The nature of conflict in community pharmacy - A pilot study of pharmacists' experiences during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has caused changes that disrupted the status quo of society. As a result, the level of conflict in community pharmacy has increased significantly. With existing conflict research more focused on the management of conflict, it is important to direct attention towards understanding the nature of conflict. This understanding will allow for informed resources to be developed to guide practice, decreasing the occurrence of and negative effects of conflict.
OBJECTIVE: This research explored experiences of pharmacists working in community pharmacies, to identify the occurrence and nature of conflicts which may have been motivated by changes resulting directly or indirectly from the COVID-19 pandemic, to provide directions for future research into the nature of conflict.
METHOD: Person-to-person semi-structured telephone interviews were conducted. Transcripts were analysed using inductive reasoning to identify themes.
RESULTS: Thirteen pharmacists agreed to participate in this study and 9 were interviewed. Analysis revealed 7 themes that described the causes, contributors, management, outcome, and essence of experienced conflict. A model that incorporated existing theory and themes derived from this study was developed to facilitate understanding of the nature of conflict in community pharmacy during the COVID-19 pandemic.
CONCLUSION: Conflict in community pharmacy settings follows a defined model with multiple interrelated themes. Guidance from this model may assist pharmacists in reducing occurrences of dysfunctional conflicts during their practice.

Context

Coronavirus disease 2019 (COVID-19) is caused by the highly infectious virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak of COVID-19 has spread quickly across the globe and was declared a pandemic by the World Health Organization (WHO) on the 11 March 2020. As of 9 August 2021, there have been 200,840,180 confirmed cases of COVID-19 globally with 4,265,903 deaths. Following the declaration of COVID-19 as a global pandemic, various public health strategies and responses were implemented by governments worldwide, including population-wide lockdowns, social distancing and other restrictions. These changes caused major disruptions to daily life and resulted in a significant increase in anxiety, stress, and other mental health issues.

Despite the increased risk of exposure to COVID-19 for frontline health workers,4, 5, 6 pharmacists continued to provide care and service to the wider community. , , During the early period of the pandemic, there were numerous reports that evidence a marked increase in incidents of customers displaying abusive and other inappropriate behaviours in community pharmacies worldwide.7, 8, 9, 10, 11, 12, 13, 14 For example, a late April 2020 survey performed by the Canadian Pharmacists Association revealed that 73% of community pharmacists (N = 1654) reported an increase in abuse and harassment from customers since the pandemic began. While these reports highlight the significant challenges faced by community pharmacists, there is a notable absence of discussion regarding the nature of conflict and how conflicts that occurred were resolved. Considering that the pandemic has caused significant disruption to the status quo, resistance to change and subsequent conflict are a natural and expected result.

Background

Change, and its relationship with conflict, have been discussed in the literature for many years. , Currently, separate models are used to describe the experience of change and the consequent process of conflict. One perspective used to understand the range of emotions that individuals may experience in response to change is the non-linear Kübler-Ross change curve model, adapted from Kübler-Ross’ five stages of grief model by various authors (see Fig. 1 ).20, 21, 22, 23 This adapted model involves seven phases which individuals transition through, before the change is accepted and internalised into their norm. Phases of the model are named according to the emotional response that occurs, with an increase in personal satisfaction as individuals transition from initial phases into later phases. Individuals may become stuck or continuously oscillate between the different phases of the model (represented in Fig. 1 by the rotating hourglass). Thus, full transition through the model may take years to complete. Conflict is likely to occur during the initial phases (presented as the phases contained in the upper-half of the hourglass in Fig. 1), as the greatest resistance to change occurs during these phases of the model.

Fig. 1

Phases of change model (non-linear).

Conflict is defined as a process where oppositions are expressed or perceived as likely to be expressed by one party to another. A model to describe conflict as a process was first developed by Pondy (1967) and further developed by later authors. , In this model, the occurrence of conflict is divided into five distinct stages (Fig. 2 ). Conflict initiates at the first ‘Latent’ stage with the presence of conflict-precipitating factors classed into three different categories based on their nature: communication, personal variables, and workplace structure. The second stage of conflict occurs when the precipitating factors are recognised. At this ‘Recognition’ stage, those involved define whether the emergent conflict is perceived (i.e. with no emotional involvement) or felt (e.g. experiencing frustration or anxiety regarding the conflict). The third ‘Objective’ stage involves individuals identifying their intentions as to how to manage the conflict, which may involve different approaches or styles of management.

Fig. 2

Stages of conflict model. Adapted from Robbins and Judge.

According to Thomas and Kilmann (1977), there are five common conflict management styles based on the level of assertiveness and cooperation: competing, avoiding, compromising, collaborating, and accommodating. Execution of these intentions using each party's preferred style occurs in the fourth ‘Manifest’ stage. Conflicts may continuously oscillate in intensity until an outcome is reached. In the final ‘Aftermath’ stage, the conflict process is further categorised as either functional or dysfunctional, based on outcomes. Functional conflict produces positive outcomes such as improved work performance. Dysfunctional conflict produces negative outcomes such as decreased team cohesion. Conflicts that lead to functional outcomes usually situate low on the conflict intensity scale in the fourth stage whilst dysfunctional conflicts usually situate higher. In healthcare environments, poorly managed workplace conflict has been demonstrated to result in decreased job satisfaction, work effort, and performance. Under these conditions, staff may experience increased anxiety, fatigue, and insomnia. ,

In addition to ensuring access to and quality use of medications, pharmacists play a key role in pandemic preparedness and response such as disease screening and providing vaccinations. However, whilst pharmacists have experienced increased levels of stress as a result of the pandemic, COVID-19 restrictions have limited the ability of individuals to execute familiar stress reducing strategies such as exercise and interacting socially with others. Consequently, pharmacists have been at greater risk of experiencing conflict and burnout. ,

To reduce pharmacist stress and avoid any hindrances to the provision of pharmacy services and care during pandemics, it is important that the occurrence of conflict in the workplace is minimised and dealt with effectively. This requires an understanding of the fundamental essence, causes, contributors, and consequences of conflict, or simply, the nature of conflict. Current pharmacy literature appears to emphasise the management and resolution of workplace conflict (e.g. models and scales for conflict management)32, 33, 34, 35 with a lesser focus on research into understanding the underlying nature of conflict. Given the disruption and demands associated with the COVID-19 pandemic, there is an urgent need for research aimed at understanding the nature of conflict experienced by community pharmacists, especially during such periods of high social volatility. This knowledge could inform the development of strategies to prevent or de-escalate conflicts in community pharmacies before their escalation results in negative impacts to the function and practice of community pharmacy. Research into the nature of conflict is therefore pertinent and timely.

Aim

This pilot study aimed to explore the nature of conflicts experienced by community pharmacists in Australia, which may have been motivated by changes resulting directly or indirectly from the COVID-19 pandemic. With the purpose of this exploration being to gain preliminary insight into understanding the nature of pandemic-induced conflict in community pharmacy so as to illuminate potential pathways for further exploration.

Method

Given the paucity of literature and research concerning the nature of conflict during a global pandemic, this pilot study took an exploratory approach in attempt to broadly capture and outline key areas for future research. A qualitative, interpretive approach was utilised, a research approach conducted through the understandings of a naturalistic paradigm. Naturalistic inquiry is predicated on a belief that human reality is an experienced or subjective reality; rather than a reality conceived as objective and “out there” to be discovered. Human realities are considered as an emergent outcome of social construction and experience through time. The interaction between participant and researcher can be considered as an experience of mutual influence and meaning-making.

Data collection used qualitative, telephone interview-based methods to gather rich, quality information from the lived experiences of community pharmacists who experienced conflict during the COVID-19 pandemic. Other data collection methods such as observation-based and document-based methods were considered but deemed unviable due to local pandemic-related restrictions preventing close personal liaison with participants.

Purposive and snowball sampling methods were used to identify potential participants. The initial sample population was purposely selected from key regions of Australia where the impact of COVID-19 was expected to result in conflict, e.g. border zones, states with greater incidence of COVID, and states with heavy COVID-related restrictions. Snowball sampling was then utilised to recruit additional participants who had experienced conflict during the course of the COVID-19 pandemic.

The inclusion criteria for this study were: a) currently registered as a pharmacist, including provisional [intern] registration; b) practising a minimum of 25 hrs/week at the same community pharmacy from 1 January 2020 up to 31 January, 2021; and c) able and willing to provide informed consent. Intern pharmacists were included to gain the widest understanding of the nature of conflict experienced by practising pharmacists. Pharmacists practising less than 25 hrs did not meet the inclusion criteria due to concerns of possible incomplete perception and understanding of cases of conflict that occurred in the respective pharmacy due to insufficient exposure to the situations.

Ethical approval to conduct this study was sought and gained (Ref No.: 2020/702) through the institutional human research and ethics committee. Invitations to participate in this study were extended to community pharmacists through the research team's word-of-mouth contacts, as well as contacts with professional Australian pharmacy bodies. Individuals that expressed interest were provided with further information regarding details of the study and asked to provide written informed consent. A time for the interview was then arranged. To garner further interest, participants were encouraged to disseminate recruitment information regarding this study to community pharmacist colleagues. No compensation or remuneration was offered for participation.

A semi-structured interview guide (Appendix 1) was developed to emphasise participant reflection and direct reporting of each pharmacist's personal and professional experience and responses to cases of conflict before and during the highly volatile time of the COVID-19 pandemic. The interview guide was not pilot tested in order to begin data collection of real-time lived experiences soon after research ethics approval.

Interviews were conducted on a “rolling” basis over a five-month period (September 2020 to January 2021) with each interview lasting 30–60 min. Interviews were audio-recorded and the recordings were manually transcribed by the chief interviewer to ensure immersion with the collected data and the maintenance of participants’ confidentiality. Field notes were taken during and immediately after the interviews to assist interview transcription and to ensure understanding and ease of data triangulation between the research team members. Transcripts had participant-identifying information removed and were checked for accuracy by other research team members who listened to the interview recordings whilst reading the transcripts. This process was used to ensure all members were equally immersed in the data to facilitate the identification of connections between each interview and correspondingly derived concepts. Participants were also offered a copy of their interview transcript for review.

Interview transcripts were organised using the qualitative data analysis software NVivo Mac version 20.3.1 to provide members of the research team a software platform for data analysis and storage of the coded data. A thematic analysis was conducted using the analysis framework and processes described by Liamputtong (2016), Nowell et al. (2017), and Roberts, Dowell, and Nie (2019).39, 40, 41 Coded data were checked for accuracy and consistency via independent review from each member of the research team. Any discrepancies and questions with the coding processes and coded data which occurred during any point of data analysis were discussed with the members of the research team until a consensus was achieved. The coding process continued until inductive thematic saturation occurred (defined as the point where incoming data produces negligible new information to address the research objectives, , i.e. no new codes, themes, or sub-themes are able to be identified). (Further methodology details and the COREQ checklist are available in the Supplementary Data.)

A total of 13 Australian community pharmacists agreed to participate in this study. Saturation was observed after the 4th interview with further interviews conducted to verify this saturation threshold. A further 5 interviews were conducted but only a single new code was generated after the 5th interview, with no new codes or themes able to be generated from interviews conducted thereafter. Upon discussion with all members of the research team, interviews were ceased after the 9th interview. Participants included intern, pharmacy manager, and pharmacy proprietor pharmacists located in various localities in Australia. A summary of participants’ basic demographics is presented in Table 1 .

Table 1

Basic participant demographics.

Participant	Gender	Role	Years in Practice*	Location (Australia)
MC1.5MQ	Male	Pharmacist-in-Charge (C)	1.5	Metro QLDa
MS3MQ	Male	Professional Services Pharmacist (S)	3	Metro QLD
MO35CQ	Male	Pharmacist/Proprietor (O)	>35	Major City QLD
MC1.5MQ2	Male	Pharmacist/Pharmacist-in-Charge	1.5	Metro QLD
MM15MQ	Male	Pharmacy Manager (M)	15	Metro QLD
FO15MQ	Female	Pharmacist Manager/Proprietor	16	Metro QLD
FI1UN	Female	Intern Pharmacist (I)	<1	Urban NSWb
FO30RV	Female	Pharmacist Manager/Proprietor	30	Rural VICc
MM23MQ	Male	Pharmacy Manager	23	Metro QLD

* Not included: any previous experience working in pharmacy in non-pharmacist roles.

Note: Participant codes relate to their highest role in the pharmacy.

Queensland, Australia.

New South Wales, Australia.

Victoria, Australia.

Findings

Seven interrelated themes that illuminate how conflicts arose, were experienced, and resolved were developed. The themes also shed light on how conflict can fluctuate, as well as the outcomes that conflict can produce. For ease of discussion, the themes are arranged into four broad categories: causes and contributors of conflict; conflict management and outcomes; essence of conflict; and effect of the COVID-19 pandemic on community pharmacy. The themes are summarised in Table 2 preceding the Discussion section for further clarity. A summary of participants’ experiences in relation to existing conflict models and additional exemplar quotes from participants for each theme are provided in the Supplementary Data.

Table 2

Summary of themes.

Theme 1: Change-derived uncertainty heralds emotional imbalance in individuals. Individuals may exhibit behaviour changes as a result of this emotional stress.

Theme 2: Conflict in community pharmacy is a multi-factorial occurrence

Theme 3: Various strategies are used to manage conflict. There is no sole management method that covers all cases of conflict.

Theme 4: Experience of conflict and its effective resolution increases resilience in all staff and results in a better adapted workplace

Theme 5: The frequency of cases of conflict is associated with the level of change present

Theme 6: Mental health of community pharmacists and other pharmacy staff has been negatively affected by the COVID-19 pandemic

Theme 7: The incidence of conflict in community pharmacy has risen as a result of the COVID- 19 pandemic

Causes and contributors of conflict

Theme 1: Change-derived uncertainty heralds emotional imbalance in individuals. Individuals may exhibit behaviour changes as a result of this emotional stress

All participants indicated the COVID-19 pandemic was unexpected and felt community pharmacies were unprepared to deal with the sudden change caused by the COVID-19 pandemic. Major factors reported to contribute to these feelings experienced by participants in the early days of the pandemic included disruptions in the supply chain and lack of COVID-19 pandemic protocols or guidance which hindered the usual practice of community pharmacy. Other contributing factors reported included: old technologies still being utilised in current workflows (e.g. fax machines); lack of personal protective equipment (PPE); new legislation and government-imposed restrictions disrupting service delivery and business operations; and a large sudden increase in the number of customers due to changes in customer behaviour. A mix of these factors, in combination with the fear of the impact of the SARS- CoV-2 virus and COVID-19 on personal safety and wellbeing, were reported to exacerbate feelings of present and future uncertainty in pharmacy staff and the general public alike. Participants disclosed that this uncertainty appeared to be derived from the rapid change brought about from the impact of the COVID-19 pandemic which removed many social norms and lifestyle certainty originally present, giving rise to feelings of anxiety and fear.

“People often didn't know and would ask us. Like what treatments would work [for COVID-19] or how do I get it, [there's] too much unknown. And I think when people don't know what's going on they basically tend to freak out. They lose control of the situation and it makes people anxious really, not knowing what's going on.” [MC1.5MQ2]

The described emotional stress, a consequence of the change from the norm, was reported to impact people's mental health and behaviour. Participants provided many examples of observed behaviour changes in customers such as the stockpiling of goods and panic buying, and reported customers were irritable, panicked, tense and impatient. Participants speculated that these behaviour changes were coping mechanisms to adjust to COVID-related changes and the accompanying stress.

“We had customers storm out when the wait time was more than 5 minutes.” [MM15MQ]

Theme 2: Conflict in community pharmacy is a multi-factorial occurrence

Participants reported that customer behaviour changes caused conflicts with staff, with reported cases of verbal abuse, physical abuse, and damage to property. Some participants speculated that the failure to meet customer needs was a driving force for conflict. Others reported COVID-related restrictions such as social distancing, purchase quantity limits, customer capacity limits, and access limitations to pharmacy and other healthcare services due to changes in operating hours and conditions of entry were major contributors to the conflicts experienced. Many of these customer-staff conflicts were speculated to be amplified by the stress felt by customers which caused irrational reactions to the changes in the services pharmacies were able to offer during the COVID-19 pandemic.

“… under stress, people don't respond well. So, they take it out on the people on the frontline, which would be me and my staff.” [FO15MQ]

“… conflicts happen because what the patient/customer wants - we can't satisfy their needs.” [MO35CQ]

Another major factor that reportedly provoked conflict was lack of awareness and understanding of the situation by individuals (customers and staff), especially during early stages of the pandemic. Participants’ narratives pointed towards a belief that these changes arose from a lack of understanding about the need for COVID-related restrictions and how these restrictions translated into access limitations to goods and services, e.g. person-to-person contact restrictions preventing delivery of blood pressure testing services. Participants communicated that the lack of individual awareness and understanding may have stemmed from preconceived notions or misunderstandings. For example, belief in conspiracy theories and the influence of the media promoting various interpretations of the situation.

Conflict management and outcomes

Theme 3: Various strategies are used to manage conflict. There is no sole management method that covers all cases of conflict

Participants reported that effective strategies used to manage the occurring conflicts included: problem solving and exploring alternative options; changing the manner of communication; explaining and offering reassurance; escalating the conflict response to a higher level staff member; and having a degree of mental preparedness and flexibility for change in the workplace. Participants described that problem solving and exploration of alternative options de-escalated conflict by meeting the needs of individuals via alternative methods. Communicating in a non-aggressive manner even when faced with conflict or having pharmacy assistants seek aid from pharmacists reportedly allowed aggression levels to dissipate during conflict situations. Explaining the situation and the reasoning behind changes or providing some form of assurance were also reported as effective methods for de-escalating conflicts, allowing individuals to come to terms with or gain an understanding of what was happening.

“… I feel like a lot of customers and patients, what they want is reassurance. So, I found that by giving them that reassurance, “like I know that it’s a really stressful time, we don't know what's going to happen. There's a lot of uncertainty. But this is us basically doing the best that we can for you.” Pretty much giving them options and getting them involved. Also telling them, “just because we can't help you here, doesn't mean we can't get you help from elsewhere.” So, I think stuff like that tends to help calm them down. And I guess they get to see that we're doing our best to help them with their needs.” [FI1UN]

Participants also reported that having a degree of mental preparedness and ability to quickly address and adapt to changes helped maintain the function of the pharmacy and effectively addressed the cases of conflict that occurred. For example, being able to promptly change or adapt existing workflows as well as improve existing conflict management protocols.

Theme 4: Experience of conflict and its effective resolution increases resilience in all staff and results in a better adapted workplace

Whilst changes to the workplace and operations may have resulted in cases of conflict, not all conflict outcomes were reported as dysfunctional. In some cases, conflict had functional outcomes which resulted in a better adapted workplace, reducing the occurrence of certain types of conflict, e.g. updating and training staff on new procedures reduced process and task related conflicts. In addition to improvements in the workplace, experiences of conflict have also reportedly increased levels of resilience in staff.

“I guess I'm a little more confident, in a way, with dealing with conflict now, which I guess is a good thing. Like before, when it only happened once a month/every 6 weeks, you're not very … you're not used to it as much. Then as COVID happened, because it has happened a lot more, we're a lot used to it, we gain a lot more confidence in how to deal with conflict.” [MC1.5MQ]

Essence of conflict

Theme 5: The frequency of cases of conflict is associated with the level of change present

Participants reported that the fluctuation of cases of conflict appeared to correlate with the level of change affecting individuals. Participants perceived a significant spike in conflict in the early stages of the pandemic which aligned with the rapidly evolving situation and implementation of new rules and regulations that affected daily lives. However, as time progressed and individuals accepted and adapted to the changes, conflict levels were reported to begin to decrease back to prior levels. Participants expressed this change may have been due to the fact that people became more aware and better understood the situation as time progressed.

“So, everything that existed before got escalated plus, then you had additional conflict because of the fact patients … I think, turned to anger so much more in COVID times. [Now], I do believe that the customers who have got any social awareness have realised just how valuable we are to them. And they were appreciative of that.” [FO30RV]

Effect of the COVID-19 pandemic on community pharmacy

Theme 6: Mental health of community pharmacists and other pharmacy staff has been negatively affected by the COVID-19 pandemic

The changes brought about by COVID-19 reportedly impacted the mental health and increased the level of work stress for community pharmacists. Participants reported that workplace stress stemmed from changes in workflows, legal obligations to comply with new legislation and government-imposed restrictions, trying to maintain services during the pandemic, and having to deal with an increased influx of customers. The usual methods to manage stress were also quite limited due to COVID restrictions which participants thought resulted in stress building up in individuals without any form of release.

“So, I think in normal times, people would've had circuit breakers away from work to go, “Ah, it doesn't matter. That person was being unreasonable. She's probably going to regret what she said to me. And I'm just going to have a break away from this.” So, nobody really took leave along the way because there was no ability to, you'd be stuck at home only able to go out 1 hour a day … COVID just invaded our whole lives. Not being able to just get together with those friends to debrief …” [FO30RV]

“You find that mentally, you're drained out in many ways because it takes energy out of you to be able to deal with this disappointment or frustration or anger from customers or unhappy customers because it makes you feel down in many ways. It makes you feel as though you haven't done the right thing. It almost makes you think it's your fault.” [MO35CQ]

Theme 7: The incidence of conflict in community pharmacy has risen as a result of the COVID- 19 pandemic

Participants described that myriad of COVID-related changes (e.g. the introduction of telehealth, electronic prescriptions, medicine supply shortages, changes in legislation, and addition of government-imposed restrictions) and the increased stress in individuals, fuelled conflicts in community pharmacy.

“… we tried to get doctors to email us instead of faxing us but they weren't sure what they could do in terms of legal aspects of that … doctors would send things and either it wouldn't be followed up or they would send it and it wouldn't go to the right place, or it would never come through, the technology just wasn't there to support it …” [MS3MQ]

In addition to external conflicts, community pharmacists and pharmacy staff also reported experiencing conflict within the work organisation. This included issues with managing staffing or obligations set in place by the headquarters of some pharmacy franchises.

Discussion

Preliminary investigation into the nature of community pharmacy conflict in the context of the COVID-19 pandemic identified seven interrelated themes. Relationships between conflict and individuals’ emotional responses to change, and its impacts, were uncovered. Participants also highlighted a lack of clear conflict management protocols in their practice settings but this was not the study focus.

Change and its relationship with conflict is well recognised in the literature. , However, current models which attempt to explain the experience of change or the process of conflict do not take into account this relationship and are often viewed independently.

As the findings regarding the essence of conflict concur with the literature on this relationship, the synthesis of two models present in the broader literature (one describing the experience of change,19, 20, 21, 22 and one describing the process of conflict) , into a singular model to describe the lived experience of conflict in community pharmacy practice is proposed.

A model of the lived experience of conflict for community pharmacists

Mentioned earlier, the adapted Kübler-Ross Model (KRM)19, 20, 21, 22 proposes that as individuals experience change, emotional fluctuations occur. Under this model (See Fig. 1), individuals usually begin at the shock phase and end at the internalisation phase. However, as the model is non-linear, the phases and corresponding emotions that an individual can experience aren't consecutive; instead, individuals may fluctuate or cycle between certain phases before progressing towards later phases. During these phase fluctuations, conflicts can occur both internally or externally as individuals respond to the change.

Comparatively, the linear five Stages of Conflict Model (SCM) , proposes that conflict is experienced through five distinct stages with each stage being consecutive. Under this model (See Fig. 2), latent conflict-precipitating factors in the situation trigger a response in individuals resulting in conflict. This conflict would then fluctuate in intensity until a conflict outcome is determined. Due to the relationship between change and conflict demonstrated in the literature and the findings relating to the essence of conflict, synthesis of the two models could occur despite their differences in linearity (See Fig. 3 ).

Fig. 3

Model for the lived experience of functional and dysfunctional conflict.

Using this lens, participants' experiences of conflict could be described by the synthesised model. For example, participants' narratives mentioned in the causes and contributors of conflict section of the findings described that customers initially felt overwhelmed and uncertain of the future (KRM shock phase). As time progressed, there was an observable change in customer behaviours such as panic-buying medications and goods such as hand sanitiser in attempts to “survive” through the pandemic, as well as some customers having a distorted perception of the pandemic due to the influence of the media and belief in conspiracy theories (KRM denial/negotiation phase). Some customers were abusive when they didn't understand why their desires and needs were not met (KRM frustration/anger phase). During this time period, individuals also felt varying levels of fear and anxiety (KRM depression phase).

These phases of the Kübler-Ross model directly relate to and oscillate between the first three SCM's stages of conflict. The customers' emotions experienced in the described phases of the Kübler-Ross model were thought by participants to be resulting from restriction to the customers' access to healthcare due to COVID restrictions and their emotional state (conflict-precipitating factors in SCM's latent stage). Participants recognised the lack of staff and supply to meet the increased demand (SCM recognition stage), and the response of the other pharmacy staff in handling customer demands (intentions of the parties involved in SCM's objective stage) contributed to the oscillation of customers' emotions through the phases of the Kübler-Ross model.

Whilst these emotional responses corresponding to the described KRM phases mainly occurred during the first three SCM stages of conflict, they could also occur during the SCM's fourth (manifest) stage of conflict before transitioning to the later phases of the Kübler-Ross model. At the SCM's fourth (manifest) stage of conflict, the impacts of the change in customer behaviours were felt by the participants' experience of increased abuse from customers, stock shortages, and having increased communication between staff and other health professionals to manage the change. Progressing through the SCM's fourth and fifth (aftermath) stages of conflict, participants believed customers began to accept the idea of a “COVID normal” (KRM acceptance phase), incorporating better hygiene practices and learning to cope with the new COVID-related change in their lifestyles (KRM incorporation phase), and proceed with the new “COVID normal” lifestyle (KRM internalisation phase). Whilst the emotions from the later KRM's phases occur and oscillate in the SCM's fourth and fifth stages of conflict, the KRM internalisation phase solely occurs during the final SCM's manifest stage of conflict and usually results in the conflict ending with a functional outcome.

However, not all conflicts experienced by participants resulted in functional outcomes. For example, the dysfunctional outcome of customers storming out contrasts with the functional outcome of increased personal resilience in staff. Methods used by participants in attempts to guide conflicts to functional outcomes (such as providing assurance to customers) were demonstrated in the conflict management and outcomes section of the findings. While some conflict narratives from participants described individuals being able to progress through situations of conflict and change to a new internalised but functional aftermath, it was also observed from the narratives that some individuals (staff and customers) can become trapped in the more negative emotional consequences if they fail to progress towards the later acceptance phase of the Kübler-Ross model. From the findings, it was observed that where conflict experiences involved parties that were unable to progress to later phases of the Kübler-Ross model, dysfunctional outcomes to the conflict usually occurred, as a true resolution to the conflict did not occur. Hence, Fig. 3 provides a comparison of the emotional progression of individuals between cases of functional (on the left) and dysfunctional (on the right) conflict.

In the cases of dysfunctional conflict described in the participants' narratives (e.g. customers storming out, staff taking leave), the initial negative emotional reactions towards change appeared to be unable to shift to the later more positive emotional reactions, and thus, an increase in personal satisfaction did not occur. This was in contrast to the other observed occurrence of conflicts by participants, where the parties involved were able to successfully progress through the phases of the Kübler-Ross model to reach the later phases of acceptance, incorporation, and internalisation. Thus, the initial negative emotions towards change were able to shift to the later more positive emotional responses so an increase in personal satisfaction occurred as a result of the conflict. In the described cases of functional conflicts, functional outcomes usually occurred as conflict management and resolution proceeded with good intentions from the parties involved. The concept of the emotional response to change being directly associated with the experience of conflict (exemplified in Fig. 3) was present in the participants’ narratives of conflicts with customers, staff, and other health professionals; appearing to apply to all categories of conflicts experienced in community pharmacy.

Aligned with theory and models present in existing literature, this study has demonstrated that conflict during the COVID-19 pandemic as experienced by pharmacists, is perceptibly associated with change, with change acting as a catalyst for conflict. Thus, this pilot study tentatively indicates the Stages of Conflict model and the adapted Kübler-Ross model could be synthesised to create a model that reveals the process of experiencing conflict in community pharmacy and the nature of conflict (see Fig. 3). Due to the preliminary nature of this finding, further research is advocated to verify and validate this model.

Directions for future research

Concurring with existing literature, this study has indicated that change appears to be a catalyst for conflict. The COVID-19 pandemic is an example of a high volatility situation where widespread change has materialised in society. Other examples of high volatility situations which can result in widespread change in society include natural disasters, war, and situations of widespread disruption (e.g. global drug shortages). , During these situations of disorder, pharmacists are known to play an important role in maintaining order and function, offering aid and other services in addition to maintaining their usual practice.44, 45, 46 Using the findings from this study as a foundation, it would therefore be valuable for future research to explore the impacts of the disruption and consequent conflict on community pharmacists and pharmacy, in relation to the scale and reach (e.g. global versus local) of the disruption. This future research could possibly allow for better disaster response planning and guidance protocols for pharmacists during times of need.

As aimed, this pilot study has provided new insight into the nature of conflict as experienced by pharmacists during a global pandemic. However, the validity of the model and themes produced from this study require comprehensive validation. It is suggested that a follow-up study with an international sample is conducted to validate the applicability of the models and themes from this study for broader pharmacy settings (e.g. hospital pharmacy settings, pharmacies in countries other than Australia, etc.), and other health professions.

At the time of this study, the COVID-19 pandemic had not concluded nor has the long-term impact of COVID-19 on community pharmacy been identified or recognised (e.g. the role of community pharmacy in COVID-19 vaccination rollouts and any consequent issues and conflicts). Thus, it would be important for future research to seek to identify the continued impact of changes resulting from the COVID-19 pandemic on community pharmacy conflict, as the pandemic and its consequences continue to unfold.

Importance of the findings to professional practice

This study has provided insight into the causes, contributors, and consequences of pharmacy conflict and presents a model for the lived experience of conflict in community pharmacy settings (see Fig. 3). The themes presented also provide an insight into the nature and development of conflict in these settings. This information may assist professional pharmacy bodies in the development of strategies and protocols to manage disaster, conflict, and risk for professional practice. Given evidence that occurrences of pandemics are increasing in frequency, the impacts of pandemic-associated conflict on pharmacy practice may be lessened by these strategies and protocols.

Moreover, pharmacy educators may find value in the study findings for the development of theory pertaining to the lived experience of community pharmacy conflict. This may include theory relating to the factors contributing to the development of conflict, as well as the different outcomes conflict may produce. This theory may assist in the professional development of conflict management skills in pharmacy students and practicing pharmacists. As a result, the negative impacts of dysfunctional conflict on mental health and the professional practice of pharmacists may be pre-empted and minimised.

Study limitations

A potential limitation to this study relates to the inability of the research team to discount participant biases in their conflict narratives. The emotional engagement of the participant in their experiences of conflict may have coloured and influenced their recount of the narratives. This is due to the fact that situations that produce negative emotions have a greater propensity to be remembered clearly compared to situations that produce positive emotions. The research team attempted to reduce these biases with the use of a variety of probing questions to expand each participant's narrative and promote recall. However, due to the inability to verify the narratives as a third party, the research team has presumed credibility of each participant's narrative based on the ethical requirements of the pharmacy profession.

Whilst saturation was observed with the study's sample, due to the COVID-19 pandemic being concurrent at the time of this study and the unforeseeable nature of pandemic outcomes, it is quite possible that our findings may not represent the full range of pandemic-induced conflict experiences. As a result, further research in this area post-COVID may be required to address any temporal shortcomings of this study.

Study strengths

In order to increase the trustworthiness of this study, the approach to this study followed two major strategies. The first strategy was to ensure all details of this study had clear connections, with the research methodology, data analysis techniques, and information synthesis processes used to construct the findings having evident links to achieving the research aim and objectives. The second strategy was ensuring this study met the recognised qualitative research criteria sets to further increase the trustworthiness of this study. As part of the study design for this strategy, the research team has closely followed the COREQ criteria (see Supplementary Data) for reporting qualitative research and the recognised quality framework for trustworthiness recommended by Lincoln and Guba. Additionally, due to the contemporaneity of the COVID-19 pandemic at the time of this study, it is likely participants’ narratives were more representative of the actual experienced situations. This is due to the notion that details of more recent memories are able to be more accurately recalled compared to more temporally distant memories.

Conclusion

Whether due to the continued presence of the COVID-19 pandemic in the near future or the occurrence of another high volatility situation which changes the status quo and function of society, the level of conflict in community pharmacy settings will likely escalate or remain elevated compared to the past. To ensure conflict does not negatively affect the function and practice of community pharmacy, such as affecting the mental health of staff, the nature of conflict needs to be better understood. This study facilitated a better understanding of the process of conflict and its outcomes through the development of seven themes to describe the nature of conflict during the COVID-19 pandemic, as well as the synthesis of a model to describe the lived experience of functional and dysfunctional conflict. As the key aim of this pilot study, directions for future research into the nature of conflict such as validating the model for the lived experience of conflict were also identified. Understanding the nature of conflict is critical to pharmacy personnel to ensure experienced conflicts do not harm staff or the function of the pharmacy, but instead act as a stepping-stone for improving the function and practice of community pharmacy, especially during times of increased disruption and conflict.

Author statement

William Lam: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing

Amary Mey: Formal analysis, Methodology, Resources, Validation, Writing - review & editing

Michelle A. King: Formal analysis, Methodology, Resources, Validation, Writing - review & editing

Phillip Woods: Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Writing - review & editing

Funding

This work was supported by the School of Pharmacy and Medical Sciences, , Queensland, Australia. No external funding was received.

Declaration of competing interest

None.

Introduction: study brief, reminder of confidentiality and removal of personal-identifying information from transcripts, no requirement to disclose information/answer all questions, estimated duration (30–60 min), confirmation of informed consent and consent for recording. Do you have any questions before we start?

Demographics: So, could you please start by providing some information about yourself? What is your role as a pharmacist and how long you have been practicing?

Opening question: As you have been practising before and during the COVID-19 pandemic, can you begin by sharing with me some of your observations regarding conflicts you have experienced before the pandemic and after the pandemic made news headlines in February?

Follow-up/probing questions (try to obtain feelings on matters as much as possible, any incidents where this was clearly evident or obvious):

• Can you describe what occurred during the conflict situations and what parties were involved?

• Can you describe how the conflict was managed by the parties involved?

• In your view, was the conflict resolved and can you elaborate on what occurred to resolve it?

• Can you tell me about any outcomes that you perceive, that resulted from the conflict? For example, positive or negative outcomes? Better teamwork? Worse communication? Etc.?

• What do you think may have been aspects or contributing factors which triggered these cases of conflict?

• How have these cases of conflict affected your practice of community pharmacy?

Additional follow-up/probing questions:

• Can you try to classify, in your own words, what are the types of conflicts that have occurred?

• How has the COVID-19 pandemic affected the function and practice of community pharmacy?

• How prepared was the pharmacy for the COVID-19 pandemic?

• Are there any aspects or factors that are related to the COVID-19 pandemic that may have contributed to the experience or level of conflict in the pharmacy?

• Can you tell me about how you prepare the pharmacy staff to manage conflict in the pharmacy, e.g. are there any conflict management training or protocols in place? Can you elaborate?

• Can you comment on your experience of conflict say, before and after COVID pandemic arrived? (e.g. Do you think there has been greater or fewer cases of conflict since the pandemic? Can you elaborate?)

Conclusion and Debrief: Would you like to add any further information to your answers? Is there anything you would like to ask or raise up before we turn off the recording to conclude the interview? End recording, thank participation, debrief, offer transcript when available, provide timeline of study and expression of interest for receiving completed findings.