Views on the role of community pharmacy in local communities: a case study of stakeholders' attitudes.

OBJECTIVES: To investigate the view of the role of community pharmacy by selected stakeholders in local Danish communities.
METHODS: A mixed method approach combining qualitative and quantitative methods was used: observations at pharmacies, questionnaires for pharmacy staff and customers, and interviews with pharmacy owners, general practitioners (GPs) and politicians. Role theory was the theoretical foundation. Data was analyzed using directed content analysis and descriptive statistics.
RESULTS: Five Danish towns were visited, resulting in five pharmacist interviews, 48 questionnaire replies from pharmacy staff, 59 customer interviews, three GP interviews and four interviews with local politicians. All stakeholders found the pharmacy to have a medical focus, although to a differing degree. While pharmacy staff and GPs had the greatest knowledge and expectations regarding the pharmacy staff's level of medical knowledge, local politicians had the least. Pharmacy staff wanted to take on more responsibility. Customers generally considered the pharmacy part of the healthcare sector with a high level of knowledge on medications. GPs' attitudes appeared to be related to the amount of communication between GP office and pharmacy. Local politicians interviewed did not seem to be aware of the competencies within the pharmacy, but once informed were open to using the pharmacy as an integrated part of the local healthcare system.
CONCLUSIONS: There was general consensus between stakeholder groups that medicine is the main area of focus at the pharmacy. However, investigated stakeholders did not appear to be aware of the full extent of the competencies within the pharmacy, and there was a general lack of consensus about the services the pharmacy should perform. If the competencies within the pharmacy are to be fully utilized, the pharmacy must not only tell but also show the local community what they can do.

INTRODUCTION

The profession of community pharmacy has undergone a paradigm shift from focus on the manufacturing of medicines to being a place for distribution and counseling.1,2 For example in the form of health-related services, such as the Danish inhalation check service. Many studies have sought to explore the current role of the community pharmacist.3,4,5,6,7,8,9,10,11 Thus the views of pharmacists, customers and general practitioners (GPs) on the role of pharmacists have been described in the international literature.

Overall, literature depicts two main views on pharmacists by pharmacy customers: the role of the pharmacist as an important stakeholder in healthcare, and the role of the pharmacist as a store employee.8,12 These are also the two views presented by politicians.13,14 Jose et al. and Kelly et al. found that customers consider pharmacists to be healthcare professionals at the same level as GPs.6,7 Jose et al further found that 80% of customers considered pharmacists to be experts on medicines.7 A Danish study has shown a correlation between the provision of health-related services and an increased view of pharmacists as healthcare professionals.15

Pharmacists see themselves as having many different identities, but they consider their main role to be that of medicines experts with tasks involving distribution, counseling and checking for medication errors.4,5,16 Other studies have further found that there is a lack of consensus regarding the expectations about pharmacist competencies, with pharmacists valuing their competencies higher than other stakeholder groups.3,17

Studies have shown that GPs generally appreciate pharmacists’ medical knowledge and their aid in prescription and interaction control.3,18 Bidwell and Thompson found that GPs appreciate being contacted by pharmacists regarding potential medical problems, and that a personal relationship is important as part of the impetus to enter into professional collaboration.18

While many studies have focused on the role of the pharmacist, few if any studies have focused on the role of the pharmacy organization as a whole in a local community.

The Danish pharmacy system

Only pharmacists are allowed to own pharmacies in Denmark, and then only one main pharmacy, but up to eight other pharmacy departments in a radius of 80 km of the main pharmacy.

Danish pharmacies have two main types of staff. Pharmacists, with a five-year university degree and pharmaconomists (Danish pharmacy technicians with a three-year education) and students of both educations. These types of staff will henceforth be referred to as pharmacy staff.

The Danish community pharmacy sector has undergone many changes, with focus on liberalization in the past few decades.19 Services such as dispensing prescriptions, once the sole task of pharmacists, are now a shared responsibility between pharmacists and pharmaconomists. While services that used to be reserved for the pharmacy are now slowly being shared with other actors such as retail stores.19 This is the case for some over-the-counter products and veterinary products. The most recent changes are 1) the introduction of ‘medicine conversations’, a health service giving newly diagnosed chronic patients the right to a conversation with a pharmacist regarding their concerns about their new treatment, 2) the introduction of increased competition within the pharmacy sector and 3) the introduction of limited prescribing rights for pharmacists.

The Association of Danish Pharmacies has a vision of Danish community pharmacy staff as the medicine experts of society, the experts who ensure health and optimal use of medicines.20 The views on the current role of Danish pharmacies could provide points of action for achieving this role. Thus, the aim of this study was to investigate the view of the role of the local community pharmacy by pharmacy staff, pharmacy customers, local GP’s and local politicians.

Theory

Role theory was used as the theoretical foundation for this research. According to Biddle and Thomas, the role of an organization is determined by the opinions and roles of stakeholders relevant to the organization. The role of an organization, is hence determined by social norms, demands and rules: roles are not only defined by the individual but also by other actors and the interactions between them.21 To investigate the role of the pharmacy as an organization, according to Role theory, one must acknowledge the impact of other stakeholders. The model by Guirguis and Chewning regards the impact of interaction between individuals and their expectations about the interactions on role perception.22 This model also shows that the role of an organization is dependent on the people in contact with the organization. The model by Sabater-Galindo et al regards factors relevant to the perceived pharmacist image.23 The models presented by Guirguis and Chewning as well as Sabater-Galindo et al. were used to create questionnaires and interview guides that would aid in illuminating the role understanding of the pharmacy by different stakeholder groups.22,23

METHODS

Study design

The study was designed as a descriptive case study, based on a mixed method approach involving the following methods: interviews, questionnaires and observational studies. Five small towns were chosen to act as cases. The choice of small towns as cases was made due to the closer proximity between the chosen stakeholders and pharmacies than in large urban areas with several pharmacies and GP practices (see inclusion criteria further down). It was assumed that stakeholders in small towns would be more likely to have a personal relationship with their pharmacy and a deeper understanding of the competencies within the pharmacy, than if the study had been conducted in a big city. The towns were chosen to represent different parts of Denmark in order to get a diverse sample, and by the following criteria: the town had to have less than 10.000 citizens, be more than 30 km to the nearest big city (Odense, Aarhus, Aalborg, Copenhagen) and have only one pharmacy in the town.

Four stakeholder groups were chosen for this study. They were chosen since they were considered the stakeholders with most power in determining the role of community pharmacy in small towns. The stakeholders chosen were:

pharmacy staff, ie. pharmacists and pharmaconomists

pharmacy customers

GPs and

local politicians

Pharmacy staff was for the sake of this study considered a homogenous group. Danish pharmaconomists have a high level of pharmacological expertise and both groups are counselling customers at the counter, with customers rarely knowing the difference between them. This was also limiting possible confusion when discussing competencies within the pharmacy with the other stakeholders.

Local politicians were included in this study since they have the power to e.g. involve pharmacy staff in the education of local health personnel and medicine management in retirement homes.

Table 1 shows the data collection methods used for the stakeholders, how questions were developed, and pilot tests.

Table 1

Methods and themes used for each stakeholder group

Stakeholder group	Customers	Pharmacy	GPs	Politicians
Method used	Structured interviews, including both closed and open-ended questions,	Questionnaire sent to all pharmacy staff + semi- structured interview with pharmacist or pharmacy owner	Semi-structured interview	Semi-structured interview
Method development*	Literature search + then matching with other stakeholder groups + two rounds of pilot studies	Questionnaire: literature search + two rounds of pilot studies Interview: Literature search + theme matching with questionnaire	Literature search + theme matching with other stakeholder groups	Literature search + theme matching with other stakeholder groups
Pilot study 1	Two test persons. Questionnaire used as structured interview guide	Four pharmacy employees used as test persons. Questionnaire used as an interview guide	NA	NA
Pilot study 2	Two test persons. Questionnaire used as structured interview guide	Response from five pharmacy employees, questionnaire sent out electronically	NA	NA
Themes	Expectations of the pharmacy, factors affecting choice of pharmacy, view on the pharmacy, view on potential pharmacy services	Questionnaire: View on the pharmacy, competencies and duties at the counter, the ideal pharmacy Interview: role of the pharmacy in society, view of the pharmacy by society, collaboration with surrounding health care sector, the ideal pharmacy	Relationship to the pharmacy, competencies of the pharmacy, possible increased use of pharmacy in society	Role of the pharmacy in the community, competencies of the pharmacy, use of pharmacy by the county, role of the pharmacy in an ideal world

Theme matching means that themes were compared across stakeholders to ensure data would be comparable between stakeholder groups.

Participant recruitment and data collection

Between three and five days were spent in each small town, with the first author visiting the pharmacy for two to three days and seeing politicians and GPs on the other days.

Pharmacy staff: Pharmacies were contacted by email and a follow up phone-call was made approximately one week after the email was sent. A total of six small town pharmacies were contacted about participating in the research project. One declined due to lack of time, leaving a total of five visited pharmacies. Questionnaires were sent out electronically and pharmacy staff was asked to answer the questionnaire before the pharmacy visit. When at the pharmacy, the researcher spent time observing everyday interactions with customers at the counter (results not shown), talking to pharmacy staff, and interviewing a leading pharmacist or pharmacy owner. Pharmacist interviews were conducted when time opened up at the counter and lasted between fifteen and forty minutes.

Pharmacy customers: Customers were recruited for participation at the counter by pharmacy staff at each pharmacy. A note describing the study was placed at each counter and pharmacy staff was instructed to ask all customers if they would be interested in participating (consecutive sampling). The interview then took place either at a far end of the counter or in a separate room at the pharmacy. At least one day was spent interviewing customers at each pharmacy.

General practitioners: There was only one GP clinic in each city. GPs in each town were contacted via telephone to explain the project and a follow-up email was sent with a more in-depth description of the study. The interview guide for GP interviews was created with the intention that the interview would last ten minutes, corresponding to an appointment with a patient. This was to aid recruitment. Interviews took place at the GPs’ offices in order to make it more convenient for them to participate. Interviews with GPs took between six and seventeen minutes.

Local politicians: Two local politicians from each town were contacted, one from each political wing. Politicians were chosen on the basis of the criteria that they were currently members of the town council and lived in the town of the pharmacy visited. The focus on a local connection to the pharmacy was valued as more important for the research than in-depth knowledge of the health policies of the municipality, thus interviewed politicians did not necessarily have health as their main area of focus in their political work. Interviews took place at a location of the interviewee’s choice. Interviews lasted between fourteen and forty-five minutes.

Methods of analysis

All interviews were recorded and transcribed, except for two customer interviews where customers were not comfortable with recording. In these cases, answers were noted by hand. All data were analysed using directed content analysis, where themes and coding schemes for analysis are decided on the base of existing literature.24

Quantitative data from interviews and questionnaires was analysed using descriptive statistics.

Ethics

According to Danish regulations, ethical approval was not required. However, ethical considerations were met. Measures were taken to safeguard participants’ confidentiality. All participants gave informed consent.

RESULTS

Data were collected from five towns (A-E) geographically spread out in Denmark. Table 2 gives an overview of the number of respondents in each town and per stakeholder group.

Table 2

Overview of amount of data collected during the study. More than one pharmacy department was visited for pharmacies B and C.

Town	Customer interview	Pharmacy questionnaire (responses)	Pharmacy interview	GP Interview	Politician interview
A	10	10	Pharmacist	0	1
B	8	5	Pharmacy owner	1	1
C	19	8	Pharmacist	1	0
D	12	14	Pharmacy owner	0	2
E	10	11	Pharmacy owner	1	0

All stakeholders will hereafter be designated according to the town they come from: stakeholders in town B, pharmacy B, GP B, politician B, etc. Two politicians were interviewed in town D, and they are designated politicians D1 and D2.

Views on the role of the pharmacy were similar within all stakeholder groups from the five towns, and different between stakeholder groups. It can generally be stated that stakeholder groups with more contact with the pharmacy had a deeper level of understanding of the competencies within the pharmacy, and thus higher expectations about the role and services of the pharmacy. The range extended from pharmacy staff with the highest expectations to GPs to customers to local politicians. The overall results of this study can be summed up as shown in Table 3.

Table 3

The views of different stakeholder groups on the investigated questions

	Customers	Pharmacy	GPs	Politicians	General view
Role of the pharmacy	NA	Drug distributors and counsellors	Distribution center and to some extent a health professional collaborator	Creates a sense of safety in society. Distribution and counseling on drugs	Distribution and counseling on drugs
Collaboration with GPs	Expected to a high degree	Primarily good	Primarily good	NA	Good collaboration with GPs
Business vs healthcare	Both	More healthcare than business	More healthcare than business	More business than healthcare	Both, but emphasis on healthcare
Competencies of the pharmacy	Good medical knowledge but less knowledgeable than the GP	High medical and health-related knowledge	Safety net for prescription ‘errors’ and interactions, and competent counsellors ⟶ good medical knowledge	Specialized medical knowledge	Good medical knowledge
The future pharmacy	Divided in willingness with regard to an expanded pharmacy role	More focus on drugs and becoming an integrated part of the healthcare system	Open towards more collaboration	The same as today, but open to more collaboration	NA

General overview

Except town A, all towns were affected by urbanisation, with empty and dilapidated houses, and the closing of many stores in the towns during the last couple of years. Towns A and E were tourist towns, so they had more town life than the other three. Pharmacies B, C, and D were country pharmacies and thus had bigger veterinary departments than the other pharmacies. Pharmacy B was located in an area where a relatively big part of the citizens was living in social housing situations, hence dose-dispensed medication was a big part of their turnover.

The majority of customers interviewed were female (70-83%), locals (75-100%) and retired or receiving social help for example in the form of sick leave (50-88%). Between 75 and 95 % of customers took medications on a regular basis and between 75 and 92 % always used the same pharmacy.

The views of pharmacy customers

Customers across towns agreed that the pharmacy was part of the healthcare sector. Most customers also acknowledged the pharmacy as a private business, although some expressed the concern that economic factors might weigh more in the minds of pharmacy staff than benefits to the customer. Pharmacy staff were highly acknowledged as experts in medicine, but for the most part not considered to be health professionals at the same level as GPs. Approximately half of customers in towns A-C considered pharmacy staff to be health professionals at the same level of GPs, while in town D this was one third and in town E 80 percent. This difference in views was also reflected in the willingness to let pharmacy staff access medical files: whereas most customers (90 percent) in town E thought this would be a good idea, town A followed with 70 percent of customers, and towns B-D with 50 percent.

In general, customers would not accept pharmacy services that required a deeper level of medical knowledge and understanding, such as medicine conversations and vaccinations, but would accept services that did not require this, such as advice on health improvement without the use of drugs or advice on minor ailments. The clear outlier here was pharmacy E, whose customers were keen on accepting all types of health services, even those requiring a deeper medical understanding. Customers were asked about their expectations of the pharmacy on a five-point Likert scale. Results are shown in Table 4. Services shown in italics refer to a standard deviation above 1, indicating a lack of complete consensus on the expectancy about the service.

Table 4

Customer expectations about the pharmacy. On a 5-point Likert scale, customers were asked about the degree to which they expected certain services. Services generally expected are defined as being 4 or above on the Likert scale, while services generally not expected are defined as being below 4 on the Likert scale. Services marked in italics had a standard deviation above 1.

Services generally expected	Services not generally expected
•The pharmacy is easily accessible, I can always enter and expect them to take the time to answer my questions	•The pharmacy can help me understand my medical treatment
•The pharmacy collaborates with my GP	•The pharmacy can tell me what to do if I forget to take my medication
•The pharmacy can tell me how to take my medication	•The pharmacy can answer questions about my disease
The pharmacy can tell me how to store my medication	The pharmacy can tell me how to handle side effects
•The pharmacy can tell me about side effects	•The pharmacy can keep track of drug-drug interactions
•The pharmacy can help me regarding the use of my medical devices	•The pharmacy can advise me on natural remedies
•The pharmacy can advise me on the use of my OTC drugs
•The pharmacy can advise me on creams

“Our role is to make sure customers get the best possible treatment with their drugs, where we want to ensure that they understand how to take them”. Pharmacist E

The views of pharmacy staff

The above quote shows the general role perception of the pharmacy staff in this study. They consider themselves to be medical experts who not only ensure that treatment is correct, but also that their customers understand the treatment.

All pharmacy staff identified themselves as being part of the healthcare system. They also acknowledged being a private business, but did not identify as sales personnel in a store. According to pharmacy staff, the most important tasks for a pharmacy are patient counseling, ensuring optimal use of medication and patient safety. This was also reflected in the services that occupied most of the personnel’s time: dealing with customers and dispensing prescription medicines. Pharmacy staff was asked about a range of counter-related services to determine if they were considered services in which the pharmacy was competent and had a professional duty to perform, and if these services were performed. These services are shown in Table 5.

Table 5

Counter-related services. Pharmacy staff were asked to rate themselves on a 5-point Likert scale with regard to the following 12 counter-related services, the degree to which they 1) considered themselves competent to offer the service, 2) whether the service was their professional obligation to perform and 3) the degree to which they performed the service in daily practice. The total mean scores are shown in parentheses.

Explaining how the medication works (4.33, 4.52, 3.92)	Counseling on OTC drugs (4.66, 4.77, 4.64)
Counseling on side effects (4.10, 4.33, 3.65)	Counseling on creams (4.19, 4.09, 4.11)
Checking for drug-drug interactions (4.38, 4.50, 3.81)	Checking for right drug in right amount (4.67, 4.83, 4.68)
Counseling on food-drug interactions (3.98, 4.42, 3.58)	Advising about correct use (4.69, 4.83, 4.58)
Explaining about legal matters such as reimbursement (4.66, 4.62, 4.45)	Uncovering wrongful use (4.13, 4.65, 4.02)
Counseling on supplements (3.85, 3.94, 3.64)	Helping customers who used to take their medication incorrectly to use it correctly and understand why it is important to do so (4.54, 4.88, 4.42)

Pharmacy staff considered the majority of the services to be obligations at which they were competent, were obligated to perform and did perform. With the exception of pharmacy D, only the service of counseling on supplements rated below a 4 on the 5-point Likert scale on all three counts.

Pharmacy staff was asked what the pharmacy would be like in an ideal world. Answers revolved around a higher focus on drugs and better collaboration within the healthcare sector.

“Well, I would like it if we could get money for distributing drugs, because that’s not what we live from today. I would like it if we didn’t have to focus so much on free trade goods, if we could be allowed some money for the time spent on counseling”. Pharmacist C

“A better link between all parties in the healthcare system. Well, it’s kind of the pharmacies and the hospitals and the GPs [uses hands to indicate boxes]. It’s not the healthcare sector; well it is, but it’s kind of grouped”. Pharmacist A

The views of General Practitioners

Three GPs were interviewed. Their degree of collaboration with the pharmacy ranged from no contact to daily contact. The primary reason for not participating was lack of time. Since the towns visited only had one GP clinic, there was no way of getting more GP’s in the study.

As can be seen from Table 6, the higher the degree of collaboration between pharmacy and GP, the more positive the view of the GP about the competencies and future use of the pharmacy. All GPs viewed the knowledge and counseling of the pharmacy as beneficial to their patients, especially in situations such as OTC purchases where the GP was not involved. The view about the health services provided by the pharmacy was diverse, ranging from the attitude that the pharmacy should not provide health-related services, to the attitude that it would be of great help to the GP if the pharmacy was more involved.

Table 6

Views of GPs on pharmacies and pharmacy competencies.

	GP B (no collaboration)	GP E (good collaboration)	GP C (high degree of collaboration)
Role of the pharmacy	Private business, a distribution center	A professional healthcare collaborator	A distribution center and professional healthcare collaborator
Competencies of pharmacy personnel	Basic counseling and checking for obvious interactions	Safety net regarding side effects, dose, and interactions	In-depth knowledge on medication and side effects, beneficial to both patient and GP
Attitudes towards pharmacy- provided health services	The pharmacy should stick to distributing	Beneficial if GP receives information and is involved in what happens to the patient	Highly relevant and would be helpful to the GPs’ workload
Where is the pharmacy essential	OTC counseling where the GP is not involved	Counseling on devices, OTC products and dietary supplements	NA

The views of local politicians

The politicians interviewed were from different political parties ranging from mid left parties to mid right parties. None of the interviewed politicians had health as their primary focus in their political work. Politicians generally viewed the pharmacy as a private business. However, all acknowledged that the level of medical knowledge and service at the pharmacy was unique for a business. Politicians viewed the pharmacy as having a role in the making and shaping of communities, providing a sense of security for people to be able to get medication and counseling, and creating a customer base for other stores in the town.

At the end of most interviews, the politicians began interviewing the researcher about the competencies of pharmacy staff and projects occurring elsewhere in the country. When informed about the competencies that lie within the pharmacy and projects run in other municipalities, politicians were open to the idea of using the pharmacy as a more integrated part of the local healthcare system:

“It’s an untapped potential that could be incorporated in all of these things [services for chronic patients]”. Politician B

“Well, I think that if the pharmacy approaches us with something …and it’s not too expensive, then I can’t imagine we would say no”. Politician D2

DISCUSSION

All stakeholder groups, except for local politicians, viewed the pharmacy primarily as a part of the healthcare system. This indicates that stakeholders with close contact to the pharmacy acknowledge the professional knowledge within the pharmacy. This supports the theory proposed by the authors when creating this study, that closer proximity to the pharmacy increases the knowledge of the competencies. It is further interesting to note that the stakeholder group representing the law-making body, and thus the body with the greatest impact on the future role of the Danish pharmacy, which is highly regulated by law, had a different view on the fundamental role of the pharmacy than all other stakeholder groups. Further studies should be made to investigate if this view of the pharmacy as a private business is general to politicians at all levels, and all political parties. If so, pharmacy organizations should take public action to show politicians that they have a role in the healthcare system - if indeed this is a role they wish to have.

The results give a clear indication that although customers consider the pharmacy as part of the healthcare system, they lack a clear definition of what they can expect from their local pharmacy. Not only are many of the points on the ‘services not generally expected’ column services the pharmacy is indeed able to perform, but many of the services are shown in italics, indicating there is no clear perspective on the role and competencies of the pharmacy. This is in keeping with the views of one of the interviewed pharmacists, who stated that customers were not aware of the full scope of competencies within the pharmacy. This view of the lack of awareness of pharmacy competencies has also been shown by Saramunee and colleagues.3 This study also pointed to uncertainty about pharmacy competencies, showing a lack of great interest in health-related services that would mark the pharmacy as a fully integrated part of the healthcare system. A similar trend has been shown in a study by Iversen and colleagues.25

Since pharmacy staff identifies themselves as medicine experts with a key role in counseling and distributing medicines, pharmacies should make an active effort to show customers the full scope of their competencies. This would encourage customers to see pharmacy staff in the role with which they identify.

This study indicates that the more collaboration between GP and pharmacy, the more positive is the attitude of the GP towards extended pharmacy services. In order to have GPs accept extended pharmacy health-related services, this study indicates that the pharmacy should:

Establish (or build on the current) collaboration and personal relationship with GPs

Ensure GP involvement in health-related services, and

Ensure a proper registration system that enables GPs to keep track of the services provided to their patients at the pharmacy.

Few if any studies have investigated the view of local politicians about the use of the pharmacy.13,14 This study therefore provides new knowledge on the view of community pharmacy in small towns in Denmark. Although politicians were not aware of the scope of competencies within the pharmacy, when they were informed about them, they were open to the idea of increased collaboration with the local pharmacy. Thus, if pharmacies want to have more responsibility in the local healthcare system, they should contact politicians about establishing such collaborations. This might be easier than most pharmacy staff thinks. Since, at least some, politicians already view the pharmacy as a key player in the making of the general community, one could assume that this, using the arguments of creating greater security, more health and more life in the city, would appeal to an already existing image in the politician mindset.

Although this study showed a high degree of similarities in views within stakeholder groups across towns, one town stood out. Pharmacy customers in town E were more likely to value pharmacy staff as health professionals at the level of GPs and were more comfortable allowing pharmacy staff access to medical files than customers at pharmacies in the other investigated towns. This view was also seen in the interview with GP E, who was keen to acknowledge the role of the pharmacy as a safety net for prescription control, interactions and OTC purchases. There were no obvious contextual factors in which pharmacy E differed from the other pharmacies. One possible explanation could however be that the pharmacy owner focused on healthcare and created a trusting environment where employees felt their role as healthcare staff was important. For example, the staff at pharmacy E’s preferred method to update their knowledge was self-study, which allowed them to concentrate on the needs of customers rather than what might be a ‘hot topic’ for pharmacy staff in general. Since no one reason could be seen for the different view on pharmacy E was discovered, it is likely that it is due to a several of factors.

The results of this study show that communication between the pharmacy and stakeholder groups, as well as information on the competencies of the pharmacy, increase the view of pharmacy staff as healthcare professionals and the desire to use the pharmacy actively in local healthcare. The ‘role through interaction circle’ (Figure 1) shows the positive correlation between interactions and presenting pharmacy competencies and a change in view on the role of the pharmacy.

Figure 1

The role through interaction circle. Showing that roles change when interaction between stakeholders are increased. The circle could be said to be a reversed “care and respect circle” compared to the one presented by Schommer et al.17

This fits well within the concepts of role theory. Guirguis and Chewning presented a model describing the four perspectives present in role theory: organizational, symbolic interactionistic, cognitive and functional.22 The results from this study add a new factor to the cognitive and functional part: the views of others. According to the model by Guirguis and Chewning, pharmacist and patient expectations affect these two perspectives of role theory. Interviews with politicians conducted for this study made clear that information from an outsider about the abilities of the pharmacy can affect their views of e.g. politicians. Since politicians can also act as patients, it could be anticipated that this is true for all stakeholders. Thus, we suggest an addition to the model by Guirguis and Chewning, where the knowledge and expectations of others can affect the views and attitudes of pharmacists and pharmacy users (Figure 2).

Figure 2

The four different perspectives in role theory and how they affect each other [22] with the addition of the effect of others’ experiences with the pharmacy. This addition was based on the first authors experience during the politician interviews were attitudes towards the pharmacy was changed when informed of the competencies within the organization. The figure further deviated from the original by the change of “pharmacist” to “pharmacy staff”.

If pharmacies want to achieve a more active role in their local healthcare systems, they should increase interaction with their local healthcare system, GPs and politicians, as well as increasing focus on presenting their competencies to their customers.

In order to achieve the role pharmacy staff wants for the pharmacy, they should focus on the following three things:

Make customers aware of what they can expect

Build a professional relationship with local GPs

Build relations with local politicians

Role theory can help understand the role the pharmacy already possesses in the local environment and give a base for strategical entry points in obtaining a desirable role. By investigating the perceived role from a Role Theory perspective, and then using the interaction circle shown in Figure 1 as a practical tool, pharmacies can work towards the role they wish to have.

Limitations

The first author, who is a pharmacist, primarily designed and collected data for this study, which introduces the risk of bias. However, the second author is not a pharmacist and was involved in all parts of the study except data collection. Combined with the fact that the preparation, collection and analysis of data were inspired by and comparable with current literature, this means that the bias is not considered a great limitation. The small sample size for number of towns and number of stakeholders per town investigated is a limitation to the transferability of the study. More studies should be conducted involving different types of towns/pharmacies. However, this study can provide useful knowledge on subjects to investigate and methods to use if one wishes to perform a similar study in another setting. That customer interviews took place in the pharmacy, could be a limitation as customers might not feel comfortable expressive negative opinions on the pharmacy in this setting. The number of different stakeholder groups should also be considered a possible limitation to this study. There are many more stakeholders relevant for determining the role of the pharmacy than the ones investigated here, for instance veterinarians, media, citizens not using a pharmacy, nurses, other shop keepers etc. However, the stakeholders chosen for this study was considered as most powerful in regards to determining the role of the pharmacy, and thus it is fair to assume that the picture drawn is general.

CONCLUSIONS

There is general consensus between the investigated stakeholder groups that medicine is the main area of focus at the pharmacy. However, the investigated stakeholders did not appear to be aware of the full extent of competencies within the pharmacy, and there was a general lack of consensus on the services the pharmacy should perform and the role it should play in society. Thus, the community pharmacy does not have a clearly defined role in the local context. If the competencies within the pharmacy are to be fully utilized to create a more defined pharmacy role as the pharmacy staff in this study want, it is up to the pharmacy to tell as well as show their local community and relevant stakeholders what they can do. The perspective of Role Theory can be used better understand the processes underlying how pharmacies are viewed, also in relation to other actors.