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The role of the Danish community pharmacist: perceptions and future scenarios • Lotte Stig Nørgaard, Lene Colberg and Mie Riise Niemann

Pharm World Sci 2001;23(4): 159-164. © 2001 Kluwer Academic Publishers. Printed in the Netherlands. Lotte Stig Nørgaard (correspondence): The Royal Danish School of Pharmacy, Department of Social Pharmacy, Universitetsparken 2, DK2100 Copenhagen, Denmark Lene Colberg: Lyngby Svane Pharmacy, Lyngby Hovedgade 27, DK2800 Lyngby, Denmark Mie Riise Niemann: Albertslund Pharmacy, Bytorvet 5, DK2620 Albertslund, Denmark Keywords Community pharmacist Denmark Development Interpretative flexibility Professional role Relevant social groups Social construction SCOT theory Abstract In recent decades, dramatic changes of the role of the Danish community pharmacist have contributed to widespread uncertainty among professionals about the future content of their job. This case study, which is based on qualitative research interviews and documentary material, describes how key actors belonging to 10 different relevant social groups who have been influential in shaping the role of Danish community pharmacists have different perceptions of the pharmacy profession. These perceptions include: the community pharmacist as a provider of technical, standardised advice, the pharmacist as a drug expert, the pharmacist as a leader, and the pharmacist as a provider of individualised advice. Five future scenarios for the community pharmacist ranging from a role as a pharmacist with no future to a role as the provider of individualised information and future role developer are also described and analysed in the paper. The case study is theoretically based on a specific social constructivist theory, the Social Construction of Technology (SCOT). Accepted May 2001

Introduction

Method Theory The theoretical foundation of the study is a constructivist theory [8,9]. Social constructivist theories are suitable for describing development processes and negotiations between actors and for describing different degrees of agreement and disagreements between actors. Since this study aimed at describing the development process in relation to the pharmacist’s professional role, we found a social constructivist perspective appropriate for a theoretical framing of the study. Social constructivists claim that people from different social backgrounds have different notions of social reality. Knowledge and truth are thus created, not discovered by a mental state [10], and a range of views can be valid in different ways. Social constructivist theories have been used, for example, to study the construction and development of theories, social objects, technologies and professions [11,12]. In this paper a specific social constructivist theory, the Social Construction of Technology Theory (SCOT theory) [8,9] is used to describe the development of a professional role: that of the Danish community pharmacist. The SCOT theory is applicable and has been used as a theoretical basis to describe the development of artefacts such as technology, scientific knowledge and professional roles [10]. Table 1 lists key concepts from the SCOT theory used as the theoretical background for this study.

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Choice of units Qualitative interviews served as the main data collection method for this study [13]. Proponents of the qualitative research interview do not use quantitative data collection methods such as surveys because data originating from qualitative interviews consist of descriptions, understandings and explanations of what defines a specific phenomenon, rather than numbers and statistics, which are the focus of quantitative studies [14]. The SCOT theory uses two methodological techniques to identify actors in a specific development: ‘roll your snowball’ and ‘follow the actors’. In accordance with the snowball technique, all study interviewees were asked to provide names of other potential interviewees. We then ‘followed’ the actors, researching their background and describing them in further detail. Among other things, we found out what the actors had published or said in public. The ‘closing of the circle’ took place after a few months.

Pharmacy World & Science

Over the last couple of decades, demands on Danish community pharmacists have changed dramatically after the elimination of the drug-compounding role. Pharmaceutical professionals have not yet agreed on a new function to take its place [1,2]. Like other areas of the Danish health care sector, pharmacies have been under increasing political pressure to make more efficient use of scarce economic resources. These demands have limited the pharmacies’ economic freedom of action and resulted in fewer resources for new initiatives, of which the development of the role of the community pharmacist is but one example [3]. Furthermore, the legislative changes of the 1980s and 1990s led to the transfer of several areas of responsibility from community pharmacists to pharmacy technicians [4,5]. As a result, today’s community pharmacists find themselves sharing their professional identity as controllers of prescriptions and patient counsellors with pharmacy technicians. The development of the role of the Danish community pharmacist in the 1990s has thus been marked by uncertainty, frustration and disagreement about a new job definition [6]. Community pharmacists never really came to terms with this professional crisis,

which surfaced in the 1980s. The pharmaceutical profession in general and the role of the pharmacist in particular continue to be at the centre of an extensive change process [7]. This study aims to describe and analyse the perceptions and opinions of relevant key actors on the current role of Danish community pharmacists and possible future development scenarios.

Table 1 Definitions of key concepts from the SCOT theory used as the theoretical basis for the study (inspired by 8 and 9)1

Relevant social group (RSG) Comprises a group of people involved in the development of an artefact (for example, a specific hardware, system, process or role) whose members associate the same set of meanings with the specific artefact. An RSG can, for instance, be identified through a description of the problems each group attributes to the artefact (technology, role, etc.) Interpretative flexibility The interpretative flexibility is the total ‘pool’ of meanings attributed to the technology, role, etc., by all the different RSGs. In fact, the contribution of the RSG to the interpretative flexibility is what constitutes the specific RSG’s view of the technology. Technological frame (TF) A technological frame is the shared frame of reference within a particular RSG, a body of knowledge against which the group views a specific artefact. A technological frame may consist of many different elements, but typically includes the following elements: goals, key problems, problem-solving strategies, requirements to be met by the problem solution, current theories, tacit knowledge, test procedures, design methods and criteria, user practices, perceived substitution function and exemplary artefacts/situation. Closure is achieved when conflicting groups reach (or impose) a specific outcome, for example, when concluding a dispute relating to a specific technology, role, etc. 1 For a more detailed description of the SCOT theory see [8] and [9]. For another study in pharmacy practice research based on SCOT theory see [11].

The interviewees were selected on the basis of the following inclusion criteria: • Identification of the interviewee by other actors (the snowball method). • Interviewee’s influence on the development of the role of Danish community pharmacists. • Interviewee’s professional reputation – the interviewee had to be known, for instance, from the Danish pharmaceutical literature.



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Data for the study were collected through 12 qualitative research interviews. The following were interviewed: a community pharmacist, a pharmacy proprietor, head of department of the Danish Ministry of Health, two pharmacy researchers, the Rector of The Royal Danish School of Pharmacy, the head of The Association of Danish Pharmacy Technicians, a former head of The Danish Pharmaceutical Association, three representatives of The Danish Pharmaceutical Association, the head of The Pharmacy Section, a former head of The Association of Danish Pharmacists, and the present head of The Association of Danish Pharmacists. Interviews with three persons known to have extensive knowledge about the development of the role of the community pharmacist were used as pilot interviews. These interviewees then ‘rolled the snowball’ to identify other interviewees. All interviews were taped and transcribed. Each interview lasted between 40 and 150 minutes, with an average length of 120 minutes. All but one interview were carried out at the interviewee’s place of work. The interviews followed a semi-structured interview guide developed from issues originating from the SCOT theory, especially technological frames such as the aim of the pharmacist role, key problems associated with the role, problem-solving strategy and future scenario for the pharmacist role. No interviewees were anonymous. An extensive amount of

documentary material was used later on to verify and supplement the interview data. Analysis In accordance with Kvale [13], the essence of the opinions was condensed from the transcribed interviews to make the material suitable for analysis. The process involved reducing the interviewee’s statements to shorter sentences, structured in accordance with the issues in the interview guide. The actors were categorised in relevant social groups (RSGs) according to their opinions on the development of the role of the Danish community pharmacist and the problems they attributed to this development.

Results Relevant Social Groups (RGSs) and perceptions Table 2 shows the 10 RSGs identified as having influenced the development of the role of the Danish community pharmacist in the 1990s. All groups, with the exception of the pharmacy technician group and the community pharmacist group, were represented in the interview study. In accordance with the SCOT theory, each RSG had its own individual perception of the development of the role of the community pharmacist, as well as current and future roles, as described in the following. The different RSG perceptions of the role of the community pharmacist can be categorised into four main groups, also known as general perceptions: 1. A provider of technical, standardised advice only 3. A drug expert 4. A pharmacy leader 5. A provider of individualised advice. This categorisation has been made in accordance with the theoretical concept of interpretative flexibili-

Table 2 Relevant social groups (RSGs) identified as having influenced the development of the Danish community pharmacist role in the 1990s The Ministry of Health group The Danish Pharmaceutical Association group (DPA group) The Association of Danish Pharmacists (ADP group) The Danish Association of Pharmacy Technicians group The Royal Danish School of Pharmacy (RDSP group) The pharmacy researcher group The pharmacy practitioner group (comprising community pharmacists and pharmacy proprietors) The Pharmacy Section group The pharmacy technician group The community pharmacist group

ty. The total interpretative flexibility of the role of the community pharmacist and the four general perceptions are shown in Table 3. The first of the four perceptions of the role of the community pharmacist, the technical adviser, implies that the job of the community pharmacist is to dispense medicine and provide pharmacy customers with brief, technical advice on how to use and store the medicine. The role of the technical adviser is to give the customer standardised information in accordance with the instructions on the drug label and

drug inserts. This information is not tailored specifically to individual customer needs. This perception was most prominent in the Ministry of Health group. The second perception is of the community pharmacist as a drug expert. In this role, the community pharmacist provides other health professionals and customers with service and information about medicines. The community pharmacist is not expected to assess the customer’s pharmaceutical care needs. The role does, however, imply that the community pharmacist co-operates with other health care professionals. This perception was seen in the DPA, The Association of Pharmacy Technicians and RDSP groups. The third perception views the community pharmacist as a pharmacy leader. In this role, the community pharmacist is expected to handle administrative work and take responsibility for the continuing education of other pharmacy personnel. This perception was often seen in combination with one of the other three general perceptions, and especially in the DPA and pharmacy practitioner groups. The fourth perception sees the community pharmacist taking responsibility for counselling the individual customer based on his or her specific therapeutic needs. In this role, the community pharmacist is required to decide on the best medical treatment for the customer. Counselling is essentially based on a comprehensive pharmaceutical assessment and analysis of the individual customer needs. This perception was seen in the ADP, pharmacy researcher and pharmacy practitioner groups.

Table 3 The contribution of the RSG to the total interpretative flexibility of the role of the community pharmacist Relevant social group

The total interpretative flexibility of the role of community pharmacist

The four general perceptions of the role

The Ministry of Health group

• Provides technical advice • Has no specific responsibility in the pharmacy

Provider of technical advice

The DPA group

• Provides individual counselling on medicines, with the help of IT databases • Manages the pharmacy • Performs professional health services

Drug expert Leader Drug expert

The RDSP group

• Has specialised knowledge of drugs

Drug expert

The Pharmacy Section group

• Provides pharmaceutical care • Manages the pharmacy • Works to develop the pharmacy

Provider of individualised advice Leader

The ADP group

• Provides individual counselling on drug use • Is an academic • Is a professional resource in the pharmacy

Provider of individualised advice

The pharmacy researcher group

• Provides pharmaceutical care • Co-ordinates local interdisciplinary initiatives • Performs professional health services

Provider of individualised advice Leader Provider of individualised advice Leader 161


The pharmacy • Provides individual counselling on drug use based on practitioner group special expertise • Manages the pharmacy • Acts as a role model for the rest of the pharmacy staff


The Danish Associa- • Secures/finds new working tasks for the pharmacy tion of Pharmacy • Responsible for educating pharmacy technicians Technicians group • Promotes co-operation with other health professionals

As is clear from the above, it was impossible to achieve any closure on the perceptions of the role of the community pharmacist. The RSGs simply did not agree about the content of the existing role of the community pharmacist.



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care. As a provider of individualised pharmaceutical counselling, the community pharmacist will thus play a role for specialised patient counselling in the pharmacy. The pharmacy will become a health care centre with other health professionals associated. The pharmacy researcher, RDSP, pharmacy practitioner and pharmacy section groups believe that customers will increasingly seek this type of individualised information in the future. Community pharmacists will thus have a central future role to play in pharmacies.

Possible future scenarios The RSGs also perceive different scenarios in the future for how the community pharmacist’s role will develop. Five scenarios were derived from the interviews: – No future – Uncertain future – Leader and authority on disease management Discussion – IT expert – Provider of individualised information and future role The results of this study clearly reveal that the RSGs have different perceptions of the role of the commudeveloper. nity pharmacist. The development of the role has 1. In the ‘No future’ scenario, a political majority deci- been, and continues to be the result of diverging des there is no need for pharmacist-based counsel- social, political and economic interests. The various future scenarios described by the RSGs ling in the pharmacy. The development of the role of the community pharmacist would be severely show how widely different models for the future of jeopardised. The pharmacy practitioner group fears the community pharmacist are possible. Most Danish that this scenario might become a reality as a con- community pharmacists would not view the future sequence of the liberalisation of the Danish phar- roles described for them in the results as at all desirable. The ‘No future’, ‘Uncertain future’ and ‘IT expert’ macy sector. scenarios all imply no or few pharmacists working in 2. In the ‘Uncertain future’ scenario pharmacy proprie- the pharmacies, making them particularly undesirators are unwilling to focus on providing pharma- ble. To a great extent, this is in keeping with results in a cist-based expertise because of financial constraints. This scenario also implies that community study by Sørensen [15], which describes how compharmacists themselves are not committed to acti- munity pharmacist’s self-perception of their own provely developing their own role. The pharmacy fessional role can be divided into four different catepractitioner and pharmacy researcher groups fear gories: The technical perception (authority for the that a consequence of this scenario would be phar- patient), the business perception (the patient is always right), the conforming perception (care for the macies with few, if any, pharmacists employed. patient) and the holistic perception (consultant for 3. The ‘Leader and authority on disease management’ and equality with the patient). Understandably, no scenario implies that community pharmacists pharmacists in the study by Sørensen [15] made spewould systematically continue training for a tradi- cific comments on the community pharmacist as an tional managerial position as deputy head, in pre- IT expert, due to the fact that the study was carried paration for a career as a pharmacy proprietor. The out in the mid-1980s where computerised patient DPA group is currently trying to develop the future medication record screening programs and use of the role of the community pharmacist within the scope Internet was nonexistant in most community pharof this scenario. According to the group, communi- macies nationally and internationally. Other studies have dealt with the future role of ty pharmacist will have a future role to play in disease management and in educating certain groups pharmacists, for instance Møldrup and Stadsgaard [7], who in their prize-winning report outlined the folof customers. lowing four different scenarios for the future of the 4. The scenario in which the community pharmacist is community pharmacists profession: an ‘IT expert’ implies that the general public will 1. The pharmacist as a Clinician (oriented towards clinical support, managed care, mail order sale and not be using the community pharmacist as a major use of the Internet) knowledge resource. This will happen as people acquire more knowledge and as new ways of see- 2. The pharmacist as DNAlchemist (oriented towards individual specific diseases, preparing and selling king specialised information evolve, for instance, medicine prescribed on basis of the individual through the Internet. The scenario foresees an patient’s genetic profile (pharmacogenomics) increasing amount of e-commerce, including sales of pharmaceutical products. The Ministry of Health 3. The pharmacist as an Alchemist (no role for the community pharmacist in the pharmacy) group envisage this scenario, which would diminish the demand for specialised pharmacist exper- 4. The pharmacist as an Informer (the pharmacist as a key person for informing patient groups about tise in the pharmacy. A possible consequence could medicines in- and outside the pharmacy). be pharmacists working from computers to serve an Internet hotline. All but one of these future scenarios, namely the phar5. The ‘Provider of individualised information and future macist as a DNAlchemist are to be found in our study role developer’ scenario implies that the community too. The Clinician has a strong likeliness to the ‘ITpharmacist will develop an identity based on the expert’, the Alchemist is comparable to our descripprovision of pharmacotherapy and pharmaceutical tions of the ‘No future’ role and the ‘Uncertain future’

which will give the researcher a specific methodological and theoretical tool for studying and analysing the development process in question [24]. Hopefully, this study may inspire others to study the development of the role of the community pharmacist in other countries, despite the differences in pharmacy system structures. Carrying out these kinds of studies is relevant, since the undefined role of the community pharmacist is discussed in most Western European countries, a point which has also been made by MacArthur [25]. A social constructivist study of any given development in pharmacy practice can raise the awareness of all relevant social groups’ different views and attitudes towards the development. Our experience is that the key concepts of the SCOT theory, interpretative flexibility and technological frames in particular, were essential for identifying the differences between the various perceptions and interests. The SCOT theory was also very useful for categorising interviewees into RSGs as well as elucidating the different future scenarios. Following and describing the attitudes of different relevant social groups towards the field of study (the interpretative flexibility) will equip project leaders in pharmacy practice with a useful management tool for developing a project further. Resistance from one or more groups can hence be taken into account and dealt with constructively, hopefully leading to less problematic and more controllable developments [20].

Conclusion The study has identified 10 different RSGs with different perceptions of the present and future roles of the community pharmacist, ranging from a role as provider of technical, standardised advice only, a role as a leader in the pharmacy, a role as drug expert in the pharmacy to a role where the community pharmacist takes responsibility for advising the customer on basis of individualised information. No closure has been achieved in the 1990s on the role of the Danish community pharmacist, since the RSGs have not yet reached consensus on the perception of either the present or the future role. Great uncertainty thus remains about the role of Danish pharmacists among the members of the different RSGs that influence the development of the profession. Possible future scenarios for the development of the community pharmacist’s role include five different scenarios: no future for the pharmacist, an uncertain future, the pharmacist as leader and authority on disease management, the pharmacist as IT expert and the pharmacist as an expert provider of individualised information to each customer.

References

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role, whereas the Informer is a reminiscent of the ‘Provider of individualised information and future role developer’. That the DNAlchemist is not existent in our material is not surprising. Dealing with pharmacogenomics (individual variation in drug metabolism) does not figure as a possible role for the community pharmacist seen from the perspectives of the RSGs in our study. This supports the assumption made by Møldrup [16] that health professionals are not yet prepared to advise patient in terms of usage and relating themselves to ethical aspects of pharmacogenomic drugs. A future abolition of the Danish pharmacy monopoly may have major implications for the development of the role of the community pharmacist. Danish politicians have shown great interest in moves made by other Nordic countries to liberalise the pharmacy sector [17]. Icelandic research has shown that disagreements among pharmacists resulted in community pharmacists having no influence whatsoever on the liberalisation process and subsequently on their own role in the pharmacies [18]. The partial liberalisation of the Danish pharmacy sector, to be implemented in 2001, was agreed by a majority of the political parties in the Parliament, and one of its consequences will be that the sale of certain OTC drugs will no longer be limited to pharmacies. In addition, pharmacy technicians will be given more areas of responsibility [19]. One possible scenario for the community pharmacist’s professional role following this could be the ‘Uncertain future’, a future where a majority of the pharmacy proprietors are unwilling to hire pharmacists for financial reasons. Although the ‘Leader and authority on disease management’ scenario does present some interesting opportunities, we definitely view the ‘Provider of individualised information and future role developer’ scenario as the most interesting, challenging and visionary. This scenario would provide professional challenges for community pharmacists in their every day work. Today, however, many pharmacists face at least one problem in relation to this role: they do not possess the necessary skills to fulfil the role in a satisfactory way. A second problem is that older, more experienced community pharmacists may be unwilling to change their role perception. In our opinion, Danish community pharmacists have every opportunity to influence the future development of their role. It is, however, crucial that they engage actively in this development. The professional organisations (the DPA and ADP groups) should preferably also agree to act in concert towards mutual goals, though this may seem an Utopian vision. Using SCOT to theoretically frame research in pharmacy practice has proved useful for framing other studies describing development processes in pharmacy practice. Thus to date at least the following developments in pharmacy practice have been or are being studied from a SCOT theoretical perspective: Two different types of patient medication records [11,20], pharmaceutical reimbursement systems [21], quality improvement systems in pharmacy practice [22], and decision-making processes in relation to the partial liberalisation of the Danish pharmacy sector [23]. Studies in pharmacy practice aiming at illuminating development processes of any kind can thus benefit from a specific social constructivist approach,

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