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Pharmacy ownership in Canada: Implications for the authority and autonomy of community pharmacy managers
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Research in Social and Administrative Pharmacy 7 (2011) 347–358
Original Research
Pharmacy ownership in Canada: Implications for the authority and autonomy of community pharmacy managers Roy Thomas Dobson, B.Sc.Phm., M.B.A., Ph.D.*, Jason Perepelkin, B.A., B.Comm., M.Sc., Ph.D. College of Pharmacy & Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon, Saskatchewan, Canada S7N 5C9
Abstract Background: In recent years, the number of independently owned pharmacies has declined even as the total number of pharmacies in Canada has increased. With increasing corporate ownership, there is concern that this trend will adversely affect the profession’s ability to influence pharmacy practice and practice change. Objective: To examine the relationship between ownership type and community pharmacy managers in terms of professional and employer authority, managerial autonomy, decision making, and amount of control. Methods: This study consisted of a cross-sectional survey of community pharmacy managers in Canada by means of a self-administered postal questionnaire sent to a stratified sample of community pharmacies. Statistical analysis consisted of exploratory factor analysis with reliability testing on identified constructs. Frequencies, 1-way analyses of variance, Scheffe post hoc tests, and general linear modeling were used to determine significant differences among groups based on ownership type. Results: In total, 646 of 1961 questionnaires from pharmacy managers were completed and returned (response rate 32.9%). Respondents rated their authority similarly across ownership types. Autonomy, decision-making capabilities, and control needed to carry out the professional role appear most limited among corporate respondents and, to a lesser extent, franchise managers. Conclusions: Pharmacy managers currently perceive a high level of authority; but with limited autonomy among corporate managers, it is unclear whether this authority is sufficient to prevent the subordination of both patient and professional interests to financial interests. Ó 2011 Elsevier Inc. All rights reserved. Keywords: Community pharmacy; Managers; Authority; Autonomy; Decision making; Control
Funding/Support: Funding was provided through an internal research grant from the College of Pharmacy & Nutrition, University of Saskatchewan. Previous Presentations: Portions of this study were presented at the American Pharmacists Association Annual Conference; March 17, 2008; San Diego, California. Preliminary results of this study were presented at the Canadian Pharmacists Association Annual Conference; June 3, 2007; Ottawa, Ontario, Canada. * Corresponding author. Tel.: þ1 306 966 6363; fax: þ1 306 966 6377. E-mail address: [email protected] (R.T. Dobson). 1551-7411/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2010.10.005
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Introduction In the past, community pharmacy in Canada was dominated by small, independent, pharmacistowned enterprises that, in their turn, employed many other pharmacists to staff and manage these businesses.1 Over time, regulatory changes throughout Canada allowed nonpharmacists to own and operate pharmacies; and in recent years, the number of independently owned pharmacies has declined even as the total number of pharmacies in Canada has increased, along with more largerscale, nonpharmacist-controlled corporate entities.2 Today, the presence of a licensed pharmacist is still required when the dispensary is open, but pharmacists are now increasingly employees in corporate-owned and -operated pharmacies,3 and the economic control of community practice is slowly, but surely, being wrested away from the profession. At the same time that the composition of pharmacy ownership in Canada is changing, the nature of pharmacy practice and the practice expectations of the profession are also evolving. Many community pharmacy practitioners are seeking greater professional autonomy and a more service-oriented, patient-focused approach to patient care, with a greater emphasis on the use of their clinical skills.4-7 Indeed, most new pharmacists express little or no interest in the business aspects of community practice and increasingly define themselves professionally in terms of their responsibilities.8,9 However, because large corporations with a decidedly stronger business orientation gain a more dominant position within community pharmacy, and because pharmacists turn away from business-related leadership roles within these organizations, pharmacists may find their ability to develop and introduce cognitive pharmacy services increasingly curtailed. Agency theory suggests that the sole social responsibility of a corporation is to increase profits.10 For these businesses, pharmacists represent very expensive but necessary human capital, and as such, business will look to maximize the productivity of these inputs.11,12 Although more reflective of the professional goals of pharmacy, clinical services not directly linked to dispensing a prescription may represent less lucrative and reliable sources of revenue.13,14 Nonpharmacist corporate owners and their senior management teams are more likely to favor expanding revenues and reducing costs through increased prescription volume and production efficiency and may be less
concerned with achieving pharmacy’s professional objectives. Activities deemed less likely to contribute to the ‘‘bottom line’’ will invariably be of a lower priority. Research suggests that professionals employed in larger organizations perceive themselves to have less autonomy, due in part to the more bureaucratic and predetermined structures of these organizations.15 Gradually, but at an increasing rate, health professionals, including pharmacists, are becoming employees in nonprofessional organizations where they are outnumbered by nonprofessional employees.16-19 Moreover, because of technical processes put in place to achieve business objectives, the ability of frontline pharmacy managers to affect steps within the organization’s decision-making processes will be increasingly limited.20 This shift in employment status also increases the likelihood of conflict between a businessoriented leadership and more professionally oriented frontline managers.21,22 When health care providers practice within a large predominantly nonprofessional organization, professional ideals can conflict with the principles and practices of the employing organization.23 Conflict arises because of competing sources of authority: the first deriving from the formal authority of the employer organization and the second from the professional expertise held by the professional and enforced by collegial authority.18 Incongruence between these 2 sources of authority can lead to a disruption of an individual’s orientation to the organization and/or the profession; criticism of the organization by pharmacists orientated toward their professional norms; the ignoring of administrative details; and stress for those pharmacists ‘‘caught in the middle,’’18 in particular, pharmacists who also have managerial responsibilities. With increasing nonpharmacist ownership, some economic autonomy is invariably removed from the profession.24 Although the professional orientation of pharmacy managers still appears to be strong,25 a concern for the profession is that with increasing nonpharmacist ownership, a business orientation to maximize shareholder value will take pre-eminence over the professional objectives of pharmacy managers.20 In effect, business-oriented ownership will use its economic authority to curtail the professional autonomy and authority of pharmacy managers, those most responsible for directing the operations of the individual pharmacy location.
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The purpose of this study is to describe the perceived authority and autonomy of community pharmacy managers in Canada and how these relate to the ownership of the pharmacies where these managers practice. Methods Data source and collection A self-administered questionnaire was mailed to community pharmacy managers across Canada. Contact information obtained from provincial regulatory agencies was used to compile a master list of 6342 community pharmacy managers. From this list, a random stratified sample of 2000 community pharmacy managers was extracted based on the number of community pharmacy managers in each province. Based on an expected response rate of 30%, a sample size of 2000 was needed to secure 600 completed questionnaires, the number calculated as necessary to achieve statistical power. The calculated number of completed questionnaires needed was based on a population size of 6342 pharmacies outside Quebec with a confidence level of 99% and a margin of error of 5%. Contact information was not obtained for community pharmacy managers in Quebec. At the time of the study, the ownership of a pharmacy in the province was restricted to a licensed pharmacist; therefore, it would not be possible to compare ownership types within Quebec. Data collection consisted of up to 4 separate mailings. The first mailing was a letter stating the study overview and purpose that went out to the entire sample. The overview letter was followed 1 week later by a package sent to the entire sample that included a cover letter restating the purpose of the study, a copy of the study questionnaire, and a prestamped return envelope. Two weeks later, a reminder postcard was sent to those in the sample who had not yet responded reminding them of the purpose of the study. The final mailing went out 4 weeks after the study had begun, which included a cover letter; copy of the questionnaire, in case the initial one was misplaced; and a return stamped envelope. Four weeks after the final mailing, data collection concluded. Measures Professional autonomy This section of the questionnaire centered on self-regulation and professional practice and
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included 12 items based primarily on the work of Schack and Hepler,26 Clark et al,27 and Snizek.28 In turn, all 3 research groups based their work on Hall’s Professionalism Scale.29 The wording of 10 items was almost exactly the same as Schack and Hepler,26 with some minor differences because these researchers were interested primarily in the professional nature of hospital pharmacists. For example, Schack and Hepler26 worded 1 item as the professional standards I will accept are those established by my pharmacy colleagues, whereas the wording for this study was the only professional practice standards I will accept are those established by my profession. Responses were measured using a 5-point Likert-type scale ranging from strongly disagree to strongly agree. The 2 items drawn from Snizek28 varied somewhat from the originating study because the sample population consisted of aeronautical engineers, nuclear engineers, and chemical engineers, physicists, and chemists. For example, the Snizek28 item, a basic problem for the profession is the intrusion of standards other than those which are truly professional, was reworded as, a basic problem in community pharmacy practice is the intrusion of standards/policies other than those which are truly professional. As well, the 5-point Likert scale used by Snizek (very well to very poorly) was replaced with strongly disagree to strongly agree. Manager autonomy This section included 6 items, centering on professional autonomy,13,30-36 developed specifically for the purposes of this project. The novel development of these items arose out of the desire to understand pharmacy manager’s level of autonomy, whether as the owner or as an employee. While using a validated instrument, in whole, part, or adapted, was preferred, no instrument was found that adequately matched the focus of this study. Decision making The 4 items in this section centered on professionals in bureaucracies and was based on the work of Carroll and Jowdy.15 They studied community pharmacists’ perceived autonomy and job satisfaction as employees in large chain pharmacies; therefore, the wording for this study changed slightly to reflect the study population of community pharmacy managers. For example, how much is your job one where you have a lot of say over what happens on your job, was reworded
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to, how much is your position on where you have a lot of say over what happens in your pharmacy? The 4-point scale was also slightly modified from none at all, a little, somewhat, and a lot to none, little, moderate, and lots, respectively. Amount of control Based on the work of Doucette et al,34,37-41 this section was composed of 5 items centering on the manager’s level of control, included pharmacists in all practice settings (independent, chain, government, hospital, etc), and explored a number of issues including workload, stress, and job satisfaction. All items, save one, were word for word. That item, the responsibilities delegated to support staff, was reworded to the responsibilities delegated to staff. The change in wording was done to better reflect the fact that the study population for this studydcommunity pharmacy managersdis responsible for both support and professional staff. As well, the wording of the 5-point Likert scale was slightly modified; the choices a little control and a lot of control were changed to little control and lots of control. The instrument was pretested with 5 community pharmacy managers not part of the study as well as 6 academics. Ethics approval was received from the University of Saskatchewan’s Behavioural Research Ethics Board on February 28, 2007. Pharmacy ownership structure Pharmacy types identified in the questionnaire were subdivided into 3 categories according to their ownership structure: independent (independent, small chain, and banner), franchise, and corporate (large chain, grocery store, department store, and mass merchandiser). Pharmacy ownership structure was the main independent variable for this study. For the purposes of this study, independent pharmacies were classified as those with fewer than 5 pharmacies under the same ownership. Franchise pharmacies were classified as those where the franchisee has some ownership stake in the pharmacy through franchising fees and still maintains some independence in adapting to the local market while still aligning with the franchise head office. Corporate pharmacies were classified as those with 5 or more pharmacies under the same ownership, with managers being employees of head office.
Data analysis All statistical tests were performed using SPSS 17.0 for WindowsÒ (SPSS Inc., Chicago, IL). In addition to descriptive statistics, exploratory factor analysis and reliability testing (Cronbach’s a O 0.70) were performed to identify multi-item scales (constructs). Exploratory factor analysis with orthogonal varimax rotation with Kaiser normalization and reliability tests was performed to reduce the number of items measured and used for analysis by combining 2 or more items that are related to create a single variable (construct) item.42,43 When analyzing results of the principal component analysis, items in a section that broke into distinct groups were extracted and reliability tests performed to assess the likelihood of loading those groups into a construct. One-way analysis of variance and post hoc testing with Scheffe’s test were performed to identify significant differences between ownership types. Finally, general linear models were created for the resulting constructs, using the independent variable pharmacy ownership structure and the control variables age, sex, and years with employer.
Results Response rate and demographics At the end of data collection, 646 responses were completed and returned. The sample of 2000 community pharmacy managers was reduced to 1961: 38 were deemed undeliverable and 1 pharmacy was in a long-term care home (the pharmacy manager felt the questionnaire did not reflect their practice). The final response rate was 32.9% (646/ 1961). Overall, provincial responses were proportional to the study samples of each province, with the exceptions of Ontario with a response rate that was slightly less than the entire sample (30%) and Saskatchewan at higher than the sample (52.7%). Most respondents (393, 60.8%) identified themselves as male. The average age of respondents was 44 years, with a range of 24-77 years (data not displayed). More than half of respondents (398, 61.6%) identified themselves as a pharmacy manager, with 33.3% (215) identifying themselves as the owner. Of the remaining respondents who stated their position, 1.1% identified themselves as pharmacist (3) and other (4) (eg, dispensing physician). Respondents were with their current employer for an average of 11.9 years, with a range between 1 month and 45 years.
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With regard to pharmacy type, 288 were independent (independent, small chain, and banner) representing 44.6% of respondents, 119 were franchise representing 18.4% of respondents, and 229 were corporate chain (large chain, grocery store, department store, and mass merchandiser) representing 35.4% of respondents. One mail order pharmacy and 9 ‘‘other’’ were excluded from the main independent variable because these pharmacies were not deemed community pharmacies and did not reflect the focus of the study. Authority With regard to authority, most items (7 of 12) had responses weighted toward agree/strongly agree and reflected items pertaining to the influence
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of professional authority on pharmacy practice (Table 1). The highest level of agreement was for the statement I depart from the employer’s policies when I judge it professionally necessary (89.6%). Five items (one item reverse scale) produced responses weighted toward disagree/strongly disagree. These items referred to employer influence with regard to professional practice, including the following: the employer should establish specific guidelines for making professional decisions (44.9%), the opportunity to exercise professional judgment should be determined by the employer (81.1%), the employer has the right to place limitations on the decisions I make concerning professional matters (57.9%), the employer has the right to influence professional decisions because the employer pays my salary (75.4%), and there is
Table 1 Attitudes of managers concerning foundations of authority Items
Disagree,a N (%) Neutral, N (%) Agree,b N (%) Total, N (%)
1. My pharmacy colleagues and I should be the only ones who determine and set standards for our professional practice. 2. The employer should establish specific guidelines for making professional decisions in my work. 3. The only professional practice standards I will accept are those established by my profession. 4. The opportunity to exercise professional judgment in my work should be determined by the employer. 5. Only another pharmacist is qualified to judge the competence of my professional work. 6. I depart from the employer’s policies when I judge it professionally necessary. 7. The employer has the right to influence my professional decisions because the employer pays my salary. 8. The public should be allowed input into the development of standards for professional competence which guide my practice. 9. The employer has the right to place limitations on the decisions I make concerning professional matters (reversed). 10. I would modify the professional standards which guide my practice only in response to recommendations made by my profession. 11. A basic problem in community pharmacy practice is the intrusion of standards/policies other than those which are truly professional. 12. There is little professional autonomy as a pharmacist with this employer.
142 (22.0)
71 (11.0)
426 (65.9)
639 (98.9)
290 (44.9)
126 (19.5)
220 (34.1)
636 (98.5)
139 (21.5)
102 (15.8)
391 (60.5)
632 (97.8)
524 (81.1)
65 (10.1)
49 (7.6)
638 (98.8)
134 (20.7)
72 (11.1)
432 (66.9)
638 (98.8)
11 (1.7)
49 (7.6)
579 (89.6)
639 (98.9)
487 (75.4)
77 (11.9)
75 (11.6)
639 (98.9)
181 (28.0)
150 (23.2)
307 (47.5)
638 (98.8)
374 (57.9)
101 (15.6)
161 (24.9)
636 (98.5)
100 (15.5)
93 (14.4)
441 (68.3)
634 (98.1)
106 (16.4)
169 (26.2)
355 (55.0)
630 (97.5)
425 (65.8)
132 (20.4)
59 (9.1)
616 (95.4)
a b
Collapsed disagree and strongly disagree for display purposes only. Collapsed agree and strongly agree for display purposes only.
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into a viable construct and were not subjected to further analysis. From the remaining 8 items, 2 viable constructs were identified (Table 5). Professional authority (Cronbach’s a 0.76) contained 4 items: profession determines and sets standards; accept standards established by the profession; only another pharmacist is qualified to judge competence; and modify standards only based on recommendations of profession (Table 1d items 1, 3, 5, and 10). Employer authority (Cronbach’s a 0.69) also included 4 items: employer should establish guidelines, opportunities to use professional judgment should be determined by employer, employer has right to influence my decisions, and employer has right to place limits on my professional decisions (items 2, 4, 7, and 9). The items used to measure manager autonomy (6 items), decision making (4 items), and amount of control (5 items) loaded into corresponding constructs. Each construct produced a very reliable scale: manager autonomy (Cronbach’s a 0.88), decision making (Cronbach’s a 0.89), and amount of control (Cronbach’s a 0.86).
little professional autonomy as a pharmacist with this employer (65.8%). Manager autonomy Most responses to all 6 items weighted toward usually/always (Table 2). However, respondents were more likely to indicate usually/always with regard to professional practice than business practice. Decision making The 4 items in this section dealt with professionals in bureaucracies (Table 3). Items surrounded the respondent’s ability to make decisions within their pharmacy. Most responses to the 4 items weighted strongly and consistently toward moderate/lots. Amount of control Items dealt with the respondent’s influence in controlling workplace processes within their pharmacy (Table 4). Although the responses of the 5 items weighted toward lots of control/total control, somewhat less control was associated with the development of workplace policies and time spent on various work activities.
Comparative analysis The constructs were compared using the independent variable pharmacy ownership type (Table 6). No statistical differences were found for professional authority based on type of pharmacy ownership. Comparative analysis of the employer authority construct resulted in a statistically
Constructs From the 12 items measured under authority, 4 of the 12 authority items (6, 8, 11, 12) did not load Table 2 Perceptions of managerial autonomy among respondents As pharmacy manager
Usually/alwaysb, Total, Never/seldoma, Half the N (%) time, N (%) N (%) N (%)
You have final approval on implementing a new professional service. You are authorized to alter company policies to specifications on patient care to better suit the needs of your patients. You have access to all information used to arrive at decisions on policies regarding clinical practice in your pharmacy. You have access to all information used to arrive at decisions on policies regarding business practices in your pharmacy. You are free to initiate research projects or educational programs such as cardiovascular risk reduction. You are free to participate in research projects or educational programs related to your patient population.
162 (25.1)
72 (11.1)
403 (62.4)
637 (98.6)
129 (20.0)
64 (9.9)
439 (68.0)
632 (97.8)
105 (16.2)
54 (8.4)
474 (73.4)
633 (98.0)
167 (25.8)
88 (13.6)
378 (58.5)
633 (98.0)
114 (17.6)
50 (7.7)
467 (72.2)
631 (97.7)
84 (13.1)
37 (5.7)
510 (78.9)
631 (97.7)
a b
Collapsed seldom and never for display purposes only. Collapsed usually and always for display purposes only.
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Dobson & Perepelkin / Research in Social and Administrative Pharmacy 7 (2011) 347–358 Table 3 Perceived decision-making ability of pharmacy managers As pharmacy manager how much Freedom does your position allow you as to how you do your work? Does your position allow you to make most decisions on your own? Does your position allow you to take part in decisions that affect you? Is your position one where you have a lot of say over what happens in your pharmacy? a
Little/none,a N (%)
Moderate, N (%)
Lots, N (%)
Total, N (%)
81 (12.1)
242 (37.5)
314 (48.6)
637 (98.6)
75 (11.7)
219 (33.9)
344 (53.3)
638 (98.8)
113 (17.5)
217 (33.6)
307 (47.5)
637 (98.6)
104 (16.1)
200 (31.0)
332 (51.4)
636 (98.5)
Collapsed none and little for display purposes only.
significant difference between corporate pharmacy respondents and those in franchise and independent pharmacies (P ! .001). Analysis of the manager autonomy scale showed significant differences among all 3 pharmacy types: corporate, franchise, and independent (P ! .001). Corporate respondents reported the least amount of manager autonomy, followed by franchise respondents, with independent pharmacy managers reporting the most autonomy. Significant differences (P ! .001) were found among the 3 pharmacy types with regard to decision making. Independent pharmacy respondents reported having the most decision-making ability, followed by franchise respondents, with corporate respondents reporting the least amount of decision-making ability. Respondents in corporate pharmacies also reported the least amount of control, followed by franchise respondents, with respondents in independent pharmacies reporting the most control. General linear model General linear modeling (GLM) of the constructs was carried out, controlling for pharmacy ownership structure, sex, age, and years with employer (Table 7). For the most part, the relationship between ownership structure and the
5 constructs measuring authority and autonomy was unchanged and the effect of the control variables was minimal. However, using GLM, no significant differences were found between ownership types and employer authority. Control variables made significant contributions to 3 of the models. Age was significantly related to professional authority (P ! .001), and years with employer were significantly related to professional autonomy (P ! .05) and decision making (P ! .05).
Discussion In this study, community pharmacy managers generally acknowledged the primacy of the profession with regard to establishing and applying professional practice standards, and in comparing managers across the 3 ownership types, no significant differences were found with regard to professional authority. In general, managers did not generally support a large role for employers in establishing or applying these standards; however, independent and franchise respondents may be more likely than corporate respondents to support employer authority. The tendency of independent and franchise pharmacy respondents to more readily accept employer involvement may
Table 4 Ability of pharmacy managers to control the work environment As pharmacy manager your ability to control
Little/no control,a N (%)
Moderate, N (%)
Lots/complete,b N (%)
Total, N (%)
The quality of care provided to patients The development of workplace policies The responsibilities delegated to staff How workplace problems are solved The time spent on various work activities
22 137 23 27 66
176 145 136 147 211
441 356 482 467 363
639 638 641 641 640
a b
(3.4) (21.2) (3.6) (4.2) (10.2)
Collapsed little and no control for display purposes only. Collapsed lots and complete for display purposes only.
(27.2) (22.4) (21.1) (22.8) (32.7)
(68.3) (55.1) (74.6) (72.3) (56.1)
(98.9) (98.8) (99.2) (99.2) (99.1)
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Table 5 Authority and autonomy constructs Construct
Number of items
Scale
Range
Mean (SD)
Cronbach’s a
Professional authority Employer authority Manager autonomy Decision making Control amount
4 4 6 4 5
Strongly disagree (1)-strongly agree (5)
4-20 4-20 6-30 4-16 5-25
14.7 9.23 22.8 13.4 19.0
0.759 0.694 0.875 0.894 0.861
Never (1)-always (5) None (1)-lots (4) No control (1)-total control (5)
(3.25) (2.89) (5.62) (2.62) (3.59)
SD, standard deviation.
be explained either by the fact that many of the respondents were themselves the owner/franchisee (ie, the employer) or worked with a pharmacistowner/franchisee. Despite similar attitudes regarding professional and employer authority, there was a clear divide among the 3 ownership types with specific managerial aspects of community pharmacy practice, as suggested by the findings for manager autonomy, decision making, and amount of control. Consistent with earlier studies,15,30,31,44,45 the corporate pharmacy managers reported having less manager autonomy than franchise managers, who in turn reported less autonomy than the independent pharmacy managers. As with manager autonomy, there was a noticeable divergence among the 3 groups with regard to decision making and amount of control. Although respondents in corporate pharmacies might be professionally oriented, they reported less decision-making ability and control than respondents in independent and, to a lesser extent, franchise pharmacies. For most organizations, including community pharmacies, there is recognition of the need to control processes and formalize duties to reduce uncertainty and error.46 However, as organizations grow in size they become more bureaucratic; levels of authority and the number of formalized procedures will grow as the organization grows
in an effort to increase the efficiency and coordination of activities across the organization.20,47 Bureaucracy has been described as the most rational and efficient way to organize work.48 However, it is also linked to the degradation of the work life of employees49; and the more bureaucratic the organization, the greater the likelihood of conflict and job dissatisfaction.50 Furthermore, professionals are guided primarily by the needs of the client/patient, whereas bureaucracies are guided by the goals of the organization.15 As a result, attempts to standardize professional work often impede and discourage professionals and can lead to impersonal and ineffective service.47 Bureaucratization can also lead to proletarianization. Specifically, ‘‘the process by which an occupational category is divested of control over certain prerogatives relating to the location, content and essentiality of its task activities’’.48 The effect is the reduction of workers to some common level to service the broader interests of capital accumulation.51 Traditionally, pharmacists were the owners of pharmacies; however, with the number of pharmacist-entrepreneurs decreasing and corporateowned pharmacies increasing,52 the profession may find itself subordinate to the broader requirements of business, with a focus on attaining the
Table 6 Comparative analysis of constructs by pharmacy ownership type (n ¼ 636) Construct
Pharmacy ownership type, mean (CI)
F value (significance)
Independent (n ¼ 289) Franchise (n ¼ 118) Corporate chain (n ¼ 229) Professional authority Employer authoritya Manager autonomyb Decision makingb Amount of controlb
14.60 9.58 26.08 14.87 20.54
(14.19-15.01) (9.20-9.96) (25.60-26.55) (14.66-15.08) (20.15-20.92)
15.02 9.68 22.26 12.91 18.53
(14.46-15.57) (9.12-10.24) (21.27-23.24) (12.41-13.40) (17.87-19.19)
14.67 8.59 19.02 11.81 17.20
(14.25-15.08) (8.26-8.93) (18.34-19.70) (11.49-12.13) (16.79-17.60)
CI, confidence interval. Scheffe’s test (P ! .05): corporate significantly different from independent or franchise. b Scheffe’s test (P ! .05): all 3 significantly different from one another. a
0.69 8.40 138.38 120.95 66.36
(P ¼ .50) (P ! .001) (P ! .001) (P ! .001) (P ! .001)
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Table 7 General linear models of constructs by ownership type and control variables Model components
Type III sum of squares
df
Mean square
F
P
R-squared (adjusted R-squared)
Professional authority Ownership Sex Age Years with employer
26.60 3.70 192.52 43.23
2 1 2 4
12.30 3.70 96.26 10.81
1.30 0.36 9.40 1.06
.274 .548 .000 .378
0.050 (0.030)
Employer authority Ownership Sex Age Years with employer
28.01 0.11 1.13 29.26
2 1 2 4
14.01 0.11 0.57 7.31
2.53 0.02 0.10 1.32
.081 .888 .903 .262
0.035 (0.015)
Professional autonomy Ownership Sex Age Years with employer
3321.39 5.95 7.44 285.14
2 1 2 4
1660.69 5.95 3.72 71.29
77.68 0.28 0.17 3.34
.000 .598 .840 .010
0.318 (0.303)
Decision making Ownership Sex Age Years with employer
723.81 3.00 3.82 51.293
2 1 2 4
361.90 3.00 1.91 12.82
73.29 0.61 0.38 2.60
.000 .438 .679 .038
0.292 (0.277)
Amount of control Ownership Sex Age Years with employer
671.42 11.17 11.54 86.52
2 1 2 4
335.71 11.17 5.77 21.63
32.21 1.07 0.55 2.08
.000 .301 .575 .083
0.174 (0.156)
df, degrees of freedom.
maximum financial return on investment.20 Although there continues to be opportunities to control the nature of one’s work, the economic and competitive influences of the marketplace are leaving many pharmacists little choice but to practice their profession as employees of large corporate entities.27 As in any large organization, whether public or private, for profit or not for profit, corporate managers can expect to encounter some degree of bureaucracy and a reduced level of autonomy30,31,44,45,53 and control.48,51,54,55 However, the relative lack of autonomy and control reported in our study among pharmacy managers regarding the nature of professional work in what is increasingly the more predominant ownership model is a concern, with important implications for the profession and Canadian society. Society grants professions the right to selfregulate, and the professions maintain their autonomy in exchange for placing the interest of society above personal and organizational
interests. As such, professional decision making must be relatively free of outside nonprofessional influences. Some have argued that economic control is essential to secure professional control.56,57 For example, physicians enjoy a high level of professional autonomy and tend to work in limited partnerships where they maintain a significant level of economic control. Others argue that economic control is less important if the objectives of the profession are supported by the employer.19 For example, some health professionals with limited economic control, such as nurses, are still able to advance their professional goals and are even obtaining greater clinical autonomy because they tend to practice within organizations, such as hospitals and health regions, where there are clear health-centered objectives consistent with the objectives of the professionals they employ.19 It is also argued that even within nonprofessional organizations, professionals can still establish professional autonomy.19 However, this
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argument assumes that these professional activities take place within distinct departments that support or are secondary to the core business. For example, lawyers in a legal department within a larger organization may be able to manage their own activities (provided they stay within budget and provide good legal advice), but this is not the case for the pharmacist-employee. For community pharmacists, their work is the core business. The actions of pharmacists and pharmacy managers directly affect the revenues and profitability of the organization; therefore, there is a considerable and persistent incentive for senior managers to seek ways to maximize revenues and minimize the costs related to the work of these employees. Unlike other professionals, the unique relationship between the profession of pharmacy and business of pharmacy places the profession at greater risk of the loss of control over the content of their professional work activities.48 Although pharmacy managers were generally secure about their ability to exercise professional authority, specific activities relating to autonomy, decision making, and control suggest a lesser ability to control the work environment among corporate pharmacy managers. Although other factors may partially explain the differences, it suggests the need for a stronger professional voice within community practice. Whether this is in the form of a stronger regulatory presence, a professional association, or some other form, it is an action that must be initiated and directed by the profession itself; although, we would argue it should occur sooner rather than later. Limitations Because of the nature of the study, limitations are to be expected and acknowledged. First, as with any self-report methodology, one must approach the results with a certain level of caution because it relies on respondents to accurately reflect their perceptions/feelings/experiences. Moreover, this study was conducted in Canada and, therefore, may not be applicable to other regions. There is the possibility that some study participants did not respond to the survey because of company policy. This was witnessed when one pharmacy manager sent an electronic mail stating that he could not respond because of company policy. As well, some in the sample requested that the questionnaire be sent to their home address, as
opposed to their pharmacy address, because they could not complete it at the pharmacy. Further to this, when presenting preliminary results at the Canadian Pharmacists Association annual conference in Ottawa, Ontario, on June 3, 2007, representatives from one company made it clear that pharmacy managers in their stores are not to respond to any survey without upper management reviewing the instrument first. Another limitation to this study is that the questionnaire and accompanying materials mailed to the sample were written only in English. Although pharmacy managers in Quebec were not included in this study, in a bilingual (English and French) country such as Canada, Frenchspeaking pharmacists exist outside Quebec, particularly in Ontario and New Brunswick. Therefore, it is possible that some study participants were unilingual Francophones and did not complete the questionnaire because of it being written only in English. As with any survey research, there is the potential for nonresponse bias between responders and nonresponders. A nonresponder survey was not conducted for this study; however, to assess the potential for nonresponder bias the method of early versus late responder analysis was completed.21,58-60 In this method of assessing nonresponder bias, the assumption is that late responders respond similar to nonresponders. Therefore, if any statistically significant differences are established between early and late responders, the same difference is assumed to occur between responders and nonresponders.21,58-60 No statistically significant differences were observed when conducting chi-square analysis on the independent variable pharmacy ownership structure. Chi-square analysis of the sex variable also did not result in any statistically significant differences between early and late responders. The final analysis of the age variable by means of an independent t test also did not result in any statistically significant differences.
Conclusions The ability of a profession to self-regulate (authority) and control how its work is performed (autonomy) is critical to meeting its social obligations.19 Pharmacy managers currently perceive a high level of authority relating to the setting of practice standards and the evaluation of professional competence; but, with declining autonomy,
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it is unclear whether professional authority is sufficient to prevent the subordination of both patient and professional interests to external financial interests. Acknowledgments The authors thank the community pharmacy managers who took time out of their busy schedules to complete and return the questionnaire and the provincial regulatory agencies for providing the contact information for community pharmacy managers in their respective province.
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35. Ritzer G. Professionalization, bureaucratization and rationalization: the views of Max Weber. Soc Forces 1975;53:627–634. 36. Scott W. Professionals in bureaucraciesdareas of conflict. In: Vollmer H, Mills D, eds. Professionalization. Englewood Cliffs, NJ: Prentice-Hall, Inc.; 1966. p. 265–275. 37. Doucette W. Workforce Survey Instruments. Iowa City, IA; 2006:Provided questionnaires used in 2004 National Pharmacist Workforce Survey. 38. Doucette W, Kreling D, Schommer J, Gaither C, Mott D, Pedersen C. Evaluation of community pharmacy service mix: evidence from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc 2006;46:348–355. 39. Kreling D, Doucette W, Mott D, Gaither C, Pedersen C, Schommer J. Community pharmacists’ work environments: evidence from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc 2006;46:331–339. 40. Mott D, Doucette W, Gaither C, Pedersen C, Schommer J. Pharmacists’ attitudes towards worklife: results from a national survey of pharmacists. J Am Pharm Assoc 2004;44:326–336. 41. Schommer J, Pedersen C, Gaither C, Doucette W, Kreling D, Mott D. Pharmacists’ desired and actual times in work activities: evidence of gaps from the 2004 National Pharmacist Workforce Study. J Am Pharm Assoc 2006;46:340–347. 42. Nunnally J, Bernstein I. Psychometric Theory. 3rd ed. Toronto, Canada: McGraw-Hill, Inc.; 1994. 43. Peter J. Reliability: a review of psychometric basics and recent marketing practices. J Mark Res 1979;6: 6–17. 44. Kronus C. Occupational values, role orientations, and work settings: the case of pharmacy. Sociol Q 1975;16:171–183. 45. Kronus C. Occupational versus organizational influences on reference group identification: the case of pharmacy. Sociol Work Occup 1976;3:303–331. 46. Aldrich H. Organizations and Environments. Englewood Cliffs, NJ: Prentice-Hall, Inc.; 1979. 47. Mintzberg H. The Structuring of Organizations: A Synthesis of the Research. Englewood Cliffs, NJ: Prentice-Hall, Inc.; 1979.
48. McKinlay J, Stoeckle J. Corporatization and the social transformation of doctoring. In: Salmon J, ed. The Corporate Transformation of Health Care Part IdIssues & Directions. Amityville, NY: Baywood Publishing Company, Inc.; 1990. p. 133–149. 49. Weber M. Economy and Society: An Outline of Interpretive Sociology. New York, NY: Bedminster Press; 1968. 50. Sorensen J, Sorensen T. The conflict of professionals in bureaucratic organizations. Adm Sci Quart 1974; 19(1):98–106. 51. McKinlay J, Arches J. Towards the proletarianization of physicians. Int J Health Serv 1985;15(2):161–195. 52. 2005 Pharmacy Trends & Insights. Rogers Media, Toronto, Canada, 2005. 53. Zoloth-Dorfman L, Rubin S. The patient as commodity: managed care and the question of ethics. J Clin Ethics 1995;6(4):339–357. 54. Coburn D. Canadian medicine: dominance or proletarianization?. In: Salmon J, ed. The Corporate Transformation of Health Care Part IIdPerspectives & Implications. Amityville, NY: Baywood Publishing Company, Inc.; 1994. p. 225–244. 55. Salmon J. The professional and corporate context: trends in the United States. In: Davis P, ed. Contested Ground: Public Purpose and Private Interest in the Regulation of Prescription Drugs. New York, NY: Oxford University Press; 1996. p. 141–158. 56. Coburn D. State authority, medical dominance and trends in the regulation of the health professions: the Ontario case. Soc Sci Med 1993;37(2):129–138. 57. Pineault R, Contandriopoulos AP, Founier MA. Physicians’ acceptance of an alternative to feefor-service payment: a possible source of change in Quebec medicine. Int J Health Serv 1985;15(3): 419–430. 58. Churchill G, Iacobucci D. Marketing Research: Methodological Foundations. 8th ed. Fort Worth, TX: Harcourt College Publishers; 2002. 59. Churchill G, Peter J. Research design effects on the reliability of rating scales: a meta-analysis. J Mark Res 1984;21(November):360–375. 60. Oppenheim A. Questionnaire Design, Interviewing, and Attitude Measurement. New York, NY: Pinter Publishers; 1992.
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Original Research
Pharmacy ownership in Canada: Implications for the authority and autonomy of community pharmacy managers Roy Thomas Dobson, B.Sc.Phm., M.B.A., Ph.D.*, Jason Perepelkin, B.A., B.Comm., M.Sc., Ph.D. College of Pharmacy & Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon, Saskatchewan, Canada S7N 5C9
Abstract Background: In recent years, the number of independently owned pharmacies has declined even as the total number of pharmacies in Canada has increased. With increasing corporate ownership, there is concern that this trend will adversely affect the profession’s ability to influence pharmacy practice and practice change. Objective: To examine the relationship between ownership type and community pharmacy managers in terms of professional and employer authority, managerial autonomy, decision making, and amount of control. Methods: This study consisted of a cross-sectional survey of community pharmacy managers in Canada by means of a self-administered postal questionnaire sent to a stratified sample of community pharmacies. Statistical analysis consisted of exploratory factor analysis with reliability testing on identified constructs. Frequencies, 1-way analyses of variance, Scheffe post hoc tests, and general linear modeling were used to determine significant differences among groups based on ownership type. Results: In total, 646 of 1961 questionnaires from pharmacy managers were completed and returned (response rate 32.9%). Respondents rated their authority similarly across ownership types. Autonomy, decision-making capabilities, and control needed to carry out the professional role appear most limited among corporate respondents and, to a lesser extent, franchise managers. Conclusions: Pharmacy managers currently perceive a high level of authority; but with limited autonomy among corporate managers, it is unclear whether this authority is sufficient to prevent the subordination of both patient and professional interests to financial interests. Ó 2011 Elsevier Inc. All rights reserved. Keywords: Community pharmacy; Managers; Authority; Autonomy; Decision making; Control
Funding/Support: Funding was provided through an internal research grant from the College of Pharmacy & Nutrition, University of Saskatchewan. Previous Presentations: Portions of this study were presented at the American Pharmacists Association Annual Conference; March 17, 2008; San Diego, California. Preliminary results of this study were presented at the Canadian Pharmacists Association Annual Conference; June 3, 2007; Ottawa, Ontario, Canada. * Corresponding author. Tel.: þ1 306 966 6363; fax: þ1 306 966 6377. E-mail address: [email protected] (R.T. Dobson). 1551-7411/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2010.10.005
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Introduction In the past, community pharmacy in Canada was dominated by small, independent, pharmacistowned enterprises that, in their turn, employed many other pharmacists to staff and manage these businesses.1 Over time, regulatory changes throughout Canada allowed nonpharmacists to own and operate pharmacies; and in recent years, the number of independently owned pharmacies has declined even as the total number of pharmacies in Canada has increased, along with more largerscale, nonpharmacist-controlled corporate entities.2 Today, the presence of a licensed pharmacist is still required when the dispensary is open, but pharmacists are now increasingly employees in corporate-owned and -operated pharmacies,3 and the economic control of community practice is slowly, but surely, being wrested away from the profession. At the same time that the composition of pharmacy ownership in Canada is changing, the nature of pharmacy practice and the practice expectations of the profession are also evolving. Many community pharmacy practitioners are seeking greater professional autonomy and a more service-oriented, patient-focused approach to patient care, with a greater emphasis on the use of their clinical skills.4-7 Indeed, most new pharmacists express little or no interest in the business aspects of community practice and increasingly define themselves professionally in terms of their responsibilities.8,9 However, because large corporations with a decidedly stronger business orientation gain a more dominant position within community pharmacy, and because pharmacists turn away from business-related leadership roles within these organizations, pharmacists may find their ability to develop and introduce cognitive pharmacy services increasingly curtailed. Agency theory suggests that the sole social responsibility of a corporation is to increase profits.10 For these businesses, pharmacists represent very expensive but necessary human capital, and as such, business will look to maximize the productivity of these inputs.11,12 Although more reflective of the professional goals of pharmacy, clinical services not directly linked to dispensing a prescription may represent less lucrative and reliable sources of revenue.13,14 Nonpharmacist corporate owners and their senior management teams are more likely to favor expanding revenues and reducing costs through increased prescription volume and production efficiency and may be less
concerned with achieving pharmacy’s professional objectives. Activities deemed less likely to contribute to the ‘‘bottom line’’ will invariably be of a lower priority. Research suggests that professionals employed in larger organizations perceive themselves to have less autonomy, due in part to the more bureaucratic and predetermined structures of these organizations.15 Gradually, but at an increasing rate, health professionals, including pharmacists, are becoming employees in nonprofessional organizations where they are outnumbered by nonprofessional employees.16-19 Moreover, because of technical processes put in place to achieve business objectives, the ability of frontline pharmacy managers to affect steps within the organization’s decision-making processes will be increasingly limited.20 This shift in employment status also increases the likelihood of conflict between a businessoriented leadership and more professionally oriented frontline managers.21,22 When health care providers practice within a large predominantly nonprofessional organization, professional ideals can conflict with the principles and practices of the employing organization.23 Conflict arises because of competing sources of authority: the first deriving from the formal authority of the employer organization and the second from the professional expertise held by the professional and enforced by collegial authority.18 Incongruence between these 2 sources of authority can lead to a disruption of an individual’s orientation to the organization and/or the profession; criticism of the organization by pharmacists orientated toward their professional norms; the ignoring of administrative details; and stress for those pharmacists ‘‘caught in the middle,’’18 in particular, pharmacists who also have managerial responsibilities. With increasing nonpharmacist ownership, some economic autonomy is invariably removed from the profession.24 Although the professional orientation of pharmacy managers still appears to be strong,25 a concern for the profession is that with increasing nonpharmacist ownership, a business orientation to maximize shareholder value will take pre-eminence over the professional objectives of pharmacy managers.20 In effect, business-oriented ownership will use its economic authority to curtail the professional autonomy and authority of pharmacy managers, those most responsible for directing the operations of the individual pharmacy location.
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The purpose of this study is to describe the perceived authority and autonomy of community pharmacy managers in Canada and how these relate to the ownership of the pharmacies where these managers practice. Methods Data source and collection A self-administered questionnaire was mailed to community pharmacy managers across Canada. Contact information obtained from provincial regulatory agencies was used to compile a master list of 6342 community pharmacy managers. From this list, a random stratified sample of 2000 community pharmacy managers was extracted based on the number of community pharmacy managers in each province. Based on an expected response rate of 30%, a sample size of 2000 was needed to secure 600 completed questionnaires, the number calculated as necessary to achieve statistical power. The calculated number of completed questionnaires needed was based on a population size of 6342 pharmacies outside Quebec with a confidence level of 99% and a margin of error of 5%. Contact information was not obtained for community pharmacy managers in Quebec. At the time of the study, the ownership of a pharmacy in the province was restricted to a licensed pharmacist; therefore, it would not be possible to compare ownership types within Quebec. Data collection consisted of up to 4 separate mailings. The first mailing was a letter stating the study overview and purpose that went out to the entire sample. The overview letter was followed 1 week later by a package sent to the entire sample that included a cover letter restating the purpose of the study, a copy of the study questionnaire, and a prestamped return envelope. Two weeks later, a reminder postcard was sent to those in the sample who had not yet responded reminding them of the purpose of the study. The final mailing went out 4 weeks after the study had begun, which included a cover letter; copy of the questionnaire, in case the initial one was misplaced; and a return stamped envelope. Four weeks after the final mailing, data collection concluded. Measures Professional autonomy This section of the questionnaire centered on self-regulation and professional practice and
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included 12 items based primarily on the work of Schack and Hepler,26 Clark et al,27 and Snizek.28 In turn, all 3 research groups based their work on Hall’s Professionalism Scale.29 The wording of 10 items was almost exactly the same as Schack and Hepler,26 with some minor differences because these researchers were interested primarily in the professional nature of hospital pharmacists. For example, Schack and Hepler26 worded 1 item as the professional standards I will accept are those established by my pharmacy colleagues, whereas the wording for this study was the only professional practice standards I will accept are those established by my profession. Responses were measured using a 5-point Likert-type scale ranging from strongly disagree to strongly agree. The 2 items drawn from Snizek28 varied somewhat from the originating study because the sample population consisted of aeronautical engineers, nuclear engineers, and chemical engineers, physicists, and chemists. For example, the Snizek28 item, a basic problem for the profession is the intrusion of standards other than those which are truly professional, was reworded as, a basic problem in community pharmacy practice is the intrusion of standards/policies other than those which are truly professional. As well, the 5-point Likert scale used by Snizek (very well to very poorly) was replaced with strongly disagree to strongly agree. Manager autonomy This section included 6 items, centering on professional autonomy,13,30-36 developed specifically for the purposes of this project. The novel development of these items arose out of the desire to understand pharmacy manager’s level of autonomy, whether as the owner or as an employee. While using a validated instrument, in whole, part, or adapted, was preferred, no instrument was found that adequately matched the focus of this study. Decision making The 4 items in this section centered on professionals in bureaucracies and was based on the work of Carroll and Jowdy.15 They studied community pharmacists’ perceived autonomy and job satisfaction as employees in large chain pharmacies; therefore, the wording for this study changed slightly to reflect the study population of community pharmacy managers. For example, how much is your job one where you have a lot of say over what happens on your job, was reworded
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to, how much is your position on where you have a lot of say over what happens in your pharmacy? The 4-point scale was also slightly modified from none at all, a little, somewhat, and a lot to none, little, moderate, and lots, respectively. Amount of control Based on the work of Doucette et al,34,37-41 this section was composed of 5 items centering on the manager’s level of control, included pharmacists in all practice settings (independent, chain, government, hospital, etc), and explored a number of issues including workload, stress, and job satisfaction. All items, save one, were word for word. That item, the responsibilities delegated to support staff, was reworded to the responsibilities delegated to staff. The change in wording was done to better reflect the fact that the study population for this studydcommunity pharmacy managersdis responsible for both support and professional staff. As well, the wording of the 5-point Likert scale was slightly modified; the choices a little control and a lot of control were changed to little control and lots of control. The instrument was pretested with 5 community pharmacy managers not part of the study as well as 6 academics. Ethics approval was received from the University of Saskatchewan’s Behavioural Research Ethics Board on February 28, 2007. Pharmacy ownership structure Pharmacy types identified in the questionnaire were subdivided into 3 categories according to their ownership structure: independent (independent, small chain, and banner), franchise, and corporate (large chain, grocery store, department store, and mass merchandiser). Pharmacy ownership structure was the main independent variable for this study. For the purposes of this study, independent pharmacies were classified as those with fewer than 5 pharmacies under the same ownership. Franchise pharmacies were classified as those where the franchisee has some ownership stake in the pharmacy through franchising fees and still maintains some independence in adapting to the local market while still aligning with the franchise head office. Corporate pharmacies were classified as those with 5 or more pharmacies under the same ownership, with managers being employees of head office.
Data analysis All statistical tests were performed using SPSS 17.0 for WindowsÒ (SPSS Inc., Chicago, IL). In addition to descriptive statistics, exploratory factor analysis and reliability testing (Cronbach’s a O 0.70) were performed to identify multi-item scales (constructs). Exploratory factor analysis with orthogonal varimax rotation with Kaiser normalization and reliability tests was performed to reduce the number of items measured and used for analysis by combining 2 or more items that are related to create a single variable (construct) item.42,43 When analyzing results of the principal component analysis, items in a section that broke into distinct groups were extracted and reliability tests performed to assess the likelihood of loading those groups into a construct. One-way analysis of variance and post hoc testing with Scheffe’s test were performed to identify significant differences between ownership types. Finally, general linear models were created for the resulting constructs, using the independent variable pharmacy ownership structure and the control variables age, sex, and years with employer.
Results Response rate and demographics At the end of data collection, 646 responses were completed and returned. The sample of 2000 community pharmacy managers was reduced to 1961: 38 were deemed undeliverable and 1 pharmacy was in a long-term care home (the pharmacy manager felt the questionnaire did not reflect their practice). The final response rate was 32.9% (646/ 1961). Overall, provincial responses were proportional to the study samples of each province, with the exceptions of Ontario with a response rate that was slightly less than the entire sample (30%) and Saskatchewan at higher than the sample (52.7%). Most respondents (393, 60.8%) identified themselves as male. The average age of respondents was 44 years, with a range of 24-77 years (data not displayed). More than half of respondents (398, 61.6%) identified themselves as a pharmacy manager, with 33.3% (215) identifying themselves as the owner. Of the remaining respondents who stated their position, 1.1% identified themselves as pharmacist (3) and other (4) (eg, dispensing physician). Respondents were with their current employer for an average of 11.9 years, with a range between 1 month and 45 years.
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With regard to pharmacy type, 288 were independent (independent, small chain, and banner) representing 44.6% of respondents, 119 were franchise representing 18.4% of respondents, and 229 were corporate chain (large chain, grocery store, department store, and mass merchandiser) representing 35.4% of respondents. One mail order pharmacy and 9 ‘‘other’’ were excluded from the main independent variable because these pharmacies were not deemed community pharmacies and did not reflect the focus of the study. Authority With regard to authority, most items (7 of 12) had responses weighted toward agree/strongly agree and reflected items pertaining to the influence
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of professional authority on pharmacy practice (Table 1). The highest level of agreement was for the statement I depart from the employer’s policies when I judge it professionally necessary (89.6%). Five items (one item reverse scale) produced responses weighted toward disagree/strongly disagree. These items referred to employer influence with regard to professional practice, including the following: the employer should establish specific guidelines for making professional decisions (44.9%), the opportunity to exercise professional judgment should be determined by the employer (81.1%), the employer has the right to place limitations on the decisions I make concerning professional matters (57.9%), the employer has the right to influence professional decisions because the employer pays my salary (75.4%), and there is
Table 1 Attitudes of managers concerning foundations of authority Items
Disagree,a N (%) Neutral, N (%) Agree,b N (%) Total, N (%)
1. My pharmacy colleagues and I should be the only ones who determine and set standards for our professional practice. 2. The employer should establish specific guidelines for making professional decisions in my work. 3. The only professional practice standards I will accept are those established by my profession. 4. The opportunity to exercise professional judgment in my work should be determined by the employer. 5. Only another pharmacist is qualified to judge the competence of my professional work. 6. I depart from the employer’s policies when I judge it professionally necessary. 7. The employer has the right to influence my professional decisions because the employer pays my salary. 8. The public should be allowed input into the development of standards for professional competence which guide my practice. 9. The employer has the right to place limitations on the decisions I make concerning professional matters (reversed). 10. I would modify the professional standards which guide my practice only in response to recommendations made by my profession. 11. A basic problem in community pharmacy practice is the intrusion of standards/policies other than those which are truly professional. 12. There is little professional autonomy as a pharmacist with this employer.
142 (22.0)
71 (11.0)
426 (65.9)
639 (98.9)
290 (44.9)
126 (19.5)
220 (34.1)
636 (98.5)
139 (21.5)
102 (15.8)
391 (60.5)
632 (97.8)
524 (81.1)
65 (10.1)
49 (7.6)
638 (98.8)
134 (20.7)
72 (11.1)
432 (66.9)
638 (98.8)
11 (1.7)
49 (7.6)
579 (89.6)
639 (98.9)
487 (75.4)
77 (11.9)
75 (11.6)
639 (98.9)
181 (28.0)
150 (23.2)
307 (47.5)
638 (98.8)
374 (57.9)
101 (15.6)
161 (24.9)
636 (98.5)
100 (15.5)
93 (14.4)
441 (68.3)
634 (98.1)
106 (16.4)
169 (26.2)
355 (55.0)
630 (97.5)
425 (65.8)
132 (20.4)
59 (9.1)
616 (95.4)
a b
Collapsed disagree and strongly disagree for display purposes only. Collapsed agree and strongly agree for display purposes only.
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into a viable construct and were not subjected to further analysis. From the remaining 8 items, 2 viable constructs were identified (Table 5). Professional authority (Cronbach’s a 0.76) contained 4 items: profession determines and sets standards; accept standards established by the profession; only another pharmacist is qualified to judge competence; and modify standards only based on recommendations of profession (Table 1d items 1, 3, 5, and 10). Employer authority (Cronbach’s a 0.69) also included 4 items: employer should establish guidelines, opportunities to use professional judgment should be determined by employer, employer has right to influence my decisions, and employer has right to place limits on my professional decisions (items 2, 4, 7, and 9). The items used to measure manager autonomy (6 items), decision making (4 items), and amount of control (5 items) loaded into corresponding constructs. Each construct produced a very reliable scale: manager autonomy (Cronbach’s a 0.88), decision making (Cronbach’s a 0.89), and amount of control (Cronbach’s a 0.86).
little professional autonomy as a pharmacist with this employer (65.8%). Manager autonomy Most responses to all 6 items weighted toward usually/always (Table 2). However, respondents were more likely to indicate usually/always with regard to professional practice than business practice. Decision making The 4 items in this section dealt with professionals in bureaucracies (Table 3). Items surrounded the respondent’s ability to make decisions within their pharmacy. Most responses to the 4 items weighted strongly and consistently toward moderate/lots. Amount of control Items dealt with the respondent’s influence in controlling workplace processes within their pharmacy (Table 4). Although the responses of the 5 items weighted toward lots of control/total control, somewhat less control was associated with the development of workplace policies and time spent on various work activities.
Comparative analysis The constructs were compared using the independent variable pharmacy ownership type (Table 6). No statistical differences were found for professional authority based on type of pharmacy ownership. Comparative analysis of the employer authority construct resulted in a statistically
Constructs From the 12 items measured under authority, 4 of the 12 authority items (6, 8, 11, 12) did not load Table 2 Perceptions of managerial autonomy among respondents As pharmacy manager
Usually/alwaysb, Total, Never/seldoma, Half the N (%) time, N (%) N (%) N (%)
You have final approval on implementing a new professional service. You are authorized to alter company policies to specifications on patient care to better suit the needs of your patients. You have access to all information used to arrive at decisions on policies regarding clinical practice in your pharmacy. You have access to all information used to arrive at decisions on policies regarding business practices in your pharmacy. You are free to initiate research projects or educational programs such as cardiovascular risk reduction. You are free to participate in research projects or educational programs related to your patient population.
162 (25.1)
72 (11.1)
403 (62.4)
637 (98.6)
129 (20.0)
64 (9.9)
439 (68.0)
632 (97.8)
105 (16.2)
54 (8.4)
474 (73.4)
633 (98.0)
167 (25.8)
88 (13.6)
378 (58.5)
633 (98.0)
114 (17.6)
50 (7.7)
467 (72.2)
631 (97.7)
84 (13.1)
37 (5.7)
510 (78.9)
631 (97.7)
a b
Collapsed seldom and never for display purposes only. Collapsed usually and always for display purposes only.
353
Dobson & Perepelkin / Research in Social and Administrative Pharmacy 7 (2011) 347–358 Table 3 Perceived decision-making ability of pharmacy managers As pharmacy manager how much Freedom does your position allow you as to how you do your work? Does your position allow you to make most decisions on your own? Does your position allow you to take part in decisions that affect you? Is your position one where you have a lot of say over what happens in your pharmacy? a
Little/none,a N (%)
Moderate, N (%)
Lots, N (%)
Total, N (%)
81 (12.1)
242 (37.5)
314 (48.6)
637 (98.6)
75 (11.7)
219 (33.9)
344 (53.3)
638 (98.8)
113 (17.5)
217 (33.6)
307 (47.5)
637 (98.6)
104 (16.1)
200 (31.0)
332 (51.4)
636 (98.5)
Collapsed none and little for display purposes only.
significant difference between corporate pharmacy respondents and those in franchise and independent pharmacies (P ! .001). Analysis of the manager autonomy scale showed significant differences among all 3 pharmacy types: corporate, franchise, and independent (P ! .001). Corporate respondents reported the least amount of manager autonomy, followed by franchise respondents, with independent pharmacy managers reporting the most autonomy. Significant differences (P ! .001) were found among the 3 pharmacy types with regard to decision making. Independent pharmacy respondents reported having the most decision-making ability, followed by franchise respondents, with corporate respondents reporting the least amount of decision-making ability. Respondents in corporate pharmacies also reported the least amount of control, followed by franchise respondents, with respondents in independent pharmacies reporting the most control. General linear model General linear modeling (GLM) of the constructs was carried out, controlling for pharmacy ownership structure, sex, age, and years with employer (Table 7). For the most part, the relationship between ownership structure and the
5 constructs measuring authority and autonomy was unchanged and the effect of the control variables was minimal. However, using GLM, no significant differences were found between ownership types and employer authority. Control variables made significant contributions to 3 of the models. Age was significantly related to professional authority (P ! .001), and years with employer were significantly related to professional autonomy (P ! .05) and decision making (P ! .05).
Discussion In this study, community pharmacy managers generally acknowledged the primacy of the profession with regard to establishing and applying professional practice standards, and in comparing managers across the 3 ownership types, no significant differences were found with regard to professional authority. In general, managers did not generally support a large role for employers in establishing or applying these standards; however, independent and franchise respondents may be more likely than corporate respondents to support employer authority. The tendency of independent and franchise pharmacy respondents to more readily accept employer involvement may
Table 4 Ability of pharmacy managers to control the work environment As pharmacy manager your ability to control
Little/no control,a N (%)
Moderate, N (%)
Lots/complete,b N (%)
Total, N (%)
The quality of care provided to patients The development of workplace policies The responsibilities delegated to staff How workplace problems are solved The time spent on various work activities
22 137 23 27 66
176 145 136 147 211
441 356 482 467 363
639 638 641 641 640
a b
(3.4) (21.2) (3.6) (4.2) (10.2)
Collapsed little and no control for display purposes only. Collapsed lots and complete for display purposes only.
(27.2) (22.4) (21.1) (22.8) (32.7)
(68.3) (55.1) (74.6) (72.3) (56.1)
(98.9) (98.8) (99.2) (99.2) (99.1)
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Table 5 Authority and autonomy constructs Construct
Number of items
Scale
Range
Mean (SD)
Cronbach’s a
Professional authority Employer authority Manager autonomy Decision making Control amount
4 4 6 4 5
Strongly disagree (1)-strongly agree (5)
4-20 4-20 6-30 4-16 5-25
14.7 9.23 22.8 13.4 19.0
0.759 0.694 0.875 0.894 0.861
Never (1)-always (5) None (1)-lots (4) No control (1)-total control (5)
(3.25) (2.89) (5.62) (2.62) (3.59)
SD, standard deviation.
be explained either by the fact that many of the respondents were themselves the owner/franchisee (ie, the employer) or worked with a pharmacistowner/franchisee. Despite similar attitudes regarding professional and employer authority, there was a clear divide among the 3 ownership types with specific managerial aspects of community pharmacy practice, as suggested by the findings for manager autonomy, decision making, and amount of control. Consistent with earlier studies,15,30,31,44,45 the corporate pharmacy managers reported having less manager autonomy than franchise managers, who in turn reported less autonomy than the independent pharmacy managers. As with manager autonomy, there was a noticeable divergence among the 3 groups with regard to decision making and amount of control. Although respondents in corporate pharmacies might be professionally oriented, they reported less decision-making ability and control than respondents in independent and, to a lesser extent, franchise pharmacies. For most organizations, including community pharmacies, there is recognition of the need to control processes and formalize duties to reduce uncertainty and error.46 However, as organizations grow in size they become more bureaucratic; levels of authority and the number of formalized procedures will grow as the organization grows
in an effort to increase the efficiency and coordination of activities across the organization.20,47 Bureaucracy has been described as the most rational and efficient way to organize work.48 However, it is also linked to the degradation of the work life of employees49; and the more bureaucratic the organization, the greater the likelihood of conflict and job dissatisfaction.50 Furthermore, professionals are guided primarily by the needs of the client/patient, whereas bureaucracies are guided by the goals of the organization.15 As a result, attempts to standardize professional work often impede and discourage professionals and can lead to impersonal and ineffective service.47 Bureaucratization can also lead to proletarianization. Specifically, ‘‘the process by which an occupational category is divested of control over certain prerogatives relating to the location, content and essentiality of its task activities’’.48 The effect is the reduction of workers to some common level to service the broader interests of capital accumulation.51 Traditionally, pharmacists were the owners of pharmacies; however, with the number of pharmacist-entrepreneurs decreasing and corporateowned pharmacies increasing,52 the profession may find itself subordinate to the broader requirements of business, with a focus on attaining the
Table 6 Comparative analysis of constructs by pharmacy ownership type (n ¼ 636) Construct
Pharmacy ownership type, mean (CI)
F value (significance)
Independent (n ¼ 289) Franchise (n ¼ 118) Corporate chain (n ¼ 229) Professional authority Employer authoritya Manager autonomyb Decision makingb Amount of controlb
14.60 9.58 26.08 14.87 20.54
(14.19-15.01) (9.20-9.96) (25.60-26.55) (14.66-15.08) (20.15-20.92)
15.02 9.68 22.26 12.91 18.53
(14.46-15.57) (9.12-10.24) (21.27-23.24) (12.41-13.40) (17.87-19.19)
14.67 8.59 19.02 11.81 17.20
(14.25-15.08) (8.26-8.93) (18.34-19.70) (11.49-12.13) (16.79-17.60)
CI, confidence interval. Scheffe’s test (P ! .05): corporate significantly different from independent or franchise. b Scheffe’s test (P ! .05): all 3 significantly different from one another. a
0.69 8.40 138.38 120.95 66.36
(P ¼ .50) (P ! .001) (P ! .001) (P ! .001) (P ! .001)
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355
Table 7 General linear models of constructs by ownership type and control variables Model components
Type III sum of squares
df
Mean square
F
P
R-squared (adjusted R-squared)
Professional authority Ownership Sex Age Years with employer
26.60 3.70 192.52 43.23
2 1 2 4
12.30 3.70 96.26 10.81
1.30 0.36 9.40 1.06
.274 .548 .000 .378
0.050 (0.030)
Employer authority Ownership Sex Age Years with employer
28.01 0.11 1.13 29.26
2 1 2 4
14.01 0.11 0.57 7.31
2.53 0.02 0.10 1.32
.081 .888 .903 .262
0.035 (0.015)
Professional autonomy Ownership Sex Age Years with employer
3321.39 5.95 7.44 285.14
2 1 2 4
1660.69 5.95 3.72 71.29
77.68 0.28 0.17 3.34
.000 .598 .840 .010
0.318 (0.303)
Decision making Ownership Sex Age Years with employer
723.81 3.00 3.82 51.293
2 1 2 4
361.90 3.00 1.91 12.82
73.29 0.61 0.38 2.60
.000 .438 .679 .038
0.292 (0.277)
Amount of control Ownership Sex Age Years with employer
671.42 11.17 11.54 86.52
2 1 2 4
335.71 11.17 5.77 21.63
32.21 1.07 0.55 2.08
.000 .301 .575 .083
0.174 (0.156)
df, degrees of freedom.
maximum financial return on investment.20 Although there continues to be opportunities to control the nature of one’s work, the economic and competitive influences of the marketplace are leaving many pharmacists little choice but to practice their profession as employees of large corporate entities.27 As in any large organization, whether public or private, for profit or not for profit, corporate managers can expect to encounter some degree of bureaucracy and a reduced level of autonomy30,31,44,45,53 and control.48,51,54,55 However, the relative lack of autonomy and control reported in our study among pharmacy managers regarding the nature of professional work in what is increasingly the more predominant ownership model is a concern, with important implications for the profession and Canadian society. Society grants professions the right to selfregulate, and the professions maintain their autonomy in exchange for placing the interest of society above personal and organizational
interests. As such, professional decision making must be relatively free of outside nonprofessional influences. Some have argued that economic control is essential to secure professional control.56,57 For example, physicians enjoy a high level of professional autonomy and tend to work in limited partnerships where they maintain a significant level of economic control. Others argue that economic control is less important if the objectives of the profession are supported by the employer.19 For example, some health professionals with limited economic control, such as nurses, are still able to advance their professional goals and are even obtaining greater clinical autonomy because they tend to practice within organizations, such as hospitals and health regions, where there are clear health-centered objectives consistent with the objectives of the professionals they employ.19 It is also argued that even within nonprofessional organizations, professionals can still establish professional autonomy.19 However, this
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argument assumes that these professional activities take place within distinct departments that support or are secondary to the core business. For example, lawyers in a legal department within a larger organization may be able to manage their own activities (provided they stay within budget and provide good legal advice), but this is not the case for the pharmacist-employee. For community pharmacists, their work is the core business. The actions of pharmacists and pharmacy managers directly affect the revenues and profitability of the organization; therefore, there is a considerable and persistent incentive for senior managers to seek ways to maximize revenues and minimize the costs related to the work of these employees. Unlike other professionals, the unique relationship between the profession of pharmacy and business of pharmacy places the profession at greater risk of the loss of control over the content of their professional work activities.48 Although pharmacy managers were generally secure about their ability to exercise professional authority, specific activities relating to autonomy, decision making, and control suggest a lesser ability to control the work environment among corporate pharmacy managers. Although other factors may partially explain the differences, it suggests the need for a stronger professional voice within community practice. Whether this is in the form of a stronger regulatory presence, a professional association, or some other form, it is an action that must be initiated and directed by the profession itself; although, we would argue it should occur sooner rather than later. Limitations Because of the nature of the study, limitations are to be expected and acknowledged. First, as with any self-report methodology, one must approach the results with a certain level of caution because it relies on respondents to accurately reflect their perceptions/feelings/experiences. Moreover, this study was conducted in Canada and, therefore, may not be applicable to other regions. There is the possibility that some study participants did not respond to the survey because of company policy. This was witnessed when one pharmacy manager sent an electronic mail stating that he could not respond because of company policy. As well, some in the sample requested that the questionnaire be sent to their home address, as
opposed to their pharmacy address, because they could not complete it at the pharmacy. Further to this, when presenting preliminary results at the Canadian Pharmacists Association annual conference in Ottawa, Ontario, on June 3, 2007, representatives from one company made it clear that pharmacy managers in their stores are not to respond to any survey without upper management reviewing the instrument first. Another limitation to this study is that the questionnaire and accompanying materials mailed to the sample were written only in English. Although pharmacy managers in Quebec were not included in this study, in a bilingual (English and French) country such as Canada, Frenchspeaking pharmacists exist outside Quebec, particularly in Ontario and New Brunswick. Therefore, it is possible that some study participants were unilingual Francophones and did not complete the questionnaire because of it being written only in English. As with any survey research, there is the potential for nonresponse bias between responders and nonresponders. A nonresponder survey was not conducted for this study; however, to assess the potential for nonresponder bias the method of early versus late responder analysis was completed.21,58-60 In this method of assessing nonresponder bias, the assumption is that late responders respond similar to nonresponders. Therefore, if any statistically significant differences are established between early and late responders, the same difference is assumed to occur between responders and nonresponders.21,58-60 No statistically significant differences were observed when conducting chi-square analysis on the independent variable pharmacy ownership structure. Chi-square analysis of the sex variable also did not result in any statistically significant differences between early and late responders. The final analysis of the age variable by means of an independent t test also did not result in any statistically significant differences.
Conclusions The ability of a profession to self-regulate (authority) and control how its work is performed (autonomy) is critical to meeting its social obligations.19 Pharmacy managers currently perceive a high level of authority relating to the setting of practice standards and the evaluation of professional competence; but, with declining autonomy,
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it is unclear whether professional authority is sufficient to prevent the subordination of both patient and professional interests to external financial interests. Acknowledgments The authors thank the community pharmacy managers who took time out of their busy schedules to complete and return the questionnaire and the provincial regulatory agencies for providing the contact information for community pharmacy managers in their respective province.
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