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Intraprofessional conflict among pharmacists, regulated technicians and assistants may undermine attempts to advance patient care in community pharmacy. There is no available research examining this issue in light of the evolution of the profession and roles within the profession.
A combination of interviews and focus groups involving pharmacists, technicians and assistants was undertaken. Each participant completed the Conflict Management Scale as a way of identifying conflict management style. Data were analyzed and coded using a constant-comparative, iterative method.
A total of 41 pharmacy team members participated in this research (14 pharmacists, 14 technicians and 13 assistants). Four key themes were identified that related to conflict within community pharmacy: role misunderstanding, threats to self-identity, differences in conflict management style and workplace demotivation.
As exploratory research, this study highlighted the need for greater role clarity and additional conflict management skills training as supports for the pharmacy team. The impact of conflict in the workplace was described by participants as significant, adverse and multifactorial.
To support practice change, there has been major evolution of roles and responsibilities of pharmacists, technicians and assistants. Conflict among pharmacy team members has the potential to adversely affect the quality of care provided to patients and is an issue for managers, owners, regulators and educators.
We talk about interprofessional conflict, often between pharmacists and physicians, and sometimes criticize physicians for how they deal with conflict. But have a look at this paper that, for the first time, addresses intraprofessional conflict (i.e., within the pharmacy team). We need only look into the mirror to realize that we have some work of our own to do in this regard. Indeed, if patients are to receive the full benefit of pharmacy services, we need to get our own shop in order! The guidelines in Box 1 are a good place to start.
With the evolution of pharmacy practice, there has been considerable attention paid to the issue of interprofessional collaboration among pharmacists and other health care professionals.1,2 Of interest, there is significantly less research and literature focused on intraprofessional collaboration among members of the community pharmacy team (pharmacists, technicians and assistants) despite the fact that, in a typical community pharmacy setting, there is far more day-to-day contact between these individuals than between interprofessional colleagues. Much of the promise of enhanced pharmacy practice rests on the premise that each member of the pharmacy team can and should practice to their full scope and potential: for pharmacists to leverage their knowledge and skills for patient care, they must be supported by well-qualified technicians and assistants who can manage drug-dispensing systems in a quasi-independent (or highly interdependent manner).3,4
Anecdotally, this idealized vision of a collaborative intraprofessional team has been called into question. Some technicians have raised concerns about their professional aspirations being blocked by pharmacists who may feel threatened by their evolving scope of practice. Conversely, nonregulated assistants have raised their own concerns about their diminishing relevance within the team, while some pharmacists have complained about increasing loss of professional authority and autonomy.5
Despite its centrality to the entire operation of community pharmacy, there have been few formal studies of intraprofessional teams and even less attention paid to a critical issue for collaboration: conflict management. As resources continue to diminish, expectations continue to rise and scopes and roles continue to evolve, conflict within the pharmacy team is likely to escalate.6,7 Such conflict need not be counterproductive to effective team functioning if it is managed effectively and consistently. To support pharmacy teams in the delivery of high-quality patient care, understanding the interpersonal and intraprofessional dynamics that undergird pharmacy team functioning and conflict development, escalation and management is important.8,9
Conflict has been described as the intersection of intellectual disagreement with emotional involvement.10 Implicit in this description is the notion that conflict requires 2 or more individuals to actually disagree in a manner where 1 or both feel personal or emotional investment in the process and the outcome. Conflict scholars note that conflict is an inevitable part of interpersonal life: indeed, if managed effectively, conflict can be both healthy and productive for team functioning. Conflict scholars have identified 5 core root causes of conflict (Table 1).10 Previously, we have published work examining conflict in community pharmacy from the pharmacist’s perspective vis-à-vis physicians and patients, resulting in the development and validation of a conflict management model (Figure 1) and conflict management scale (Table 2) to support self-reflection and identification of one’s own conflict management style.11 At the time of these initial studies, little or no attention was paid to intraprofessional conflict, perhaps because of the belief that the strongly hierarchical nature of the pharmacy workforce belied the notion of an interdependent team. Today, with expanding scopes and responsibilities for pharmacy technicians, evolution in roles for pharmacists and a shift in the status of assistants, there is a greater need to study conflict management within the pharmacy team as a way to support organizational development and quality improvement.
The objective of this research was to describe and characterize the experience of intraprofessional conflict within the pharmacy team from the perspective of pharmacists, technicians and assistants. Given the lack of current scholarship in this area, an exploratory approach was used to identify potential areas for further in-depth research.
Pharmacists, technicians and assistants who participated in this research were all from Ontario, Canada. All participants self-identified as community practitioners and all were working at least 35 hours/week or more within 1 practice site. Individuals, rather than existing teams, were recruited for this study primarily because of logistics issues: the nature of “teams” in community pharmacy in Ontario at the time of this study was constantly shifting, and few participants reported consistently working with the same individuals and instead reported an itinerant shift-style pattern of work that involved intraprofessional contact among different individuals within the site. Inclusion criteria for pharmacists were licensed, part A pharmacist in the province of Ontario working a minimum of 35 hours/week in a single community pharmacy setting for at least the past 2 years. Inclusion criteria for technicians were regulated pharmacy technician (as defined by the Ontario College of Pharmacists) working a minimum of 35 hours/week in a single community pharmacy setting for at least the past 2 years. Inclusion criteria for assistants were completion of a community college or private vocational college pharmacy assistant program working for a minimum of 35 hours/week in a single community pharmacy setting for at least the past 2 years. Only English-speaking individuals who completed informed consent procedures were enrolled in this study.
Participants were recruited through use of e-mail and flyers that were distributed at continuing education events typically attended by pharmacists in the province. In addition, e-mail blasts were used to recruit individuals (typically pharmacists) who were affiliated with the University of Toronto’s clinical teaching program. Those interested in participating in the study undertook an informed consent process approved by the University of Toronto’s research ethics board. Once enrolled in the study, participants were encouraged to provide suggestions for others in their personal networks who might be interested in this work, using a snowball, purposive sampling technique that was particularly important in identifying technicians and assistants to participate.
A combination of individual semistructured interviews and focus group discussions (see Appendix 1 at cph.sagepub.com/supplemental) were used to gather data, using the same protocol and questions. Initially, participants were interviewed in person or by telephone to build a preliminary data set to facilitate analysis and identification of themes. As this data set and analysis matured, we switched to a focus group method for more efficient data gathering and thematic confirmation. All interviews and focus groups were audio-recorded pursuant to informed consent provisions. Prior to the interview or focus group, each participant was asked to complete the Conflict Management Scale, which was used during the interview as a topic for discussion. A semistructured interview/focus group guide was used to support exploration of individuals’ experiences with conflict and their perceptions of conflict management within an intraprofessional community pharmacy practice context.
Verbatim transcripts were produced following each interview/focus group. Constant-comparative data coding and analysis was used after each interview to support generation of preliminary—and subsequent confirmation of final—themes relevant to the research objectives. Several key sensitizing concepts were used to guide data analysis: previous work examining pharmacist-physician/pharmacist-patient conflict provided a general template for contextualizing these data and for defining initial coding categories. Discussion related to the Conflict Management Scale provided the interviewer and participant with an initial starting point and common vocabulary for discussing conflict. Rather than use post hoc member checking, participants who were focus group members later in the research process were asked questions to support understanding and confirmation of thematic analysis.
A total of 41 individuals participated (Table 3) in this research, which occurred over an 18-month period from October 2014 to March 2016.
Thematic analysis of transcripts yielded the following key findings (Table 4):
According to conflict theorists, lack of clarity around workplace roles and responsibilities is often a source of conflict in organizations.12 Unstructured teams without clear hierarchy and reporting channels have the advantage of greater flexibility and responsiveness to immediate issues but sometimes at the cost of producing unhelpful overlap and diffusion of responsibility.13,14 All participants in this study noted that the newly emerging role of regulated pharmacy technician introduced uncertainty into the traditional hierarchy of the pharmacy team, and in many cases, this uncertainty was managed through simple avoidance of discussion. Several participants noted that the introduction of regulated technicians into the workplace produced a “2 solitudes” model of practice, in which communication between pharmacists and technicians or technicians and assistants actually seemed to decrease because of the assumption (by all parties) that technicians had greater autonomous authority. This decrease in communication among team members was almost unanimously described in negative terms, as potentially unsafe or harmful to patient care and counterproductive to organizational functioning. Despite this characterization, few of the participants were actually able to describe positive steps they had personally and successfully undertaken in their practices to address this identified problem; instead (particularly for the pharmacists in this study), it was framed as a “management issue” or a “head office problem,” not a local, interpersonal issue that adult colleagues could or should fix themselves. Participants indicated that clearer direction from those in authority was required to define who does what within the pharmacy. Interestingly, even those who worked in independent pharmacy settings or owner-operator practices indicated a desire for greater role clarity to be defined by external agencies such as the regulatory body (Ontario College of Pharmacists). For almost all participants in this study, the issue was not an interpersonal dynamic focused on individual idiosyncrasies; instead, it was a managerial problem that should be “fixed” by better policies and procedures.
A common theme across all subgroups of participants related to shifting perceptions of one’s own role and status within the pharmacy team as the role of regulated technicians expanded and evolved. Most participants framed this as a zero-sum game: increased status and responsibility for one team member meant decreased status and responsibility for another. While many participants (in particular pharmacists) acknowledged the intent of scope of practice change and regulation for technicians was to “liberate” pharmacists from more technical tasks, allowing them to focus on clinical activities, these same participants indicated the lived experience of this was different than the ideal projected by leaders in the profession. Pharmacists, regardless of their age or years in practice, expressed a sense of loss and a diminution in their role when dispensing, inventory management and certain human resources functions became unclear within the team. Similarly, assistants, regardless of their age or years in practice, described a sense of marginalization and a frank concern regarding the job prospects of the role itself, which produced a psychological tension around fully embracing the role of the technician. Technicians, again regardless of age or years in practice, expressed concerns that their new role was not adequately respected, and several openly questioned if the time, energy and money required to complete certification requirements were actually worthwhile.
These different experiences were frequently framed by participants in an inward-looking way, one that related to each individual’s self-identity and status within the team. Virtually all participants indicated that, in their experience, their status was in decline, paradoxically belying their initial thoughts that status within the community pharmacy team was a zero-sum game. While pharmacists, technicians and assistants all experienced and interpreted the evolution of an intraprofessional collaboration differently, for the most part, they all experienced it as negative from a professional and personal self-identity perspective.
In conjunction with discussion and review of the Conflict Management Scale, several individuals noted that this negative self-identity issue perhaps contributed to conflict escalation as an emotional underlay to day-to-day disagreements that are inevitable in practice. In particular, those who felt most threatened by job losses or salary declines, or those who felt their new/additional certification was not adequately recognized socially or financially, reported higher instances of conflict with more enduring consequences.
Conflict management style has long been identified as a useful tool for self-reflection and understanding escalation of interpersonal conflict.11 This was the first study to attempt to characterize conflict management styles of technicians and assistants. Previous work involving pharmacists suggested that their dominant conflict management style was Settler, with a statistically significant clustering of male community pharmacists as Avoiders.11
Technicians and assistants in this study were, for the most part, thwarters in their conflict management style. Conflict theory suggests the intersection of those with a thwarting and those with a settling or avoidant style may produce interpersonal tension, because of differences in communication style (indirect vs direct) and world view (pragmatic vs principled). At its most acute, the pragmatic, direct communication style of the Settler may seem like a completely foreign language to the more unyielding, indirect communication style of the Thwarter. The inability to decipher significance and meaning of one another’s words and intentions in such a situation can frustrate attempts at conflict deescalation.
This issue of conflict management style difference was a common theme in the interviews, with pharmacists generally indicating they interpreted “indirect” communication as “unclear” or “vague.” Conversely, technicians and assistants interpreted the “direct” communication style of pharmacists as “intimidating,” “aggressive” and sometimes verging on “bullying.” Similarly, the relatively pragmatic world view of pharmacists—who were most interested in simply solving problems as efficiently as possible—sometimes appeared to clash with the somewhat more unyielding world view of technicians and assistants, who in these types of interactions may appear to be more rule bound and less interpretive. Again, pharmacists might interpret this as “inflexible” or “rigid,” while technicians and assistants might interpret the pharmacist’s actions as “flying by the seat of his pants.” As emotional labels are ascribed to interpersonal experiences involving intellectual disagreements, the likelihood of conflict escalation increases.
Many participants highlighted the need for and value of conflict management training within the profession, not just for managing patients and physicians but to enhance intraprofessional collaboration. This self-identified learning need was generally agreed upon, but only a handful of participants reported attending workshops or receiving any training in this area despite the “obvious need” for it.
Virtually all participants in this study commented frequently on the demotivating nature of intraprofessional conflict, highlighting the personal stress associated with workplace-based conflict. For many participants, conflict avoidance was described as a day-to-day coping strategy that had been incorporated into daily practice, sometimes at the expense of patient care. Some participants were frankly cynical regarding the “promise” of intraprofessional collaboration and regulation of technicians and the actual experience they encountered in their pharmacies.
It is important, however, to note that despite this observation, virtually all participants agreed with the notion that well-qualified regulated technicians were essential to allowing pharmacists to practice to their full scope and potential. Most participants made clear distinctions between the ideals of intraprofessional collaboration and the unique interpersonal experiences they lived within their practice setting. For most individuals, the key to resolving this cognitive dissonance involved the role of leadership within the profession and management of their specific pharmacy. Most participants indicated their belief that poor management practices (ranging from nonspecific job descriptions to lack of conflict management training to poor workplace conditions involving too many prescriptions in too little space) were the real cause of intraprofessional conflict, not interpersonal differences or turf wars between pharmacists, technicians or assistants. Specific groups or individuals named by participants included regulatory bodies (for not more clearly defining practice scope of pharmacy technicians), corporations (for not developing appropriate job descriptions or overburdening all staff through poor workplace design and conditions), pharmacy owners (for not investing sufficiently in conflict management training), and so forth. Few individuals engaged in self-reflection that highlighted their own potential contribution to intraprofessional conflict, and if they did, they generally connected this to specific workplace conditions.
As exploratory research, this study provides useful information for diverse audiences (Box 1). First, pharmacy leaders should be interested in the lived experience of intraprofessional collaboration and how different it may be from idealized models promulgated during initial registration of technicians. Second, pharmacy owner-operators may be interested in learning more about their staff’s self-identified learning needs related to conflict management training and causes and consequences of conflict from both a business and patient care perspective. In particular, concerns related to demotivating workplace conditions that accelerate conflict and compromise patient care are important to consider. Third, the notion that, by trait or by temperament, those who are pharmacists may have a conflict management style that is different from that of technicians or assistants introduces challenges and opportunities with respect to training and a form of psychological diversity management.
There are important limitations to consider with this study. Its qualitative nature and the interview method used cannot be interpreted in a generalizable manner—it is presented as indicative of those participants in Ontario who elected to participate. It is important to note that the convenience sampling method used for practical purposes (i.e., word-of-mouth recruitment, lack of direct recruitment of participants, etc.) will likely have produced an unrepresentative sample group for this study; as an exploratory study, however, this approach was both reasonable and appropriate, although the generalizability of the findings will be affected. Although the sample size was relatively large for qualitative work, it was divided among 3 different and distinct cohorts, so caution must be used in applying findings more broadly. While the constant-comparative coding and iterative analysis methods used in this study are standard and well accepted in qualitative research,15 and a variation of member checking was used for confirmation of themes to establish trustworthiness of this data,16 the interpretation of data and framing of themes presented here await further confirmation by others.
The key objective of this research was to provide an initial exploration and characterization of a thorny issue in community pharmacy practice—intraprofessional conflict and its consequences at the individual, operational and patient care levels. Findings of this research may be useful to diverse stakeholders including educators, employers, regulators and policy makers who are interested in moving beyond idealized rhetoric toward concrete supports designed to facilitate a significant change in pharmacy practice—the evolution of the regulated pharmacy technician.
Interpersonal conflict is an inevitable part of day-to-day life, including the evolving intraprofessional relationships of pharmacists, technicians and assistants. While there is widespread agreement regarding the necessity and value of this evolution, the day-to-day experience of the community pharmacy team needs to be examined closely to ensure timely and appropriate supports are provided to enhance likelihood of success. Conflict management is a critical issue for workplace satisfaction, quality of patient care and operational efficiency. All stakeholders need to consider how best to support the community pharmacy team in working together most effectively to achieve best possible outcomes for patients. ■
Author Contributions:P.A.M. Gregory was responsible for data collection and primary data analysis, drafted and edited the manuscript and wrote the final draft. Z. Austin initiated and supervised the project; was responsible for design, methodology and secondary data analysis; and reviewed the final draft.
Declaration of Conflicting Interests:The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding:This research was supported in part through funding from the Ontario College of Pharmacists.