacists, significant differences were noted for
drug information resource (1.71 ± 0.82 vs. 1.32 + 0.68, p
<.03) and clinical activities (3.16 ± 0.78 vs. 2.52 + 0.95,
p <.002) in the community setting. These findings further
support the conclusion that the younger cohort women are
significantly more supportive than other segments of
clinical roles for pharmacists.
The reasons women pharmacists are more supportive of
clinical activities for pharmacists are open to
speculation. It may be that women are more comfortable
with the person-to-person contact and interprofessional
interaction demanded of a clinical role. Women may pose
less of a threat to male physicians* autonomy and authority
as well, and this may make it easier for women pharmacists
to take on some of the clinical activités without the need
for direct assertion in dealing with physicians. As noted
previously, nurses, by nature of their socialization as
women, are able to wield considerable power and autonomy by
**tactful** interaction with male physicians. Women
pharmacists may also play this "game," thus gaining more
freedom in playing their role.
234
Clearly the findings support the contention of diversity
within the profession in terms of definitions of
appropriate role activities for practicing pharmacists,
6.3 CONCLUSIONS: EFFECTS CONDITIONAL VARIABLES
The final set of hypotheses was concerned with
delineation of the effects of three conditional variables
on levels of support for expanded roles: dominant value
orientation toward pharmacists, experiences with clinical
pharmacists, and perception of the pharmacist as "drug
expert. "
The majority of pharmacists, pharmacy faculty, nurses
and consumers ranked the pharmacist as "clinician" higher
than the pharmacist as "businessman." The opposite pattern
was observed for physicians, with the majority of this
group ranking "businessman" higher than "clinician."
Pharmacists, physicians and nurses defined as having a
"clinical" orientation toward pharmacists were
significantly more supportive of expanded roles compared to
those health professionals defined as having a "business"
orientation.
A symbolic interactionism approach was useful in
explaining these findings. Each person*s expectations of
others are influenced by how those others are perceived in
235
some overall, summary way. The relative importance to the
perceiver of the "hats" another person wears in his various
jsocial roles determines what behaviors will be expected.
;Those pharmacists, nurses and physicians who saw the
pharmacist primarily as a health educator and clinician
were more supportive of patient-oriented, clinical role
activities for pharmacists than were those professionals
who primarily saw the pharmacist as a technician and
businessman. Similarly, those nurses and physicians who,
for whatever reasons, perceived the pharmacist as the "drug
expert" were more supportive of role activities where this
perceived expertise would be useful (drug information
resource and clinical activities). Physicians and nurses
who did not perceive the pharmacist this way were not as
supportive of these role activities.
Finally, regardless of how another person*s social role
is perceived, the opportunity to gain first hand experience
in interaction with that person allows for negotiation and
renegotiation between the two individuals in interaction.
In this process, previously held stereotypes may be
examined and attitudes and values may be changed based on
testing with reality. Apparently this occurred with many
of the nurses in this study. Those nurses who had
experiences with clinical pharmacists were significantly
236
more likely to view the pharmacist as the drug expert, and
were more supportive of clinical role activities. Why this
relationship did not occur for physicians who had
experiences with clinical pharmacists required further
speculation.
Even though the majority of physicians who worked with a
clinical pharmacist evaluated the experiences as
"excellent," this had little effect on perception of the
pharmacist as drug expert. It may be that since the
majority of physicians perceived the pharmacist as
primarily a businessman and technician, it was very
difficult to reconcile this dominant value orientation with
the reality of what the clinical pharmacist does. Most
physicians rated clinical pharmacists as excellent, but it
may be that they attribute this excellence to something
unique in the individual, since this experience was so
divergent from their general perceptions. It may also be
that by acknowledging the excellence of these "deviant"
clinical pharmacists, physicians can preserve their
stereotypes.
237
6.4 POSSIBLE APPLICATIONS OF FINDINGS
In Chapter I it was suggested that a study of the
expansion of a professional role should include three
assessments; social power of the professional membership,
consensus on the proposed role changes, and the degree to
which aspired changes are realistic. This study was
concerned with the second component primarily. However,
speculations may be put forth concerning the other two.
Today * s pharmacists, particularly those graduated from
doctoral level programs, are trained as drug specialists.
Their perceptions of themselves are as professionals, and
crucial members of the health care team. This study has
shown that the majority of nurses sampled also perceive
pharmacists in this way. In addition, nurses are willing
to support pharmacists’ role expansion in areas that do not
directly threaten their own turf. Thus, armed with
increased knowledge, a more professional identity, the
potential for alliance with other health professionals, and
increased functional importance in the detection and
prevention of adverse drug reactions, it would appear that
pharmacists are in a good position to make many of the
changes desired by those at the helm.
Although there is still quite a bit of diversity within
the profession concerning the appropriateness of expanded
238
roles, the trend toward increased support exhibited by
younger pharmacists confirms the contention that pharmacy
has moved rapidly away from a product orientation toward a
patient orientation. This shift in value may facilitate
the development of a more cohesive, less competitive
membership. A high level of consensus among pharmacists on
expanded roles will increase the profession’s power
position even more.
Finally, there is the question of how realistic the
proposed role changes of pharmacists are. This is
difficult to evaluate beyond pointing out that all of the
role activities included in this study can be and are
performed by pharmacists in California. Senate Bill 502
(1983) recently amended Section 4046 of the Business and
Professions Code related to pharmacists to further clarify
the pharmacist’s autonomous role in licensed health care
facilities. Kronus’ (1976) discussion of the cyclic nature
of role change comes to mind at this point. A clinical
role for pharmacists has gone beyond the ’ ’blurring of
boundaries" stage, has become legalized (and therefore
given legitimation), and it will just take a while for the
final stage of institutionalization to occur.
A final question concerns how the findings of this study
can be used to make predictions about inclusion of expanded
239
role activities in future definitions of the role of the
ipharmacist by others, and how the findings may be used to
[direct role change in a more purposeful way. It may be
I
pseful to compare both the level of support and the degree
|of consensus (or resistance) for the individual role
activities between pharmacists and other health care
professionals. A mapping of the positioning of the role
activities in two-dimensional space makes it easier to
determine potential for change in levels of acceptance.
Efforts to influence others concerning the acceptability of
role activities may be relatively easy for some role tasks,
and met with fierce resistance for other tasks. The
following exploratory model is presented as a way to
graphically compare present levels of support and consensus
between pharmacists and other groups and illustrate
potential for social role change. It is intended only as a
means of organizing the findings and no claim is made as to
its usefulness. This will be a task for future studies.
240
Table 32. Model of Relationship of Degree of Consensus and Magnitude
of Support to Potential for Social Role Change.
INTRAjGROUP CONSENSUS
HIGH
MAGNITUDE OF SUPPORT
POSITIVE NEGATIVE
GROUP A (Pharmacists)
LOW
MAGNITUDE OF SUPPORT
POSITIVE NEGATIVE
1 — LU
m q ; >
z: o 1 — »
Q- h—
O.
. s- — ) (/?
o t / 0 O
CL
to u_
Q o
z;
LU
Q LU
CÛ ZD ■>
1 — 1 — 1
Q- I —
zr. z: *=G
O CD CD CD
cxl < LU
o 3C s: z:
CO
r > 1 — LU
t / O àz >
o
LU a . 1 —
t / 0 Q -
z: = D t / )
o C O O
o CL
LL.
a . o
= >
o LU
q ; Q LU
C D = > >
1 H -
■< 1 —
o: z:
1 — 'is CD CD
z: o < = C LU
1 — 1 _ J s: z :
a b
e f
c d
9
h
i
j
m n
k 1 0
P
241
In the model presented in Table 32 levels of consensus
and the magnitude of support for individual role activities
are compared between pharmacists and other health
professionals (physicians and nurses). The cells are
labelled from "a" to "p". Depending on where (which cell)
a role activity is placed, predictions may be made about
what action is likely to occur in the future. Four actions
may be predicted: 1) there may be a "push" for change by
either group A or group B; 2) there may be opposing
"pushes" from both A and B; 3) there may be pressure from
either A or B to maintain the status quo; or 4) there may
be no pressure from either A or B.
In looking at the model in Table 31 the following
predictions can be made for each of the cells:
1. a,d: high inter-role consensus ; no pressure for
change.
2. b,c: high inter-role dissensus; open conflict must
be resolved by adaptation or change.
3. e,f: salient issues to B; would find pressure from B
for change or adaptation by A; "selling" by B to A;
less resistance from A.
4. g,h: salient issues to B to NOT have A do them; A
not strongly unified ; therefore response by both A
and B would be to "ignore".
242
5. i,k: salient issues to A; would find pressure from A
for change or adaptation by B; "selling" by A to B ;
less resistance from B; role activities most open to
change by pharmacists (A).
6. j,l: issues pharmacists feel strongly about NOT
doing; no pressure, "ignore."
7. m,n,o,p: issues on which there is little consensus;
high role ambiguity; no predictions can be made
concerning change.
For this illustration, magnitude of support was defined
as positive (mean < 3.0) and negative (mean 2 3.0), and
(Consensus was defined as high ( SD < .95) and low (> .95).
Responses to the 20 role items by physicians and nurses
^ere mapped using the model in Table 31. The cells of most
interest to this discussion are a and d, and i and k. For
nurses, the following r;ole activities were located in cell
a : 1, 2, 4, 5 (community) and 1, 2, 3, 4, 5 (hospital).
(See Table 13, page 185, to identify role items by number.)
These activities represent role behaviors on which there is
high support and high agreement between pharmacists and
nurses. For physicians, items 2 and 5 (community) and 1,
2, 4, 5 (hospital) were placed in cell a. No items were
located in cells b,c, or d.
243
Items 6, 7, 8, 9, 12, 15 (community) and 6, 9 (hospital)
fell in cell i for nurses. These represent items which are
salient to pharmacists to have included in their role
definition. There is less agreement among nurses over
these items, but the overall level of support is positive.
Therefore, these items may be "sold" to the nurses as
appropriate to the pharmacist’s role. There would probably
be little resistance, since many nurses do accept these
items. For physicians, items located in cell i included;
1, 4, 6, 7, 8, 9, 12, 15 (community) and 3, 6, 9
(hospital). Again, these items will probably be relatively
easy to include in the definition of the pharmacist’s role.
These are areas that pharmacists can begin working on to
gain support from more physicians.
There were no items in cells e, f, g, h, j, k or 1 for
nurses. No items were located in cells e, f, j, or 1 for
physicians. Three items fell into the g or h cells for
physicians. Item 18 (community) was placed in cell g, and
items 17 and 20 (community) in cell h. These items are
ones which physicians feel strongly about pharmacists NOT
doing, and activities that it would be difficult to include
in the pharmacist’s role at this time.
The remaining items for nurses and physicians fell into
cells m to p. It is difficult to predict what will happen
244
to these activities in terms of incorporation into the
pharmacist’s role in the future.
It is obvious, of course, that the placement of items in
the cells depends on the definitions of consensus and
support used. It is logical to divide support at 3.0 based
on labels for the responses from 1 to 5 (definitely yes to
definitely no). The issue of where to divide consensus
(i.e. what cut-off point to use in variance or standard
deviation) is more troublesome. For this demonstration,
the SD of .95 was picked based on examination of the
frequency distributions. This was a rather arbitrary
determination, however, and better rationale for selection
of boundary between consensus and no consensus must be
determined.
Obviously this exercise was only meant to illustrate one
possible use of the findings in delineating those role
activities on which most groups agree the pharmacist should
do, the set of role activities which are most open to
purposeful change and which could be assertively pursued by
pharmacists, and finally the role activities on which there
is truely no clear consensus. It may be possible for
pharmacists to focus on educating other health;
professionals concerning their competence to engage in the
activities located in cell i. In addition, a re-assessment
245
in the future may show how these activities "move" across
cells.
5.5 RECOMMENDATIONS FOR FUTURE RESEARCH
Several areas of need for future research come to mind.
First; further analyses of data already collected from a
sub-sample of the pharmacists group concerning the 20 role
activities is in progress. Variables to be examined
include; 1) the frequency of performance of each activity
reported by pharmacists; 2) if the role activity is an
important part of the pharmacist’s role; 3) if the role
activity is a satisfying part of the pharmacist’s role; 4)
the pharmacist’s role-taking ability (i.e. how well does he
predict levels of support of the faculty, nurses and
physicians groups); and 5) barriers which prevent
pharmacists from engaging in an activity more (may be
attitudinal, cognitive, situational or legal).
Other areas in which future studies are planned include;
1) the relationship of consensus to role stress, role
conflict, and job and career satisfaction ; 2) evaluation of
pharmacy students’ levels of support and consensus for
expanded role activities ; and 3) evaluation of a random
sample of consumers using the instrument tested with the
consumer panel.
246
Finally, the demographic changes occuring within the
profession warrant further investigation. What impact will
the change in pharmacy from a white male-dominated health
profession to possibly a female-dominated profession have?
What impact will the increase in Asian pharmacists have on
the profession? These are major changes occuring in a
relatively short period of time.
Pharmacy is a profession under extreme tension. Many
external factors are exerting pressure for immediate
change. The final direction the profession will take is
difficult to predict. The sociology of pharmacy is an
exciting sub-field in medical sociology. There is much
original work to be done with this "invisible" health
profession. If sociology continues to ignore the study of
pharmacy, then pharmacists will have to continue to study
themselves.
247
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263
Appendix A
PHARMACISTS SURVEY
SCHOOL OF pharmacy
April 8, 1983
Dear Pharmacists
The School of Pharmacy/ in conjunction with the Development and
Demonstration Center in Continuing Education for Health Professionals,
a project of the W.K. Kellogg Foundation, at the University of Southern
California, is conducting a survey of California pharmacists to evaluate
continuing education in general and different methods for providing
continuing education to pharmacists. In addition, we are involved in
evaluating the role of the pharmacist as perceived by practicing
pharmacists, physicians, nurses and other health professionals, and
consumers.
We would appreciate your taking the time to fill out the enclosed
survey. It is anticipated that it will take about 30-40 minutes to
complete.
In order to express our thanks for your participation in this
study, we will hold a drawing for those respondents who return completed
surveys. The prize will be $100, and the drawing will be held on June 1, 1983.
The winner will be notified by mail. To enter the drawing, please
complete the entry form at the end of the survey. This sheet will be
separated from the survey by the secretary who receives the mail so that
your responses to the questionnaire will remain anonymous.
Again, thank you for your assistance with this survey.
cerely yours.
A. Biles, Ph.D.
ean. School of Pharmacy
Philip Oppenheimer, Pharm.D.
Director, Community Pharmacy
Enhancement Project
BA : ba
Enc.
Barbara Adamcik, M,A.
Research Associate
JOHN STAUFFER PHARMACEUTICAL SCIENCES CENTER
UNIVERSITY OF SOUTHERN CALIFORNIA, 1985 ZONAL AVENUE, LOS ANGELES, CALIFORNIA 90033
264
CONTINUING EDUCATION SURVEY OF CALIFORNIA PHARMACISTS
INSTRUCTIONS: Please check appropriate blank, enter scale response, or fill in answer
for eoch question.
BACKGROUND INFORMATION
AGE:____
SEXi M F
ETHNIC BACKGROUND: .CAUCASIAN
.BLACK
.ORIENTAL
.HISPANIC
.OTHER:
PLEASE INDICATE YOUR PRACTICE LOCATION AND POSITION;
HOSPITAL
COMMUNITY (INDEPENDENT)
COMMUNITY (CHAIN)
PHARMACEUTICAL INDUSTRY
PHARMACY SCHOOL
OTHER:____________
OWNER/CO-OWNER
DIRECTOR/MANAGER
ASSISTANT DIRECTOR/MANAGER
SUPERVISOR
STAFF PHARMACIST
CLINICAL PHARMACIST
OTHER :_ _ _ _ _ _ _ _ _ _ _ _ _ _
YEAR FIRST LICENSED TO PRACTICE PHARMACY:________
NUMBER OF YEARS EMPLOYED IN PRESENT POSITION:_____
POPULATION OF THE CITY/TOWN IN WHICH YOU PRACTICE:
less than 20,000 20,000 - 100,000 100,000
WORK STATUS:
...FULL-TIME
PART-TIME « 30 HR/WK)
RETIRED
OTHER:___________
DEGREE(S);
B.A./B.S.
M.A./M.S.
Pharm.D.
Ph.D.
OTHER)________
PHARMACY SCHOOL:
ZIP CODE: _______
500,000 over 500,000
CONTINUING PHARMACY EDUCATION
PLEASE INDICATE TOUR LEVEL OF SATISFACTION WITH THE FOLLOWING ASPECTS OF CONTINUING ÉDUCATION.
CIRCLE YOUR RESPONSE FOR EACH QUESTION. ALSO, PLEASE INDICATE WHETHER YOU HAVE PARTICIPATED
IN EACH TYPE OF PROGRAM WITHIN THE PAST TWO YEARS.
LEVEL OF SATISFACTION,
• TYPE OF CONTINUING EDUCATION PROGRAM:
PARTICIPATED PAST 2 YRST
1 TO 3 HOUR LECTURE 1 2 3 4 5 YES NO
6 TO B HOUR, ONE DAY PROGRAM 1 2 3 4 5 YES NO
12 TO 15 HOUR, TWO DAY PROGRAM 1 2 3 4 5 YES NO
30 OR MOam noun, < to 7 d a y PnOORAM 1 3 3 4 9 Y E 9 N O
SELF-PACED PROGRAM IN AN AUDIO TAPE, 1 2 3 4 5 YES NO
CORRESPONDENCE OR HOME STUDY FORMAT
LOCATION OF CONTINUING EDUCATION PROGRAM:
TRAVEL PROGRAM 1 2 3 4 5 YES NO
PROGRAM ASSOCIATED WITH CONVENTION 1 2 3 4 5 YES NO
PROGRAM WITHIN OWN COMMUNITY 1 2 3 4 5 YES NO
PROGRAM AT PLACE OF BUSINESS/WORK 1 2 3 4 5 YES NO
PROGRAM AT HOME 1 2 3 4 5 NO
SPONSOR OF CONTINUING EDUCATION PROGRAM:
SCHOOL OF PHARMACY 1 2 3 4 5 YES NO
LOCAL PHARMACY ASSOCIATION 1 2 3 4 5 YES NO
STATE PHARMACY ASSOCIATION 1 2 3 4 5 YES NO
NATIONAL PHARMACY ASSOCIATION 1 2 3 4 5 YES NO
PHARMACEUTICAL INDUSTRY 1 2 3 4 5 YES NO
HOSPITAL 1,
2 3 4 5 YES NO
PLEASE INDICATE POSSIBLE CONTINUING EDUCATION TOPICS OF INTEREST TO YOU WHICH YOU WOULD LIKE TO
SEE OFFERED IN THE FUTURE:
• WHAT HAVE BEEN YOUR MOST NEGATIVE EXPERIENCES WITH PAST CONTINUING EDUCATION PROGRAMS YOU HAVE
PARTICIPATED IN? (please check oil that apply)
POOR SPEAKER OR LECTURER
COVERAGE OP TOPIC NOT AT
"level I DESIRED
POOR FACILITIES OR ARRANGEMENTS
.FORMAT OF PROGRAM
.TIMING OP PROGRAM
DISTANCE I HAD TO
“TRAVEL TO ATTEND
.COST OP PROGRAM
OTHER,__________
NO SIGNIFICANT NEGATIVE
"eafehiences with C.E.
• APPROXIMATELY HOW MUCH DO YOU PAY FOR TUITION FOR 30 HOURS OF C.E. IN A 2 YEAR PERIOD? $_
* WHAT PERCENTAGE OF YOUR TUITION EXPENSES ARE REIMBURSED BY YOUR EMPLOYER OR PHARMACY?
• WHAT PERCENTAGE OF RELATED EXPENSES ARE REIMBURSED (e.g. travel, food, lodging)?
265
HOW DO YOU CURRENTLY ASSESS YOUR CONTINUING EDUCATION NEEDS? (check all that q d dIy )
aURVEY PÂTIÉNT or PRESCRIPTION RECORDS
ASK PHYSICIANS, OENTISTS, NURSES WHAT
THEY NEEO FROM ME
_ASK PATIENTS WHAT THEY NEEO FROM ME
USE SELF-ASSESSMENT QUESTIONNAIRES
.ASSESS AREAS OF MY PRACTICE WHICH NEEO
IMPROVEMENT
DETERMINE MY FUTURE PLANS FOR MY PHARMACY
"PRACTICE
I DO NOT CURRENTLY ASSESS MY C.E. NEEDS
WHEN YOU SELECT A CONTINUING EDUCATION PROGRAM TO ATTEND, TO WHAT DEGREE IS YOUR DECISION
(pieuse circle approprlote response)
THE PROGRAM I
AOORESSES MY EDUCATIONAL NEED
IS PRESENTED AT A CONVENIENT TIME
COVERS TOPICS I'M INTERESTED IN
FITS IN WITH MY WORK SCHEDULE
FITS IN WITH MY FAMILY SCHEDULE
CAN BE COMBINED WITH VACATION/RECREATION
PRESENTED AT AN APPROPRIATE KNOWLEDGE LEVEL
(I.e. NEITHER TOO GENERAL NOR TOO SPECIFIC) FOR ME
IS LOCATED WITHIN MY OWN COMMUNITY
COST
SPONSOR
ALWAYS USUALLY SOMETIMES RARELY NEVER
AFTER COMPLETION OF A C.E. PROGRAM, WHAT CRITERIA
IMPORTANT
DO YOU USE TO EVALUATE IT?
IMPORTANT
MET MY NEEDS 1 - 2 3 4 5
RELEVANT TO MY INTERESTS 1 2 3 4 5
APPLICABLE TO MY PRACTICE 1 2 3 4 5
RECEIVED NEW INFORMATION 1 2 3 4 5
LEARNED A NEW SKILL 1 2 3 4 S
SUSTAINED MY INTEREST, NOT BORING 1 2 3 4 5
PROGRAM RAN SMOOTHLY, WELL PLANNED 1 2 3 4 5
AFTER COMPLETION OF A C.E. PROGRAM, HOW LIKELY IS IT THAT YOU WOULD BE INTERESTED IN FURTHER
ASSISTANCE WITH THE TOPIC(S) DISCUSSED, OR FOLLOW-UP INFORMATION? (circle response)
VERY LIKELY 1 2 3 4 5 VERY UNLIKELY
IF A PROGRAM WERE OFFERED FOR CONTINUING EDUCATION CREDIT WHICH WOULD BE INDIVIDUALIZED,
BASED UPON YOUR OWN PRACTICE NEEDS, WHICH WOULD INCLUDE EDUCATIONAL MATERIALS TAILORED
TO YOUR SPECIFIC REQUIREMENTS, AND WHICH COULD BE COMPLETED AT YOUR OWN PACE, AT HOME OR WORK:
HOW MUCH OF A NEED IS THERE FOR THIS
TYPE OF INNOVATIVE, PRACTICE-BASED
CONTINUING EDUCATION PROGRAM?
HOW LIKELY IS IT THAT YOU MIGHT CONSIDER
PARTICIPATING IN THIS TYPE OF PROGRAM?
GREAT LITTLE
WOULD YOU PREFER TO PAY FOR SUCH
UNIT OF C.E. CREDIT?
CONTINUING EDUCATION PROGRAM BY I
SCOPE AND DEPTH OP COVERAGE OF TOPIC?
HOW MUCH WOULD YOU BE WILLING TO PAY FOR EACH UNIT OF C.E. CREDIT?
DO YOU FEEL IT IS APPROPRIATE TO SURVEY YOUR PATIENTS AND/OR PRESCRIBERS TO SEE WHAT SPECIFIC
SERVICES OR ACTIVITIES THEY WOULD LIKE TO HAVE INSTITUTED OR IMPROVED IN YOUR PHARMACY?
SURVEY PATIENTS?
SURVEY PRESCRIBERS?
VERY
APPROPRIATE
1 2
1 2
NOT
APPROPRIATE
HAVE YOU EVER SURVEYED
THIS GROUP?
YES NO
YES NO
WOULD YOU BE INTERESTED IN:
ASSISTANCE IN IDENTIFYING YOUR EDUCATIONAL NEEDS? 1
ASSISTANCE IN PLANNING FOR THE DEVELOPMENT ANO/OR 1
IMPLEMENTATION OF NEW PHARMACY SERVICES?
A SERVICE WHICH WOULD HELP YUU LOCATE C.E. PROGRAMS 1
ON SPECIFIC TOPICS, AVAILABLE CERTIFICATION PROGRAMS,
OR EXPERT CONSULTANTS TO HELP YOU DEVELOP NEW SERVICES?
SUBSCRIBING TO A SERVICE IHIERE A MEDICAL LIBRARIAN WOULD 1
PROVIDE YOU, ON A REGULAR BASIS, UPDATED INFORMATION
(BIBLIOGRAPHIES ANO COPIES OF ARTICLES) ON TOPICS YOU SELECT?
THE OPPORTUNITY TO STUDY A TOPIC IN DEPTH AND/OR 1
SCOPE SIMILAR TO THAT COVERED IN PHARMACY SCHOOL?
ATTENDING A SIX-MONTH HIGH QUALITY, HIGH COST 1
INTENSIVE EXECUTIVE TRAINING PROGRAM FOR PHARMACY MANAGERS?
ENROLLING IN A MASTERS OF SCIENCE IN PHARMACY 1
ADMINISTRATION DEGREE PROGRAM, EQUIVALENT TO A MASTERS
PROGRAM IN BUSINESS ADMINISTRATION?
NOT AT ALL
INTERESTED
S
S
266
WHAT SOURCE!S) DO YOU CURRENTLY USE WHEN YOU NEED IMMEDIATE ACCESS TO INFORMATION (I.e. TO FILL
A PRESCRIPTION, COUNSEL A PATIENT, ANSWER A QUESTION FROM A PHYSICIAN OR NURSE, ETC,)?
(check oil that apply)
BOOKS ___ANOTHER PHARMACIST DRUG COMPANY REPRESENTATIVE MEDICAL LIBRARY
.JOURNALS PHYSICIAN (OR OTHER DRUG INFORMATION SERVICE ___OTHER,__________ PHYSICIAN (OR OTHER
"HEALTH PROFESSIONAL)
WHAT SOURCE!S) DO YOU CURRENTLY USE WHEN YOU NEED NON-CRITICAL INFORMATION (I.e. TO DEVELOP NEW
SERVICES, REGARDING PHARMACY MANAGEMENT, ETC,)? (check oil that apply)
BOOKS ___ANOTHER PHARMACIST DRUG COMPANY REPRESENTATIVE MEOICAL LIBRARY
JOURN)U, ___PHYSICIAN (OR OTHER DRUG INFORMATION SERVICE OTHER, _________
HEALTH PROFESSIONAL)
C.E. COURSE PROFESSIONAL ASSOCIATION
IF YOU WERE TO USE AN INFORMATION SERVICE OF A MEDICAL LIBRARY, WHICH SERVICES WOULD YOU MOST NEED?
(Please rank from 1 to 5)
INFORMATION UPDATES ON SPECIFIC TOPICS
COMPUTER-PRODUCED LITERATURE SEARCHES
JOURNAL ARTICLES COPYING SERVICE
CONSULTATION WITH PHARMACY SCHOOL FACULTY MEMBER TO DISCUSS AN ISSUE OR TOPIC
REFERENCE SERVICES
• WHAT TYPES OF INFORMATION WOULD YOU MOST LIKELY REQUIRE FROM AN INFORMATION SERVICE?
(check 0 11 that apply)
drug IDENTIFICATION ___DRUG INTERACTIONS/COMPATIBILITY ESTABLISHING NEW SERVICES
THERAPEUTIC USE ___SIDE EFFECTS/ADVERSE REACTIONS ___PHARMACY MANAGEMENT
AVAILABILITY ___DISEASE STATES ___OTHER:_____________________
DOSAGE FOLLOW-UP ON C.E. COURSE TOPIC(S)
• DO YOU USE A COMPUTER IN YOUR PRACTICE? YES
IF YES, IS IT: IN-HOUSE? ON-LINE?
_N0 YEAR INSTALLED:
MODEL:______
• HOW IS THE CO.MPUTER CURRENTLY USED? (check all that apply)
DISPENSING (GENERATING LABELS, RECORD KEEPING)
BILLING
INVENTORY CONTROL/PURCHASING
IDENTIFICATION OF POTENTIAL DRUG INTER
ACTIONS, ALLERGIES, INCOMPATIBILITIES, BTC.
ASSESSMENT OF NEEDS (EDUCATIONAL NEEDS,
"NEW SERVICES, IMPROVEMENTS, ETC.)
ASSESSMENT OF PRACTICE (TYPES OF PATIENTS,
COMMONLY PRESCRIBED ORUCS, ETC.)
PATIENT PROFILES
HOW HAS THE COMPUTER AFFECTED YOUR PRACTICE? (Check lüfi most Important OenefIt to you)
GREATLY REDUCED THE TIME SPENT ON PAPER WORK
ALLOWS ME MORE TIME TO SPEND IN PATIENT CARE
"activities
I CAN NOW DO A BETTER JOB IN MANAGING MY
"pharmacy
I CAN NOW DO A BETTER JOB IN CARING FOR
"patients
MORE PRESCRIPTIONS CAN NOW BE PROCESSED
"resulting in potentially more PROFIT
DO YOU BELIEVE THAT THE PHARMACIST'S ROLE SHOULD BE EXPANDED TO INCLUDEi
DEFINITELY PROBABLY NOT PROBABLY DEFINITELY
YES YES SURE NO NO
PRESCRIBING ORUGS 1 2 3 4 5
PERFORMING PHYSICAL ASSESSMENT 1 2 3 4 5
ADMINISTERING ORUGS 1 2 3 4 5
ORDERING LAD TESTS 1 2 3 4 5
HOW WOULD YOU BEST DESCRIBE YOUR USUAL RELATIONSHIP WITH PHYSICIANS?
strong
RARE
INFORMAL
TENSE
satisfactory
WEAK
FREQUENT
FORMAL
RELAXED
UNSATISFACTORY
• HOW WOULD YOU BEST DESCRIBE YOUR USUAL RELATIONSHIP WITH NURSES?
STRONG ___ ___ ___ ___ ___ WEAK
RARE ___ ___ ___ ___ ___ FREQUENT
INFORMAL ___ ___ ___ ___ ___ FORMAL
TENSE ___ ___ ___ ___ ___ RELAXEO •
SATISFACTORY ___ UNSATISFACTORY
• HOW WOULD YOU BEST DESCRIBE YOUR USUAL RELATIONSHIP WITH NURSE PRACTITIONERS/PHYSICIAN ASSISTANTS?
STRONG ___ ___ ___ ___ ___ WEAK
RARE ___ ___ ___ ___ ___ FREQUENT
INFORMAL ___ ___ ___ ___ ___ FORMAL
TENSE ___ ___ ___ ___ ___ RELAXED
SATISFACTORY UNSATISFACTORY
267
HOW MANY DRUG INFORMATION REQUESTS DO YOU AVERAGE PER WEEK FROM THE FOLLOWING PERSONS:
OTHER PHARMACISTS___________ ___NURSES
PHYSICIANS ___NURSE PRACTITIONERS
dentists ___PHYSICIAN ASSISTANTS
YOUR PATIENTS
GENERAL PUBLIC
HOW MANY HOURS PER WEEK DO YOU SPEND READING PHARMACY ANÜ/UH MEDICAL JOURNALS? _Nr/wK
WHAT TOPICS ARE THE SUBJECT OF INTERACTIONS WITH HEALTH PROFESSIONALS?
GENERAL HEALTH-RELATED ISSUES
INDIVIDUAL R CLARIFICATION
DRUG INFORMATION
PATIENT MONITORING
PRODUCT availability, COST, ETC.
ALMOST
ALWAYS
1
1
1
OFTEN
2
2
2
SOME
TIMES
3 .
3
3
3
3
NEVER
5
5
5
5
S
DO YOU PROVIDE ANY OF THE FOLLOWING SERVICES IN YOUR PRACTICE? (Check Oil that QPPly)
HOME CARE SERVICES (OXYGEN, PARENTERAL NUTRITION, ETC.)
DRUG INFORMATION SERVICE TO HEALTH PROFESSIONALS
EDUCATION OF STUDENTS AND HEALTH PROFESSIONALS
BLOOD PRESSURE MONITORING
_PATIENT EDUCATION MATERIALS
COMMUNITY HEALTH EDUCATION
“(TALKS, SEMINARS, NEWSLETTER, ETC.)
DURABLE MEDICAL/SURGICAL SUPPLIES
“AND/OR EQUIPMENT
DRUG THERAPY CONSULTING/MONITORING AT SKILLED
“nursing facility, mental HEALTH CLINIC, ETC.
OTHERi_________________________________________
WHAT IS A PHARMACIST? BELOW ARE LISTED SEVERAL "ROLES" FOR PHARMACISTS,
FROM 1 ((nost Important) to 8 (least Importont).
businessman/merchant________________________clinician
HEALTH CARE PROFESSIONAL___________________MANAGER
HEALTH EDUCATOR__________________________ ___TECHNICIAN
CRAFTSMAN SCIENTIST
PLEASE RANK THEM
HOW DOES PHARMACY COMPARE WITH THE OTHER HEALTH PROFESSIONS? PLEASE RANK THE FOLLOWING
PROFESSIONS FROM 1 (highest) to 7 (lowest) ON EACH OF THE TEN SCALES.
VALUE TO SOCIETY
SKILLFULNESS
TRAINING
APPROACHABLE
AUTONOMY
STATUS/PRESTIGE
INCOME
POWER
ACCESSIBLE
SYMPATHETIC
268
• PLEASE INDICATE YOUR AGREEMENT WITH THE FOLLOWING STATEMENTS. <
(c ir c le appropriate response)
1. PHYSICIANS HAVE NOTHINQ TO LOSE BY AN EXPANDING PHARMACY ROLE.
2. PHARMACISTS WHO PERFORM PATIENT CARE SERVICES SHOULD BE PAID ON
A FEE-FOR-SERVICE BASIS.
3. PRESCRIBERS SHOULD STIPULATE THEIR DIAGNOSES ON THE PRESCRIPTION.
4. PHARMACISTS KNOW MORE ABOUT THE EFFECTS OF DRUGS ON THE BODY THAN
00 PHYSICIANS.
5. THE PHARMACIST IS THE MOST USED-SOURCE OF DRUG INFORMATION.
6. PHARMACISTS SHOULD CONSULT WITH PHYSICIANS WHO PRESCRIBE
"INEFFECTIVE" DRUGS.
7. THE PHARMACIST IS OFTEN THE FIRST HEALTH CARE PROFESSIONAL
TO SEE A PATIENT CONCERNED ABOUT SYMPTOMS OP. ILLNESS.
B. PHARMACISTS POSSESS A VAST AMOUNT OF KNOWLEDGE OF DRUGS THAT IS
NOT BEING USED IN THE CARE OF PATIENTS.
9. PHYSICIANS TEND TO RELY ON SOURCES OTHER THAN THE PHARMACIST FOR
MUCH OF THEIR DRUG INFORMATION.
10. PHARMACISTS RESPECT THE PHYSICIANS IN THEIR AREA.
11. PHYSICIANS ARE COMPETENT AND WELL INFORMED.
12. PHYSICIANS GENERALLY COOPERATE WITH THE PHARMACIST.
13. THE PHARMACIST IS THE HEALTH PROFESSIONAL MOST KNOWLEDGEABLE
ABOUT DRUGS.
14. PHYSICIANS TEND TO BE CONCEITED AND ALOOF.
13. OTHER pharmacists ARE GENERALLY COMPETENT.
16. PHARMACY IS RESPECTED BY MOST PATIENTS.
17. PHARMACY IS RESPECTED BY MOST PHYSICIANS.
IB. PHARMACY IS RESPECTED BY MOST NURSES.
19. PATIENTS LACK APPRECIATION OF PHARMACY AND COMPLAIN TOO MUCH
ABOUT PRICES.
20. PHARMACISTS ENJOY THE PERSONAL INTERACTIONS WITH PATIENTS.
21. PHARMACISTS DERIVE SATISFACTION FROM GIVING ADVICE TO PATIENTS.
22. PHARMACISTS DERIVE SATISFACTION FROM GIVING ADVICE AND
information to health professionals.
23. THE FINANCIAL REWARDS AND SECURITY OF PHARMACY PRACTICE PROVIDE
GRATIFICATION.
24. THE HOURS ARE TOO LONG IN PHARMACY PRACTICE.
25. THERE IS NOT ENOUGH TIME TO DO EVERYTHING I WANT TO IN MY
PRACTICE.
26. I Have difficulty in keeping informed on current drug information.
27. my knowledge CONCERNING DRUGS IN NOT ADEQUATE.
2B. PHARMACY IS ONE OF THE MOST SATISFYING CAREERS ONE COULD FOLLOW.
29. IF I "HAD IT TO DO OVER AGAIN" I WOULD DEFINITELY BECOME A
PHARMACIST.
30. MY CAREER AS A PHARMACIST HAS LIVED UP TO THE EXPECTATIONS I HAD
BEFORE ENTERING IT.
31. IP A FRIEND OR RELATIVE WERE CONSIDERING A CAREER IN HEALTH CARE,
I WOULD definitely advise HIM/HER TO APPLY TO PHARMACY SCHOOL.
32. I WOULD LIKE TO SEE A CHANGE IN THE WAY I PRACTICE AS A PHARMACIST
33. I FEEL THAT I AM A PART OF A HEALTH CARE TEAM.
34. I FEEL I OFFER MORE PATIENT CARE SERVICES THAN THE AVERAGE
pharmacist.
35. I FEEL I DON'T SPEND ENOUGH TIME WITH PATIENTS IN PROVIDING
INFORMATION TO THEM ABOUT PRESCRIPTION AND OTC DRUGS.
36. THE PHYSICIANS I KNOW PERSONALLY LOOK UPON ME AS A DRUG EXPERT.
37. PRESCRIBERS GENERALLY FOLLOW THE ADVICE I GIVE THEM ABOUT A DRUG.
IB, PATIENTS CENFBALLY FOLLOW ÏHE ADVICE I GIVE THEM ABOUT DRUGS.
39. NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS UTILIZE MY DRUG
CONSULTATION AND INFORMATION SERVICES MORE THAN DO PHYSICIANS.
40, MOST PHARMACY BCHOOL FACULTY MBMB**! DON'T BSALLY UMPPBSTANB THE
PROSLCNS PACSO SY PRACTICINO PHARMACISTS.
269
INSTRUCTIONS! BELOW ARE LISTED ACTIVITIES WHICH HAVE BEEN PERFORMED BY PHARMACISTS.
NOT ALL PHARMACISTS, IN ALL PRACTICE SETTINGS DO EACH OF THESE ACTIVITIES,
HOWEVER, YOU PROBABLY DO SOME OF THESE THINGS IN YOUR DAILY PRACTICE.
PLEASE READ EACH STATEMENT, "Th* ph*rro*olit . . .", AND RESPOND TO BACH
QUESTION.
THIS IS AN APPROPRIATE ROLE FORi
A COMMUNITY
PHARMACIST
A HOSPITAL
pharmacist
PHARMACISTS
ARE
COMPETENT
TO DO THIS
THIS IS A VERY
IMPORTANT
ASPECT or HY
PHARMACIST ROLE
1 2 3 4 5
: :
1 3 3 4 5
THE PHARMACIST;
...SERVES AS A DRUG INFORMATION RESOURCE
AND/OR DRUG THERAPY CONSULTANT TO PHYSICIANS
AND OTHER HEALTH CARE PROFESSIONALS.
Cog
a a. Z A. Q
S'- * s
N s a s K
iiii §
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 2 3 4 5
...PREPARES SPECIAL DRUG FORMULATIONS, FILLS
DRUG orders/prescriptions, and DISPENSES
MEDICATIONS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...TEACHES PHARMACOLOGY TO HEALTH CARE
PROFESSIONALS AND STUDENTS IN THE HEALTH
CARE PROFESSIONS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...SELECTS THE SOURCE OF SUPPLY (MANUFACTURER)
OF DRUG PRODUCTS ORDERED BY PRESCRIBERS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...MANAGES AND CONTROLS PHARMACY SUPPLIES
AND/OR PHARMACY PERSONNEL. 1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...COUNSELS PATIENTS ABOUT THE PRESCRIPTION
DRUGS THEY TAKE (e.g. DISCUSS DIRECTIONS,
SIDE EFFECTS, INTERACTIONS, CONTRA
INDICATIONS) TO PROMOTE COMPLIANCE.
1 3 3 4 5
1 3 3 4 5 1 3 3-4 5
...CONSULTS WITH PATIENTS TO PROPERLY IDENTIFY
SYMPTOMS IN ORDER TO ADVISE AND ASSIST IN THE
SELECTION OF NON-PRESCRIPTION (OTC) PRODUCTS
FOR SELF-MEDICATION.
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...SERVES AS AN IMPORTANT ENTRY POINT TO THE
HEALTH CARE SYSTEM BY TALKING WITH PATIENTS
ABOUT THEIR HEALTH CONCERNS, ASSESSING NON
EMERGENCY conditions, and making referral to
APPROPRIATE HEALTH PROFESSIONAL WHEN NEEDED.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5
...maintains medication profiles for
PATIENTS TO PREVENT HARMFUL DRUG INTER
ACTIONS, MINIMIZE ABUSE, DETECT COMPLIANCE
PROBLEMS AND PRESCRIBING ERRORS.
1 3 3 4 5 1 3 3 4 5
1 2 3 4 5 1 2 3 4 5
...USING PROTOCOLS ESTABLISHED WITH A
PATIENT'S PRESCRIBER, MAKES ADJUSTMENTS
IN PATIENT'S DRUG THERAPY (e.g. CHANGE
DOSAGE, SUBSTITUTE DRUG, ETC.).
1 3 3 4 5 1 2 1 4 5
1 3 3 4 5 1 2 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, PRESCRIBES DRUG THERAPY FOR
PATIENTS WITH ACUTE, UNCOMPLICATED
DISEASE STATES.
1 2 3 4 5
1 2 3 4 5 1 3 3 4 5
...ADVISES PATIENTS IN PERSONAL HEALTH
MATTERS (e.g. SMOKING, NUTRITION, ETC.) 1 3 3 4 5 1 3 3 4 5
1 2 3 4 5 1 2 3 4 5
...SERVES AS A CONSUMER EDUCATOR, COUNSELOR
AND ADVISOR ON DRUG- AND HEALTH-RELATED
CONCERNS, AND PARTICIPATES IN EDUCATION AND
SCREENING PROGRAMS FOR CHRONIC DISEASES.
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, PROVIDES TRAINING OF AND
SERVICES TO HOME CARE PATIENTS (e.g. OXYGEN
THERAPY, TOTAL PARENTERAL NUTRITION,
INTRAVENOUS ADMIXTURES, ETC.).
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5
...PROVIDES AND INSTRUCTS PATIENTS IN THE
USE OP DURABLE MEDICAL EQUIPMENT, AND
MEDICAL AND SURGICAL SUPPLIES.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 2 3 4 5
...TAKES PATIENT'S BLOOD PRESSURE, INTERPRETS
READING(S) TO PATIENT, ANSWERS QUESTIONS
PATIENT MAY HAVE ABOUT BLOOD PRESSURE, AND
MAKES REFERRAL TO PHYSICIAN WHEN NECESSARY.
1 2 3 4 5 1 2 3 4,5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, ORDERS DRUG THERAPY-RELATED
LABORATORY TESTS NECESSARY TO MONITOR
PATIENT'S THERAPY RESPONSE.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5
1 3 3 4 5
1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, ASSUMES PRIMARY RESPONSIBILITY
FOR LONG-TERM CARE OF PATIENTS REQUIRING
CONTINUOUS DRUG THERAPY.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5
...PROVIDES DRUG CONSULTATION SERVICES TO
HOME HEALTH AGENCIES, SKILLED NURSING
FACILITIES, MENTAL HEALTH CLINICS, AND OTHER
INSTITUTIONS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5
...UNDER THE SUPERVISION OF A PHYSICIAN,
ADMINISTERS INJECTABLE DRUGS AND
BIOLOGICALS, INCLUDING IMMUNIZATIONS.
1 3 3 4 5 1 3 3 4 5
270
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. WE APPRECIATE YOUR
TAKING THE TIME TO CONTRIBUTE TO THIS IMPORTANT STUDY.
TO ENTER THE DRAWING FOR $100, OR TO RECEIVE INFORMATION ON
NEW PROGRAMS WE ARE PLANNING, PLEASE FILL OUT THE FORM BELOW
AND RETURN WITH YOUR COMPLETED SURVEY. THIS PAGE WILL BE
SEPARATED FROM THE SURVEY AND YOUR RESPONSES TO THE QUESTIONNAIRE
WILL REMAIN ANONYMOUS.
PLEASE SEND ME FURTHER INFORMATION ON THE FOLLOWING PROGRAMS BEING
DEVELOPED.
SELF-DIRECTED, PRACTICE-BASED, INDIVIDUALIZED CONTINUING EDUCATION
USE OF COMPUTERIZED PATIENT PROFILE DATA TO ASSESS EDUCATIONAL
NEEDS OF PHARMACISTS AND/OR PRESCRIBERS
EXECUTIVE TRAINING PROGRAM FOR PHARMACY MANAGERS
MASTERS OF SCIENCE IN PHARMACY ADMINISTRATION DEGREE PROGRAM
PLEASE ENTER MY NAME IN THE DRAWING FOR $100 TO BE HELD 6/1/83
NAME:
ADDRESS:
COMMENTS:
271
Appendix B
FOLLOW-UP POSTCARD TO PHARMACISTS
M a y 1 , 1 9 8 3
REMINDER 1 ! I
It's not too late to return the Continuing Education Survey
you received a few weeks ago and enter the drawing for $1001
Your opinions, as a practicing pharmacist, concerning innovations
in Continuing Education, and future roles for pharmacists, are
desperately needed in this study.
We recognize that the survey is long, and we would have rather
spent a half-hour or so talking with you in person, but of
course that was not possible. Only 500 surveys were sent out
so your responses will "count". Please return the survey
as soon as possible, if you haven't already done so.
Thank you'.
Barbara Adamcik, M.A.
Research Associate
Medical Sociologist
use School of Pharmacy
Eos Angeles, CA 90033
272 I
Appendix C
HEALTH CARE PROFESSIONALS SURVEY
S C H O O L O F P H A R M A C Y
June 6, 1983
Dear Health Care Professional:
The use School of Pharmacy, in conjunction with the Development
and Demonstration Center in Continuing Education for health professionals,
a project funded by the W.K. Kellogg Foundation, is conducting a survey
to evaluate the role of the pharmacist as perceived by practicing pharmacists,
physicians, nurses, other health professionals and consumers.
Pharmacy is a health profession in transition, and you, as a
health professional who interacts regularly with the pharmacist, are
in a position to help the profession determine its role in the 1980's.
Please take a few minutes to complete the attached survey. It is
anticipated that it will take about 15 minutes to complete.
In order to express our thanks for your participation in this
study, we will hold a drawing for those respondents who return a completed
survey. The prize will be $100, and the drawing will be held on July 6, 1983.
The winner will be notified by mail. To enter the drawing, complete the
entry form at the bottom of this letter. This sheet will be separated from
the survey by the secretary who receives the mail so that your responses to
the questionnaire'will remain annonymous.
Again, thank you for your assistance with this important study,
t i v c e r e l y y o u r s , .
PLEASE ENTER MY NAME IN THE DRAWING;
NAME:
ADDRESS :
hn A. Biles, Ph.D.
an. School of Pharmacy
Philip Oppenheimer, Pharm.D.
Director, Community Pharmacy
Enhancement Project
Barbara Adamcik, M,A.
Research Associate
JOHN' ST AL’FFF.R P H A R M A C E U T I C A L SCIENCES C E N T E R
L M V f RSlTY O F S O U T H E R N CALIFORNIA. 1VS5 Z O N A L A\ E N L E, L O S AN G E L E S . C A LI FOR NI A 4003.1
273
SURVEY O F H EA LTH P R O F E S S IO N A L S '
P E R C E P T IO N S O F TH E ROLE O F TH E PH A R M A C IS T
BACKGROUND IN FO R M A T IO N
A G E ;
S E X : M F
E D U C A T IO N
H i g h e s t D e g r e e ;
E T H N IC BACKGROUND
C a u c a s i a n
B l a c k
H i s p a n i c
O r i e n t a l
O t h e r :
O t h e r ;
P R O F E S S IO N
P h y s i c i a n
N u r s e ___________
N u r s e P r a c t i t i o n e r
P h y s i c i a n A s s i s t a n t
NUMBER O F Y EA RS IN P R O F E S S IO N ;
PRIM A RY WORK LO C A T IO N
H o s p i t a l
HMO
C l i n i c
P r i v a t e / G r o u p
P r a c t i c e O f f i c e
O t h e r :
AREA O F S P E C IA L IZ A T IO N
I n t e r n a l M e d i c i n e
F a m i l y P r a c t i c e
O B /G Y N
P e d i a t r i c s
P s y c h i a t r y
j G e n e r a l P r a c t i c e
S u r g e r y
D e r m a t o l o g y
O t h e r :
I S ANY MEMBER O F YOUR F A M IL Y ( s p o u s e , p a r e n t , s i b l i n g , c h i l d ) A P H A R M A C IS T ? YES NO
U T IL IZ A T I O N O F PHARMACY S E R V IC E S
DO YOU REGULARLY HAVE YOUR P R E S C R IP T IO N S F I L L E D A T ONE PHARM ACY?
I F Y E S , HOW LONG HAVE YOU U SED TH A T PHARM ACY? _________ Y r s
Y ES NO
WHAT T Y P E O F PHARMACY DO YOU M OST FR EQ U EN TLY U S E ?
M e d i c a l B u i l d i n g P h a r m a c y
S h o p p i n g C e n t e r P h a r m a c y
D i s c o u n t D r u g S t o r e
( c h e c k o n l y o n e )
P r o f e s s i o n a l P h a r m a c y ( o n l y s e l l s d r u g s a n d / o r
m e d i c a l s u p p l i e s )
C l i n i c P h a r m a c y
O t h e r :
WHAT I S TH E MOST IM PO R TA N T REA SO N F O R U S IN G TH E PHARMACY TH A T YOU DO U S E ?
( c h e c k u p t o t h r e e o n l y )
P h a r m a c i s t k e e p s p a t i e n t p r o f i l e s ( i . e . m e d i c a t i o n
r e c o r d s , h e a l t h h i s t o r y , e t c . )
I l i k e t h e p h a r m a c i s t
_ L o w p r i c e s
_ F a s t s e r v i c e
_ C o n v e n i e n t l o c a t i o n
D e l i v e r y s e r v i c e
_ C li a i'y ê a c u u u i i L s
S e l l s s u n d r y i t e m s
P h a r m a c y o f f e r s m a n y p a t i e n t s e r v i c e s
_ I t * s a p r o f e s s i o n a l p h a r m a c y
O t h e r :
DO YOU USUALLY RECOMMEND A P A R T IC U L A R PHARMACY TO P A T IE N T S ?
I F N O , WHY N O T ? ________________________________________________________________ ___
YES NO
274
» WHEN YOU NEED DRUG-THERAPY RELATED INFORMATION, WHAT RESOURCES DO YOU QONSULT?
Almost Some-
Always Often times Rarely Never
Books (texts, PRO, etc.) 1 2 3 4 5
Journals 1 2 3 4 5
A physician 1 2 3 4 5
A pharmacist 1 2 3 4 5
Other health professional 1 2 3 4 5
Drug company representative 1 2 3 4 5
Drug information service 1 2 3 4 5
Medical librarian 1 2 3 4 5
» COMPARED TO OTHER RESOURCES, WHAT TYPES OF INFORMATION DO YOU BELIEVE A PHARMACIST
CAN BEST PROVIDE?
Selection of correct drug for a patient 1 2 3 4 5
Proper dosage form 1 2 3 4 5
Appropriate route of administration 1 2 3 4 5
Choice of and timing of specimens for 1 2 3 4 5
laboratory monitoring of drug therapy response
Pharmacokinetics of drugs 1 2 3 4 5
Drug interactions, side effects, tojtic 1 2 3 4 5
reactions, : adyerse'- fea'cfeiona, etc.
Therapeutic use of drugs 1 2 3 4 5
Clinical drug research findings 1 2 3 4 5
Product availability, cost, etc. 1 2 3 4 5
HOW WOULD YOU BEST DESCRIBE YOUR USUAL RELATIONSHIP WITH PHARMACISTS?
STRO NG _____ _____ _____ _____ _____ WEAK
RA R E _____ _____ _____ _____ _____ FR EQ U E N T
IN FO R M A L _____ _____ _____ _____ _____ FORMAL
S A T IS F A C T O R Y ____________ _______ _____ _____ U N S A T IS FA C T O R Y
OVERALL, WHICH HEALTH PROFESSIONAL DO YOU CONSIDER TO BE THE "EXPERT" ON DRUG THERAPY
RELATED MATTERS? (check one)
Physician Nurse Pharmacist
HOW MANY HOURS PER WEEK DO YOU SPEND READING PROFESSIONAL JOURNALS? _____ hrs.
HAVE YOU EVER WORKED WITH A CLINICAL PHARMACIST IN THE HOSPITAL SETTING? YES NO
IP YES, HOW WOULD YOU EVALUATE THAT EXPERIENCE? Excellent " Poor
275
ROLE OF THE PHARMACIST
• DO YOU BELIEVE THE PHARMACIST'S ROLE SHOULD BE EXPANDED TO INCLUDE;
Prescribing Drugs
Performing Physical Assessment
Administering Drugs
Ordering Lab Tests
Definitely
Yes
1
1
1
1
Probably
Yes
2
2
2
2
Not
Sure
3
3
3
3
Probably
No
4
4
4
4
Definitely
No
5
5
5
5
# WHAT IS A PHARMACIST? BELOW ARE LISTED SEVERAL "ROLES" FOR PHARMACISTS.
RANK THEM FROM 1 (most important) to 8 (least important).
PLEASE
Businessman/Merchant
_Craftsman
_Health Care Professional
Manager
jClinician
Health Educator
JTechnician
Scientist
• HOW DO THE HEALTH PROFESSIONS LISTED BELOW COMPARE ON THE TEN SCALES?
PLEASE RANK EACH PROFESSION ON EACH SCALE BY PLACING A "1" (highest) to a "7" (lowest)
IN EACH BOX.
VALUE TO SOCIETY
SKILLFULNESS
TRAINING
APPROACHABLE
AUTONOMY
STATUS/PRESTIGE
INCOME
SYMPATHETIC ,
276
• PLEASE INDICATE YOUR AGREEMENT WITH THE FOLLOWING STATEMENTS.
(circle appropriate response)
1. I have nothing to lose by an expanding pharmacy role.
2. Pharmacists who perform patlenk care services should be paid on a
fee-for-service basis.
3. Prescribers should Indicate the patient's diagnosis on the
prescription order.
4 Pharmacists know more about the effects of drugs on the body
than do physicians.
5. The pharmacist is the most used source of drug information.
6. Pharmacists should consult with physicians who prescribe
"ineffective" drugs.
7. The pharmacist is often the first health care professional to see
a patient concerned about symptoms of illness.
8. Pharmacists possess a vast amount of knowledge of drugs that is
not being used in the care of patients.
9. I tend to rely on sources other than the pharmacist for much of
my drug information.
10. It is important for patients to have all of their prescriptions
filled at one pharmacy.
11. Patients should choose their pharmacist as carefully as they choose
their other health professionals.
12. Pharmacy is respected by other health professions,
13. Pharmacy is respected by patients.
14. Pharmacists tend to be aloof and conceited.
15. Pharmacists respect my profession.
16. Pharmacists generally cooperate with me,
17. Pharmacists are competent and well informed. -
18. The pharmacist is the health professional most knowledgeable
about drugs.
19. Patients lack appreciation of pharmacy and complain too much
about prices.
20. I have difficulty in keeping informed on current drug information.
21. My knowledge concerning drugs is not adequate.
22. I look upon the pharmacists I know as drug experts.
23. I generally follow the advise I receive from pharmacists.
24. Pharmacists are adequately trained to take on more patient care
responsibilities.
25. I would like the pharmacist to consult with me more than he/she
does presently about my patient's medication needs and problems.
26. I generally find the Information I receive from a pharmacist
extremely helpful.
27. I feel an expanded clinical role for the pharmacist to ba a threat
to my role domain and autonomy.
2
3
3
2
2
2
2
2
2
:
2
2
2
2
2
2
2
2
# HOW MANY YEARS OP COLLEGE LEVEL EDUCATION WOULD YOU SAY TODAY'S PHARMACY GRADUATE HAS HAD
2 years, plus apprenticeship ___ 8 years
4 years____________________________________Don't Know
6 years __
WHAT OTHER REQUIREMENTS ARE THERE TO PRACTICE PHARMACY IN CALIFORNIA?
licensure examination internship residency
none Don't know
277
INSTRUCTIONS! BELOW ARE LISTED ACTIVITIES WHICH HAVE BEEN PERFORMED BY PHARMACISTS. NOT
ALL PHARMACISTS, IN ALL PRACTICE SETTINGS DO EACH OF THESE ACTIVITIES, BUT
AT LEAST SOME OP THEM ARE DONE BY MOST PHARMACISTS. PLEASE BEAD EACH STATEMENT,
"The pharHiadi-afc . . . " ANU UECIUE IK YUU PEEL THAT IS AN AHPHUPKIATIS KUUIl
FOR A PHARMACIST IN A COMMUNITY AND/OR HOSPITAL SETTING, CAN PHARMACISTS DO THIS
AND DOES THIS ACTIVITY OVERLAP WITH YOUR ROLE? (CIRCLE YOUR RESPONSE)
THIS IS AN APPROPRIATE ROLE FOR:
A COMMUNITY
HI#lRMACI3T
A HOSPITAL
PHARMACIST
PHARMACISTS
ARE
COMPETENT
TO DO THIS
THIS ACTIVITY
GREATLY
OVERLAPS
WITH MY ROIB
U s *
y!ii
g 1 1 £ i
h @ 5
liiif
THE PHARMACIST:
5^ S a
K a a a B
Hill
I e « ^ g
3 S 3
U U g
1 1 3 4 5 1 3 3 4 5
...SERVES AS A DRUG INFORMATION RESOURCE
AND/OR DRUG THERAPY CONSULTANT TO PHYSICIANS
AND OTHER HEALTH CARE PROFESSIONALS.
1 3 3 4 5 1 2 3 4 5
1 3 1 4 5 1 3 3 4 5
...PREPARES SPECIAL DRUG FORMULATIONS, FILLS
DRUG ORDERS/PRESCRIPTIONS, AND DISPENSES
MEDICATIONS.
1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...TEACHES PHARMACOLOGY TO HEALTH CARE
PROFESSIONALS AND STUDENTS IN THE HEALTH
CARE PROFESSIONS.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...SELECTS THE SOURCE OF SUPPLY (MANUFACTURER)
OF DRUG PRODUCTS ORDERED BY PRESCRIBERS.
1 3 3 4 5 1 3 3 4 5
1 3 1 4 5 1 3 3 4 5
...MANAGES AND CONTROLS PHARMACY SUPPLIES
AND/OR PHARMACY PERSONNEL.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...COUNSELS PATIENTS ABOUT THE PRESCRIPTION
DRUGS THEY TAKE (e.g. DISCUSS DIRECTIONS,
SIDE EFFECTS, INTERACTIONS, CONTRA
INDICATIONS) TO PROMOTE COMPLIANCE.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...CONSULTS WITH PATIENTS TO PROPERLY IDENTIFY
SYMPTOMS IN ORDER TO ADVISE AND ASSIST IN THE
SELECTION OF NON-PRESCRIPTION (OTC) PRODUCTS
FOR SELF-MEDICATION.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...SERVES AS AN IMPORTANT ENTRY POINT TO THE
health CARE SYSTEM BY TALKING WITH PATIENTS
ABOUT THEIR HEALTH CONCERNS, ASSESSING NON
EMERGENCY CONDITIONS, AND MAKING REFERRAL TO
APPROPRIATE HEALTH PROFESSIONAL WHEN NEEDED.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...MAINTAINS MEDICATION PROFILES FOR
PATIENTS TO PREVENT HARMFUL DRUG INTER
ACTIONS, MINIMIZE ABUSE, DETECT COMPLIANCE
PROBLEMS AND PRESCRIBING ERRORS.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
.,.USING PROTOCOLS ESTABLISHED WITH A
PATIENT’S PRESCRIBER, MAKES ADJUSTMENTS
IN PATIENT'S DRUG THERAPY (e.g. CHANGE
DOSAGE, SUBSTITUTE DRUG, ETC.).
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, PRESCRIBES DRUG THERAPY FOR
PATIENTS WITH ACUTE, UNCOMPLICATED
DISEASE STATES.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...ADVISES PATIENTS IN PERSONAL HEALTH
MATTERS (e.g. SMOKING, NUTRITION, ETC.). 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...SERVES AS A CONSUMER EDUCATOR, COUNSELOR
AND ADVISOR ON DRUG- AND HEALTH-RELATED
CONCERNS, AND PARTICIPATES IN EDUCATION AND
SCREENING PROGRAMS FOR CHRONIC DISEASES.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING protocols established WITH
PRESCRIBER, PROVIDES TRAINING OF AND
SERVICES TO HOME CARE PATIENTS (e.g. OXYGEN
THERAPY, TOTAL PARENTERAL NUTRITION,
INTRAVENOUS ADMIXTURES, ETC.).
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...PROVIDES AND INSTRUCTS PATIENTS IN THE
USE OF DURABLE MEDICAL EQUIPMENT, AND
MEDICAL AND SURGICAL SUPPLIES.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...TAKES PATIENT’S BLOOD PRESSURE, INTERPRETS
READING(S) TO PATIENT, ANSWERS QUESTIONS
PATIENT MAY HAVE ABOUT BLOOD PRESSURE, AND
MAKES REFERRAL TO PHYSICIAN WHEN NECESSARY.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, ORDERS DRUG THERAPY-RELATED
laboratory tests necessary to monitor
PATIENT’S THERAPY RESPONSE.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 .4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, ASSUMES PRIMARY RESPONSIBILITY
FOR LONG-TERM CARE OF PATIENTS REQUIRING
CONTINUOUS DRUG THERAPY.
1 2 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
.. .PROVIDES ns.un consultation services to
HOME health agencies, skilled NURSING
facilities, mental HEALTH CLINICS, AND OTHER
INSTITUTIONS.
1 3 3 4 5 1 3 3 4 3
1 3 3 4 5 1 3 3 4 5
...UNDER THE supervision OF A PHYSICIAN,
administers injectable drugs AND
BIOLOGICALS, INCLUDING IMMUNIZATIONS.
1 3 3 4 5 1 3 3 4 5
278
Appendix D
CONSUMERS SURVEY
S C H O O L OF PH AR M A C Y
May 13 , 1983
Dear Consumer:
The u s e School of Pharmacy, in conjunction with the Development
and Demonstration Center in Continuing Education for Health Professionals,
a project funded by the W.K. Kellogg Foundation, is conducting a survey
to evaluate the role of the pharmacist as perceived by consumers.
We would appreciate your assistance in filling out the attached
questionnaire. It is anticipated that it will take about 15 minutes to
complete.
Please return the survey in the attached envelope,
for your assistance with this important survey.-
Thank you
r n c e r e l y y o u r s , .
BA:ba
E n c .
Jéhn A. Biles, Ph.D.
ean. School of Pharmacy
Philip Oppenheimer, Pharm.D.
Director, Community Pharmacy
Enhancement Project
Barbara Adamcik, M,A.
Research Associate
Medical Sociologist
JOH N STAL'FFF.R PHARMACEUTICAL SCIENCES CENTER
L \ l \ [RSITY OF SO U TH ER N CALIFORNIA, 1YS5 ZO N A L AVENUE. LOS ANG ELES. CALIFORNIA «00'
279
SURVEY OF CONSUMER'C rERCEPTIONC
OF THE ROLE OF THE PHARMACIST
A. BACKGROUND INFORMATION
AGE: ETHNIC BACKGROUND;
SEX: M F
MARRIED? YES
EDUCATION; 1
NO
2 3 4
Caucasian
Black
Hispanic
jOriental
Other:
8 9 10 11 12 13 14 15 16 17 18 19 20+
Primary - Secondary
Please circle highest yeaur of education completed.
YOUR OCCUPATION:
College Graduate
DEGREE :
SPOUSE'S OCCUPATION;
FAMILY INCOME LEVEL; less than $10,000
10.000 - 15,000
15.000 - 20,000
20.000 - 30,000
30.000 - 40,000
over $40,000
NUMBER OF CHILDREN LIVING AT HOME IN FOLLOWING AGE GROUPS;
under 5 yrs________________13-17 yrs
5-12 yrs________________ ___over 17 yrs
IS ANY MEMBER OF YOUR FAMILY (parent, spouse, sibling, child) A PHARMACIST? YES NO
B. USE OF PHARMACY SERVICES
• DO YOU REGULARLY HAVE YOUR P R E S C R IP T IO N S F IL L E D A T ONE PHARM ACY? Y ES NO
• WHAT TYPE OF PHARMACY DO YOU MOST FREQUENTLY USE? (check only one)
Medical Building Pharmacy Professional Pharmacy (sells only
_ s h o p p i n g c e n t e r P h a r m o y s u p p l i e s )
_ D i s c o u n t D r u g S t o r e _ C l i n i o P h a r n e o y
Other;
pharmacist keeps a record of my
medications, health history, etc.
WHAT IS THE MOST IMPORTANT REASON FOR USING THE PHARMACY THAT YOU DO USE?
(check up to three only)
Low prices
Fast service
I like the pharmacist
Pharmacy offers many patient services
My physician recommended it
Convenient location
Delivery service
_Charge accounts
Sells non-drug items Other ;
HAS YOUR PHYSICIAN EVER RECOMMENDED A PARTICULAR PHARMACY TO YOU? YES NO
280
• DO YOU REG U LA RLY TA K E A P R E S C R IP T IO N M E D IC A T IO N ( i . e . a t l e a s t o n c e p e r d a y f o r
t h e p a s t 3 - m n n t h s ) ? YE S_ __ ____ NO
• HOW LONG H AS I T B E E N S IN C E YOU HAVE S E E N A P H Y S IC IA N ?
less than 1 month 4-12 months over 5 years
1-3 months over 1 year over 10 years
• HOW LONG HAS I T B EE N S IN C E YOU HAVE HAD A P R E S C R IP T IO N F I L L E D ?
less than 1 month 4-12 months over 5 years
1-3 months over 1 year over 10 years
C. THE ROLE OF THE PHARMACIST
• WHAT IS A PHARMACIST? BELOW ARE LISTED SEVERAL "ROLES" FOR PHARMACISTS.
PLEASE RANK THEM FROM 1 (most important) to 8 (least important).
Businessman/Merchant ___Clinician
Craftsman ___Health Educator
Health Care Professional_____________________Technician
Manager ___Scientist
• HOW DO THE HEALTH PROFESSIONS LISTED BELOW COMPARE ON THE TEN SCALES?
PLEASE RANK THE PROFESSIONS LISTED ALONG THE TOP OF .THE CHART ON EACH OF THE
SCALES BY PLACING A "1" (highest) to a "7" (lowest) IN EACH BOX.
VALUE TO SOCIETY
SKILLFULNESS
TRAINING
APPROACHABLE
AUTONOMY
STATUS/PRESTIGE
INCOME
POWER
ACCESSIBLE
SYMPATHETIC
281
INSTRUCTIONS! BELOW ARE LISTED SEVERAL ACTIVITIES WHICH HAVE BEEN DONE BY SOME PHARMACISTS.
or COURSE, NOT ALL PHARMACISTS IN ALL PRACTICE SETTINGS DO EACH OF THESE ACTIVITIES.
HOWEVER, AT LEAST SOME OF THEM ARE DONE BY MOST PHARMACISTS. PLEASE READ EACH
STATEMENT AND DECIDE IF YOU FEEL IT IS AN APPROPRIATE ROLE FOR PHARMACISTS
WORKING IN A COMMUNITY PHARMACY SETTING (drug store) OR IN A HOSPITAL SETTING.
ALSO DECIDE IF YOU FEEL PHARMACISTS ARE NOW TRAINED TO DO THIS.
(CIRCLE APPROPRIATE RESPONSE)
THIS IS AN APPROPRIATE ROLE FOR:
A COMMUNITY
PHARMACIST
A HOSPITAL
PHARMACIST
PHARMACISTS
ARE TRAINED
TO DO THIS
THE PHARfWCIST
12 14 5 1 2 3 4 5 ACTS AS A DRUG THERAPY CONSULTANT AND PROVIDES DRUG
INFORMATION TO PHYSICIANS, NURSES, DENTISTS, ETC.
12 14 5
1 2 1 4 5 1 2 3 4 5 FILLS PRESCRIPTIONS AND DRUG ORDERS, PREPARES SPECIAL
DRUG FORMULATIONS, AND DISPENSES MEDICATIONS TO
PATIENTS.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 TEACHES PHARMACOLOGY TO HEALTH CARE PROFESSIONALS
(i.e. NORSES, DOCTORS, DENTISTS, ETC.) AND STUDENTS
IN THE HEALTH PROFESSIONS.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 CHOOSES THE SOURCE OF SUPPLY (i.e. MANUFACTURER)
OF Drug products ordered by physician.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 MANAGES AND CONTROLS THE PHARMACY AND/OR PHARMACY
SUPPLIES AND INVENTORY.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 COUNSELS PATIENTS ABOUT THE PRESCRIPTION DRUGS THEY
TAKE, INCLUDING DISCUSSING DIRECTIONS, SIDE EFFECTS,
POSSIBLE INTERACTIONS AND CONTRAINDICATIONS TO HELP
PROMOTE BETTER COMPLIANCE IN TAKING MEDICATIONS.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 CONSULTS WITH PATIENTS TO HELP THEM PROPERLY
IDENTIFY SYMPTOMS IN ORDER TO ADVISE AND ASSIST
THEM IN SELECTING NON-PRESCRIPTION (OTC)
PRODUCTS FOR SELF-MEDICATION.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 SERVES AS AN IMPORTANT ENTRY POINT TO THE HEALTH
CARE SYSTEM BY TALKING WITH PATIENTS ABOUT THEIR
HEALTH CONCERNS, ASSESSING NON-EMERGENCY CONDITIONS
AND MAKING REFERRAL TO THE APPROPRIATE HEALTH
PROFESSIONAL WHEN NEEDED.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 MAINTAINS RECORDS OF PATIENT^ MEDICATION AND HEALTH
HISTORY (PATIENT PROFILES) TO PREVENT HARMFUL DRUG
INTERACTIONS, MINIMIZE ABUSE, DETECT PROBLEMS IN
COMPLIANCE, AND DETECT ERRORS IN PRESCRIBING.
1 3 3 4 5
1 2 3 4 5 1 2 3 4 5 MAKES ADJUSTMENTS IN PATIENT'S DRUG THERAPY
(e.g. CHANGE DOSAGE, SUBSTITUTE DRUG, ETC.) UNDER
AN AGREEMENT (PROTOCOL) DEVELOPED WITH THE PATIENT'S
PHYSICIAN.
1 2 3 4
1 2 3 4 5 1 2 3 4 5 PRESCRIBES DRUG THERAPY FOR PATIENTS WITH ACUTE,
UNCOMPLICATED ILLNESSES, UNDER PROTOCOL DEVELOPED
WITH THE PATIENT'S PHYSICIAN.
1 2 1 4 5
1 2 3 4 5 1 2 3 4 5 ADVISES PATIENTS IN PERSONAL HEALTH MATTERS, LIKE
SMOKING, NUTRITION, EXERCISE, ETC.
1 2 3 4 5 1 2 3 4 5 SERVES AS A CONSUMER EDUCATOR, COUNSELOR AND ADVISOR
ON DRUG- AND HEALTH-RELATED CONCERNS, AND PARTICI
PATES IN HEALTH EDUCATION AND SCREENING PROGRAMS.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 PROVIDES TRAINING OF AND SERVICES TO PATIENTS BEING
CARED FOR AT HOME (e.g. OXYGEN THERAPY, INTRAVENOUS
NUTRITION, CANCER THERAPY, ETC.) . _____________________
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 PROVIDES FOR SALE OR RENT, AND INSTRUCTS PATIENTS
IN THE USE OF MEDICAL EQUIPMENT, AND MEDICAL AND
SURGICAL SUPPLIES,
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 MONITORS PATIENT'S BLOOD PRESSURE BY TAKING BLOOD
PRESSURE READING, INTERPRETING RESULT TO PATIENT,
ANSWERING QUESTIONS PATIENT MAY HAVE ABOUT BLOOD
PRESSURE, AND MAKING REFERRAL TO PHYSICIAN IF NEEDED.
1 2 3 4
1 2 3 4 5 ORDERS LABORATORY TESTS NECESSARY TO PROPERLY
MONITOR A PATIENT'S DRUG THERAPY RESPONSE, UNDER
PROTOCOL DEVELOPED WITH A PATIENT'S PHYSICIAN.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 ASSUMES PRIMARY RESPONSIBILITY FOR THE LONG-TERM
CARE OP PATIENTS REQUIRING CONTINUOUS DRUG THERAPY
UNDER PROTOCOL ESTABLISHED WITH A PATIENT'S DOCTOR.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 PROVIDES DRUG THERAPY CONSULTATION SERVICES TO HOME
HEALTH CARE AGENCIES, SKILLED NURSING FACILITIES,
MENTAL HEALTH CLINICS AND OTHER INSTITUTIONS.
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5 ADMINISTERS INJECTABLE DRUGS ("SHOTS"), INCLUDING
IMMUNIZATIONS,UNDER SUPERVISION OF A PHYSICIAN.
1 2 3 4 5
282
Appendix E
PHARMACY FACULTY MEMBERS SURVEY
SCHOOL OF PHARMACY
April 30, 1983
Dear Pharmacy School Faculty;
The School of Pharmacy, in conjunction with the Development
and Demonstration Center in Continuing Education for Health
Professionals, a project of the W.K. Kellogg Foundation, is
conducting a survey to evaluate the role of the pharmacist.
Pharmacy students, practicing pharmacists, pharmacy faculty
members, physicians, nurses and consumers will be surveyed.
We would appreciate your taking the time to fill out the
attached questionnaire. It is anticipated it will take about
20 minutes to complete. Your perspective as a fadulty member
is very important to this study.
Thank you for your assistance with this survey. When you
have completed it, please fold it in half and staple or tape the
bottom. It can be sent in the USC Intercampus mail to the
address below.
BA
Enc.
c e r e l y y o u r s * .
5hn A. Biles, Ph.D.
5eaji, School of Pharmacy
Philip Oppenheimer, Pharm.D.
Director, Community Pharmacy
Enhancement Project
Barbara Adamcik, M.A.
Research Associate
INTERCAMPUS MAIL
SEND TO; BARBARA ADAMCIK, M.A.
COMMUNITY PHARMACY ENHANCEMENT PROJECT
KAM 307a
HEALTH SCIENCES CAMPUS
283
SURVEY OF PHARMACY SCHOOL FACULTY'S PERCEPTION
OF THE ROLE OF PHARMACIST
A. BACKGROUND INFORMATION
AGE;______
SEX: M F
DEGREE(S):
ETHNIC BACKGROUND: jCaucasian
Black
Oriental
Hispanic
C ther s
YEAR FIRST LICENSED TO PRACTICE PHARMACY:
FACULTY POSITION/RANK:
MAJOR AREA(S) OF TEACHING RESPONSIBILITY:
Basic Sciences
Pharmaceutics
_Pharmacology/Pharmacokinetics
Pharmaceutical Sciences
Other ;
ARE YOU FULL-TIME FACULTY? YES
Clinical Pharmacy
Pharmacy Practice/Management/Law
Radiopharmacy
Pharmacy Administration/Social or Behavioral
Sciences
NO
IF NO, ARE YOU INVOLVED IN PHARMACY PRACTICE?
ROLE OF THE PHARMACIST
• WHAT IS A PHARMACIST? BELOW ARE LISTED SEVERAL "ROLES" FOR PHARMACISTS. PLEASE RANK THEM
FROM 1 (most Importent) to 8 (leost Important).
BUSINESSMAN/MERCHANT
HEALTH CARE PROFESSIONAL
_HEALTH EDUCATOR
CRAFTSMAN
_CLINICIAN
MANAGER
TECHNICIAN
SCIENTIST
HOW DOES PHARM:ACY COMPARE WITH THE OTHER HEALTH PROFESSIONS? PLEASE RANK THE FOLLOWING
PROFESSIONS FROM 1 (highest) to 7 (lowest) ON EACH OF THE TEN SCALES.
VALUE TO SOCIETY
SKILLFULNESS
TRAINING
APPROACHABLE
STATUS/PRESTIGE
NCOME
POWER
ACCESSIBLE
SYMPATHETIC
284
PLEASE INDICATE YOUR AGREEMENT WITH THE FOLLOWING STATEMENTS. »
(circle QPproprlQte resp o n se)
Î, PHYSICIANS HAYE NOTHING TO LOSE BY AN EXPANDING PHARMACY ROLE.
3. pharmacists who perform PATIENT CARE SERVICES SHOULD BE PAID ON
A FEE-FOR-SERVICE BASIS.
3. prescribers should STIPULATE THEIR DIAGNOSES ON THE PRESCRIPTION.
i. PHARMACISTS KNOW MORE ABOUT THE EFFECTS OF DRUGS ON THE BODY THAN
DO PHYSICIANS.
5. THE PHARMACIST IS THE MOST USED SOURCE OF DRUG INFORMATION.
6. PHARMACISTS SHOULD CONSULT WITH PHYSICIANS WHO PRESCRIBE
•INEFFECTIVE* DRUGS.
7. THE PHARMACIST IS OFTEN THE FIRST HEALTH CARE PROFESSIONAL
TO SEE A PATIENT CONCERNED ABOUT SYMPTOMS OF. ILLNESS.
8. PHARMACISTS POSSESS A VAST AMOUNT OF KNOWLEDGE OF DRUGS THAT IS
NOT BEING USED IN THE CARE OF PATIENTS.
9. PHYSICIANS TEND TO RELY ON SOURCES OTHER THAN THE PHARMACIST FOR
MUCH OF their DRUG INFORMATION.
10. PHARMACISTS RESPECT PHYSICIANS.
11. PHYSICIANS ARE COMPETENT AND V/ELL INFORMED.
12. PHYSICIANS GENERALLY COOPERATE WITH THE PHARMACIST.
13. THE PHARMACIST IS THE HEALTH PROFESSIONAL MOST KNOWLEDGEABLE
ABOUT DRUGS.
14. Physicians tend to be conceited and aloof.
15. PHARMACISTS ARE GENERALLY COMPETENT.
16. PHARMACY IS RESPECTED BY MOST PATIENTS.
17. PHARMACY IS RESPECTED BY MOST PHYSICIANS.
18. PHARMACY IS RESPECTED BY MOST NURSES.
19. PATIENTS LACK APPRECIATION OP PHARMACY AND COMPLAIN TOO MUCH
ABOUT PRICES.
20. PHARMACISTS ENJOY THE PERSONAL INTERACTIONS WITH PATIENTS.
21. PHARMACISTS DERIVE SATISFACTION FROM GIVING ADVICE TO PATIENTS.
22. PHARMACISTS DERIVE SATISFACTION FROM GIVING ADVICE AND
INFORMATION TO HEALTH PROFESSIONALS.
23. THE financial REWARDS AND SECURITY OF PHARMACY PRACTICE PROVIDE
gratification.
24. THE HOURS ARE TOO LONG IN PHARMACY PRACTICE.
most PHARMACY SCHOOL FACULTY MEXBIRS DON'T REALLY UNDERSTAND THE
PROBLEMS FACED BY PRACTICIMC PHARMACISTS,
26. I HAVE DIFFICULTY IN KEEPING INFORMED ON CURRENT DRUG INFORMATION
27. MY KNOWLEDGE CONCERNING DRUGS IN NOT ADEQUATE.
28. PHARMACY IS ONE OP THE MOST SATISFYING CAREERS ONE COULD FOLLOW.
29. IF I ’HAD IT TO DO OVER AGAIN" I WOULD DEFINITELY BECOME A
PHARMACIST.
30. MY CAREER AS A PHARMACIST HAS LIVED UP TO THE EXPECTATIONS I HAD
BEFORE ENTERING IT.
32. THE PHYSICIANS I KNOW PERSONALLY LOOK UPON ME AS A DRUG EXPERT.
» WHAT DO YOU FEEL ARE THE MAJOR BARRIERS WHICH PREVENT PRACTICING PHARMACISTS FROM
PROVIDING MORE PATIENT-ORIENTED, PROFESSIONAL SERVICES?
_Lack of time
Lack of space
_No consultation area
Legal barriers
Pharmacists' attitudes
Patients not interested
Attitudes of physicians,
nurses, etc.
(please rank your responses)
Lack of reimbursement
Pharmacists not competent
Other;
DO YOU BELIEVE THAT THE PHARMACIST'S ROLE SHOULD BE EXPANDED TO INCLUDE;
PRESCRIBING DRUGS
PERFORMING PHYSICAL ASSESSMENT
ADMINISTERING DRUGS
ORDERING LAB TESTS
DE/INIIILY
YES
1
1
1
1
PROBABLY
YES
NOT
SURE
3
3 ,
3
3
PROBABLY
NO
D2FINIT2LÏ
NO
5
5
S
5
28 5
INSTRUCTIONS: BELOW ARE LISTED ACTIVITIES WHICH HAVE BEEN PERFORMED BY PHARMACISTS.
PROBABLY MOST PHARMACISTS DO AT LEAST SOME OP THESE THINGS IN THEIR
PRACTICE. PLEASE READ EACH STATEMENT, "The pharmacist ..." AND
CIRCLE YOur KtSFUNbt; T'U each yULb'l'iUN AT THE TUP UP THE CULUMNS.
THIS IS AN APPROPRIATE ROLE FOR:
A COMMUNITY A HOSPITAL
PHARMACISTS
ARE
COMPETENT
PHYSICIANS
WOULD BE
SUPPORTIVE
PHARMACIST PIUIBMACIST XO DO THIS OF THIS
il
Ivil
u § S § u
5 s il
s i 1 i i
THE PHARMACIST;
1 i 1 11
i 11 1 i
§ :
i i 11 i
iili §
1 3 3 4 S 1 3 3 4 5
...SERVES AS A DRUG INFORMATION RESOURCE
AND/OR DRUG THERAPY CONSULTANT TO PHYSICIANS
AND OTHER HEALTH CARE PROFESSIONALS.
1 3 3 4 5 1 3 3 4 5
• 1 3 3 4 5 1 3 3 4 5
...PREPARES SPECIAL DRUG FORMULATIONS, FILLS
DRUG ORDERS/PRESCRIPTIONS, AND DISPENSES
MEDICATIONS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...TEACHES PHARMACOLOGY TO HEALTH CARE
PROFESSIONALS AND STUDENTS IN THE HEALTH
CARE PROFESSIONS.
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...SELECTS THE SOURCE OF SUPPLY (MANUFACTURER)
OF DRUG PRODUCTS ORDERED BY PRESCRIBERS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...MANAGES AND CONTROLS PHARMACY SUPPLIES
AND/OR PHARMACY PERSONNEL.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...COUNSELS PATIENTS ABOUT THE PRESCRIPTION
DRUGS THEY TAKE (e.g. DISCUSS DIRECTIONS,
SIDE EFFECTS, INTERACTIONS, CONTRA
INDICATIONS) TO PROMOTE COMPLIANCE.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3-4 £
...CONSULTS WITH PATIENTS TO PROPERLY IDENTIFY
SYMPTOMS IN order TO ADVISE AND ASSIST IN THE
SELECTION OF NON-PRESCRIPTION (OTC) PRODUCTS
FOR SELF-MEDICATION.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...SERVES AS AN IMPORTANT ENTRY POINT TO THE
HEALTH CARE SYSTEM BY TALKING WITH PATIENTS
ABOUT THEIR HEALTH CONCERNS, ASSESSING NON
EMERGENCY CONDITIONS, AND MAKING REFERRAL TO
appropriate HEALTH PROFESSIONAL WHEN NEEDED.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...MAINTAINS MEDICATION PROFILES FOR
PATIENTS TO PREVENT HARMFUL DRUG INTER
ACTIONS, MINIMIZE ABUSE, DETECT COMPLIANCE
PROBLEMS AND PRESCRIBING ERRORS.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 1 4 5
...USING PROTOCOLS ESTABLISHED WITH A
PATIENT'S PRESCRIBER, MAKES ADJUSTMENTS
IN PATIENT'S DRUG THERAPY (e.g. CHANGE
DOSAGE, SUBSTITUTE DRUG, ETC.).
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, PRESCRIBES DRUG THERAPY FOR
PATIENTS WITH ACUTE, UNCOMPLICATED
DISEASE STATES.
1 3 3 4 5 1 2 3 4 5
1 3 3 4 5 1 3 3 4 5
...ADVISES PATIENTS IN PERSONAL HEALTH
MATTERS (e.g. SMOKING, NUTRITION, ETC.). 1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...SERVES AS A CONSUMER EDUCATOR, COUNSELOR
AND ADVISOR ON DRUG- AND HEALTH-RELATED
CONCERNS, AND PARTICIPATES IN EDUCATION AND
SCREENING PROGRAMS FOR CHRONIC DISEASES.
1 2 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, PROVIDES TRAINING OF AND
SERVICES TO HOME CARE PATIENTS (e.g. OXYGEN
THERAPY, total PARENTERAL NUTRITION,
INTRAVENOUS ADMIXTURES, ETC.).
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...PROVIDES AND INSTRUCTS PATIENTS IN THE
USE OF DURABLE MEDICAL EQUIPMENT, AND
MEDICAL AND SURGICAL SUPPLIES.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 2 3 4 5
...TAKES PATIENT'S BLOOD PRESSURE, INTERPRETS
READING(S) TO PATIENT, ANSWERS QUESTIONS
PATIENT MAY HAVE ABOUT BLOOD PRESSURE, AND
MAKES REFERRAL TO PHYSICIAN WHEN NECESSARY.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, ORDERS DRUG THERAPY-RELATED
LABORATORY TESTS NECESSARY TO MONITOR
PATIENT'S THERAPY RESPONSE.
1 3 3 4 5 1 2 3 4 5
1 3 1 4 5 1 3 3.45
...USING PROTOCOLS ESTABLISHED WITH
PRESCRIBER, ASSUMES PRIMARY RESPONSIBILITY
FOR LONG-TERM CARE OF PATIENTS REQUIRING
CONTINUOUS DRUG THERAPY.
1 3 3 4 5 1 3 3 4 5
1 3 3 4 5 1 3 3 4 5
...PROVIDES DRUG CONSULTATION SERVICES TO
HOME HEALTH AGENCIES, SKILLED NURSING
FACILITIES, MENTAL HEALTH CLINICS, AND OTHER
INSTITUTIONS.
1 3 3 4 5 1 3 3 4 5
1 3 14 5 1 3 3 4 5
...UNDER THE SUPERVISION OF A PHYSICIAN,
ADMINISTERS INJECTABLE DRUGS AND
BIOLOGICALS, INCLUDING IMMUNIZATIONS.
1 2 3 4 5 1 3 3 4 5
286
Appendix F
FACTOR ANALYSIS; 20 ROLE ITEMS FOR COMMUNITY PRACTICE
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288
Appendix G
F A C T O R ANALYSIS; 20 R O L E IT E M S F O R HO SPITA L PRA CTICE
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Asset Metadata
Creator
Adamcik, Barbara Ann
(author)
Core Title
Differential acceptance of a new role for pharmacists
School
Graduate School
Degree
Doctor of Philosophy
Degree Program
Sociology
Degree Conferral Date
1984-05
Tag
OAI-PMH Harvest
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC11256329
Unique identifier
UC11256329
Legacy Identifier
DP31834
Document Type
Dissertation