Research in Social and Administrative Pharmacy 10 (2014) 701–703
Editorial
Social psychology in an evolving profession: A research agenda for advancing clinical pharmacy services Much has happened since the advent of clinical pharmacy services, particularly in the 25 years since Hepler and Strand1 coined the term “pharmaceutical care” to describe a practice model in which pharmacists share in the responsibility for medication-related outcomes. As Schommer and Gaither2 point out in the introduction to their article, pharmacists have been developing new practice models. These new models often incorporate pharmacists’ knowledge as drug therapy consultants and place them in direct patient care roles. Laws and regulations have been enacted that allow pharmacists to perform activities that extend beyond traditional medication distribution and dispensing.3 Evidence from research has shown the value of clinical pharmacy services to patients, providers and payers.4 As a result, new practice and payment models that recognize pharmacists’ direct patient care roles continue to emerge.5 Schommer and Gaither also point out that not all pharmacists will change their practice patterns, nor will patients change their views and utilization patterns for pharmacists’ services, over a short period of time. Using data collected at three-year intervals over a fifteen year period (1995–2010), they found that how pharmacists segment themselves (the largest group of pharmacists citing time pressures for not providing patient consultant services) and how patients view obtaining medication services (the largest group of patients view medication consulting as being primarily the role of their physicians) had not appreciably changed over that time. This has resulted in a continued cycle of dysfunction in which pharmacists, citing time pressures, do not provide patient care services, and patients, having little reason to expect much from pharmacists other than medication dispensing, continue to look to physicians for consultation about their medications. As the saying goes, “the more things change, the more they stay the same.”
Schommer and Gaither recognize that there are substantial numbers (although not a majority) of pharmacists who view themselves as providers of consultative and direct patient care services, despite the time pressures of contemporary pharmacy practice. They also found that many patients (also not a majority) view their pharmacist as a medication advisor. Schommer and Gaither wisely call for the identification of these segments, as well as learning the connections between them, to better position pharmacist services and gain opportunities in markets of patients, providers and payers. The next natural step for research in this area is to identify the qualities and characteristics of pharmacists and consumers willing to provide and obtain medication consultative services. Social psychology research has and can continue to play an important role in identifying segments of pharmacists who have or may be willing to adopt new practice models. Researchers have long employed models such as the Theory of Reasoned Action, the Theory of Planned Behavior, and other social-psychology models to use attitudes, norms and past behaviors to predict the behaviors and behavioral intentions of pharmacists,6,7 their patients,8,9 and of other health professionals toward pharmacists.10 In explaining and predicting pharmacists’ professional practice actions, one can utilize measures such as moral reasoning (the processes and stages that one goes through in determining which actions to take), locus of control (the extent to which one feels they can control their environment to achieve desired outcomes), or even Machiavellianism (pragmatic, maintain emotional distance, ends justify the means).11 One may hypothesize that a reason why the largest proportion of pharmacists view time pressures as a primary reason for not providing clinical services is that they are pragmatic. These pharmacists recognize that existing fee-for-service
1551-7411/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.06.004
702
Editorial / Research in Social and Administrative Pharmacy 10 (2014) 701–703
payment methods (drug cost þ dispensing fee) place more utility on dispensing medications than on providing clinical services. However, pharmacists should note that what may have been a pragmatic response in the past is not guaranteed to continue to be rational in the future. Schommer and Gaither point out that reimbursement for dispensing drug products continues to sink lower, and that new health care payment models (Medicare Part D MTM, ACOs/PCMHs, Teambased care, Pay-for-Performance) provide additional incentives for pharmacists to provide direct patient care.12 Psychologists have long considered locus of control an important aspect of personality. Locus of control refers to an individual’s perception about the underlying main causes of events in his/ her life.13 Locus of control is conceptualized along a spectrum ranging from external (one believes that his/her behavior is guided by fate, luck, other people, other external circumstances) to internal (beliefs that one’s behaviors are guided by his/ her own personal decisions and efforts, not those of others). Locus of control develops and is guided by reinforcements, the rewards and punishments one comes to hold about the causes and consequences of their actions. When reflecting on pharmacy, one could hypothesize that pharmacists who fall into the time pressure segment are likely to have an external locus of control. They view themselves as reacting to the demands of patients, employers, providers and payers to quickly and accurately dispense medications at the lowest possible cost, and have been reinforced to believe that they have little ability to determine how they will spend their time. On the other hand, one could also hypothesize that pharmacists in Schommer and Gaither’s “all low” segment are more likely to have an internal locus of control, a sense of empowerment that they can decide how to spend their time and what they should do to best serve their patients and employers, health care providers, payers, and others who depend on their services. Most psychologists believe that it is healthier for individuals to perceive that they have control over those things in which one is capable of influencing.14 A sense of self-determination or personal control is valued by many, particularly in the health professions, where our decisions have implications across the spectrum from patients to society. But simply having an internal locus of control alone does not assure good outcomes for either the individual making the decisions or for
those impacted by their decisions. An internal locus of control needs to be matched by competence (e.g., choosing the correct medication and monitoring parameters, giving the appropriate advice to patients), self-efficacy (the strength in one’s beliefs in one’s own ability to make decisions and reach goals) and opportunity (the time and place to put one’s decisions to action). A healthy internal locus of control is largely a result of learning to have a realistic sense of one’s ability to take actions that are likely to result in desired outcomes for themselves and others. When reflecting on Schommer and Gaither’s call to identify pharmacists who are more likely to view themselves as patient care providers, it is important that those charged with selecting and educating student pharmacists continue to look beyond the traditional variables used to admit students into our programs (primarily academic performance and standardized test scores, with a more recent emphasis on oral and written communications skills).15 While these traditional variables will continue to be important in helping identify those likely to develop the competencies necessary to care for patients, other variables, such as leadership skills, moral reasoning and locus of control may also help us achieve our goal of identifying future pharmacists who will take the actions necessary to provide new levels of service, and in turn change the perceptions of what patients, health care providers, payers and society can come to expect from their pharmacists. David P. Zgarrick, Ph.D., FAPhA, Professor and Chair Department of Pharmacy Practice Northeastern University Bouve´ College of Health Sciences School of Pharmacy 360 Huntington Avenue (140 TF) Boston, MA 02115, USA Tel.: þ1 617 373 4664 E-mail address: [email protected]
References 1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Pharm Educ 1989;53:7S. 2. Schommer JC, Gaither CA. A segmentation analysis for pharmacists’ and patients’ views of pharmacists’ roles. Res Soc Adm Pharm 2014;10:508–528.
Editorial / Research in Social and Administrative Pharmacy 10 (2014) 701–703 3. Survey of Pharmacy Law. Mount Prospect, IL: National Association of Boards of Pharmacy; 2014. 4. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service; Dec. 2011. 5. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated teams. Health Aff (Millwood) 2013;32(11): 1963–1970. 6. Herbert KE, Urmie JM, Newland BA, Farris KB. Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior. Res Soc Adm Pharm 2006;2:299–314. 7. Mutavdzic A. Hospital pharmacists and behavioural change theory: who, why and how? J Pharm Pract Res 2010;40:43–45. 8. Patwardhan PD, Amin ME, Chewning BA. Intervention research to enhance community pharmacists’ cognitive services: a systematic review. Res Soc Adm Pharm 2014;10:475–493.
703
9. Watson MC. Why educational interventions are not always effective: a theory-based process evaluation of a randomized controlled trial to improve nonprescription medicine supply from community pharmacies. Int J Pharm Pract 2007;15:79–81. 10. Kucukarslan S. Physician beliefs and attitudes toward collaboration with community pharmacists. Res Soc Adm Pharm 2011;7:224–232. 11. Latif D. Moral reasoning: should it serve as a criterion for student and resident selection in pharmacy? Am J Pharm Educ 2001;65:119–124. 12. Amara S. Accountable care organizations: impact on pharmacy. Hosp Pharm 2014;49:253–259. 13. Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr 1966;80:1–28. 14. Neill J. What is locus of control. Available at: wilderdom.com/psychology/loc/LocusOfControlWhatIs.html; Accessed 24.06.14. 15. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, IL: Accreditation Council for Pharmacy Education; 2011.
Editorial
Social psychology in an evolving profession: A research agenda for advancing clinical pharmacy services Much has happened since the advent of clinical pharmacy services, particularly in the 25 years since Hepler and Strand1 coined the term “pharmaceutical care” to describe a practice model in which pharmacists share in the responsibility for medication-related outcomes. As Schommer and Gaither2 point out in the introduction to their article, pharmacists have been developing new practice models. These new models often incorporate pharmacists’ knowledge as drug therapy consultants and place them in direct patient care roles. Laws and regulations have been enacted that allow pharmacists to perform activities that extend beyond traditional medication distribution and dispensing.3 Evidence from research has shown the value of clinical pharmacy services to patients, providers and payers.4 As a result, new practice and payment models that recognize pharmacists’ direct patient care roles continue to emerge.5 Schommer and Gaither also point out that not all pharmacists will change their practice patterns, nor will patients change their views and utilization patterns for pharmacists’ services, over a short period of time. Using data collected at three-year intervals over a fifteen year period (1995–2010), they found that how pharmacists segment themselves (the largest group of pharmacists citing time pressures for not providing patient consultant services) and how patients view obtaining medication services (the largest group of patients view medication consulting as being primarily the role of their physicians) had not appreciably changed over that time. This has resulted in a continued cycle of dysfunction in which pharmacists, citing time pressures, do not provide patient care services, and patients, having little reason to expect much from pharmacists other than medication dispensing, continue to look to physicians for consultation about their medications. As the saying goes, “the more things change, the more they stay the same.”
Schommer and Gaither recognize that there are substantial numbers (although not a majority) of pharmacists who view themselves as providers of consultative and direct patient care services, despite the time pressures of contemporary pharmacy practice. They also found that many patients (also not a majority) view their pharmacist as a medication advisor. Schommer and Gaither wisely call for the identification of these segments, as well as learning the connections between them, to better position pharmacist services and gain opportunities in markets of patients, providers and payers. The next natural step for research in this area is to identify the qualities and characteristics of pharmacists and consumers willing to provide and obtain medication consultative services. Social psychology research has and can continue to play an important role in identifying segments of pharmacists who have or may be willing to adopt new practice models. Researchers have long employed models such as the Theory of Reasoned Action, the Theory of Planned Behavior, and other social-psychology models to use attitudes, norms and past behaviors to predict the behaviors and behavioral intentions of pharmacists,6,7 their patients,8,9 and of other health professionals toward pharmacists.10 In explaining and predicting pharmacists’ professional practice actions, one can utilize measures such as moral reasoning (the processes and stages that one goes through in determining which actions to take), locus of control (the extent to which one feels they can control their environment to achieve desired outcomes), or even Machiavellianism (pragmatic, maintain emotional distance, ends justify the means).11 One may hypothesize that a reason why the largest proportion of pharmacists view time pressures as a primary reason for not providing clinical services is that they are pragmatic. These pharmacists recognize that existing fee-for-service
1551-7411/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.06.004
702
Editorial / Research in Social and Administrative Pharmacy 10 (2014) 701–703
payment methods (drug cost þ dispensing fee) place more utility on dispensing medications than on providing clinical services. However, pharmacists should note that what may have been a pragmatic response in the past is not guaranteed to continue to be rational in the future. Schommer and Gaither point out that reimbursement for dispensing drug products continues to sink lower, and that new health care payment models (Medicare Part D MTM, ACOs/PCMHs, Teambased care, Pay-for-Performance) provide additional incentives for pharmacists to provide direct patient care.12 Psychologists have long considered locus of control an important aspect of personality. Locus of control refers to an individual’s perception about the underlying main causes of events in his/ her life.13 Locus of control is conceptualized along a spectrum ranging from external (one believes that his/her behavior is guided by fate, luck, other people, other external circumstances) to internal (beliefs that one’s behaviors are guided by his/ her own personal decisions and efforts, not those of others). Locus of control develops and is guided by reinforcements, the rewards and punishments one comes to hold about the causes and consequences of their actions. When reflecting on pharmacy, one could hypothesize that pharmacists who fall into the time pressure segment are likely to have an external locus of control. They view themselves as reacting to the demands of patients, employers, providers and payers to quickly and accurately dispense medications at the lowest possible cost, and have been reinforced to believe that they have little ability to determine how they will spend their time. On the other hand, one could also hypothesize that pharmacists in Schommer and Gaither’s “all low” segment are more likely to have an internal locus of control, a sense of empowerment that they can decide how to spend their time and what they should do to best serve their patients and employers, health care providers, payers, and others who depend on their services. Most psychologists believe that it is healthier for individuals to perceive that they have control over those things in which one is capable of influencing.14 A sense of self-determination or personal control is valued by many, particularly in the health professions, where our decisions have implications across the spectrum from patients to society. But simply having an internal locus of control alone does not assure good outcomes for either the individual making the decisions or for
those impacted by their decisions. An internal locus of control needs to be matched by competence (e.g., choosing the correct medication and monitoring parameters, giving the appropriate advice to patients), self-efficacy (the strength in one’s beliefs in one’s own ability to make decisions and reach goals) and opportunity (the time and place to put one’s decisions to action). A healthy internal locus of control is largely a result of learning to have a realistic sense of one’s ability to take actions that are likely to result in desired outcomes for themselves and others. When reflecting on Schommer and Gaither’s call to identify pharmacists who are more likely to view themselves as patient care providers, it is important that those charged with selecting and educating student pharmacists continue to look beyond the traditional variables used to admit students into our programs (primarily academic performance and standardized test scores, with a more recent emphasis on oral and written communications skills).15 While these traditional variables will continue to be important in helping identify those likely to develop the competencies necessary to care for patients, other variables, such as leadership skills, moral reasoning and locus of control may also help us achieve our goal of identifying future pharmacists who will take the actions necessary to provide new levels of service, and in turn change the perceptions of what patients, health care providers, payers and society can come to expect from their pharmacists. David P. Zgarrick, Ph.D., FAPhA, Professor and Chair Department of Pharmacy Practice Northeastern University Bouve´ College of Health Sciences School of Pharmacy 360 Huntington Avenue (140 TF) Boston, MA 02115, USA Tel.: þ1 617 373 4664 E-mail address: [email protected]
References 1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Pharm Educ 1989;53:7S. 2. Schommer JC, Gaither CA. A segmentation analysis for pharmacists’ and patients’ views of pharmacists’ roles. Res Soc Adm Pharm 2014;10:508–528.
Editorial / Research in Social and Administrative Pharmacy 10 (2014) 701–703 3. Survey of Pharmacy Law. Mount Prospect, IL: National Association of Boards of Pharmacy; 2014. 4. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service; Dec. 2011. 5. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated teams. Health Aff (Millwood) 2013;32(11): 1963–1970. 6. Herbert KE, Urmie JM, Newland BA, Farris KB. Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior. Res Soc Adm Pharm 2006;2:299–314. 7. Mutavdzic A. Hospital pharmacists and behavioural change theory: who, why and how? J Pharm Pract Res 2010;40:43–45. 8. Patwardhan PD, Amin ME, Chewning BA. Intervention research to enhance community pharmacists’ cognitive services: a systematic review. Res Soc Adm Pharm 2014;10:475–493.
703
9. Watson MC. Why educational interventions are not always effective: a theory-based process evaluation of a randomized controlled trial to improve nonprescription medicine supply from community pharmacies. Int J Pharm Pract 2007;15:79–81. 10. Kucukarslan S. Physician beliefs and attitudes toward collaboration with community pharmacists. Res Soc Adm Pharm 2011;7:224–232. 11. Latif D. Moral reasoning: should it serve as a criterion for student and resident selection in pharmacy? Am J Pharm Educ 2001;65:119–124. 12. Amara S. Accountable care organizations: impact on pharmacy. Hosp Pharm 2014;49:253–259. 13. Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr 1966;80:1–28. 14. Neill J. What is locus of control. Available at: wilderdom.com/psychology/loc/LocusOfControlWhatIs.html; Accessed 24.06.14. 15. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, IL: Accreditation Council for Pharmacy Education; 2011.
