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Situational Factors as Determinants of Community Pharmacists' Clinical Decision Making Behavior
RESEARCH
Situational Factors as Determinants of Community Pharmacists' Clinical Decision Making Behavior David A. Latif Objective: To examine the relative contribution of two work-related pressures, workload and perceived normative beliefs of signiff cant others, to community pharmacists' clinical decision making behavior. Design: Systematic random sample design. Setting: A large southeastern city. Participants: 450 independent and chain community pharmacists identified from the state board of pharma· cy list of licensed community pharmacists. Interventions: A mailed questionnaire asking about community pharmacists' workloao pressures and the perceived beliefs of their patients and employers (significant others) approving or disapproving of them providin! pharmaceutical care. Main Outcome Measures: Clinical decision making behavior, as measured using a subset of the Behavioral Pharmaceutical Care Scale. Results: Response rate was 31.8%. Workload was not significantly related to clinical decision makin!. After controlling for social desirability and workload, perceived normative beliefs of significant others was highly significant; it accounted for 7.6% of the variance associated with clinical decision making behavior. Conclusion: Workload pressures did no! appear to influence the provision of pharmaceutical care. Community pharmacists' perceived normative beliefs about their patients' and employer's approval or disapproval of the provision of pharmaceutical care should be further examined within the larger conte~ of the pharmacy organization's climate.
JAm Pharm Assoc. 1998;38:446-50,
As the pharmacy profession continues its paradigm shift toward comprehensive patient care, studies that examine the relative impact of the pharmacy organization's climate on pharmacists' patient care activities may help to explain and predict individual decisions made in the provision of this care. Climate is the atmosphere that employees perceive as a result of an organization's practices, procedures, and rewards. These perceptions are based on what actually happens in an organization-not what management, the company newsletter, and the annual report proclaim. l The type of climate in an organization fosters certain behaviors among employees. For example, the 3M Company has created and maintained a climate of innovation in which many informal meetings are held to discuss new product ideas. Similarly, in Received June 30, 1997, and in revised form September 29, 1997. Accepted for publication October 18, 1997. David A. Latif, PhD, MBA, is assistant professor of pharmacy administration, School of Pharmacy, Shenandoah University, Winchester, Va. At the time this article was accepted, Dr. Latif was assistant professor of pharmacy administration, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York. Correspondence: David A. Latif, PhD, MBA, School of Pharmacy, Shenandoah University, 1460 University Drive, Winchester, VA 22601 . Fax: (540) 665-1283.
the community pharmacy setting, a patient-centered climate C3l1 foster the provision of pharmaceutical care. Two situational fac· tors-{)r pressures-inherent in community practice are components of a pharmacy organization's climate: workload pressurel and the perceived normative beliefs of managers and patientl about the provision of comprehensive patient care. Pharmacists who experience high workload pressures, such al routinely dispensing a high volume of prescriptions per day,mal provide patients with a different level of care than those pharma· cists with more time available for interactions with patients Workload pressure is affected by the availability of assistance from technicians and other pharmacists. 2 The extent to which community pharmacists perceive theW port or disapproval of employers, managers, and patientstermed "significant others" in this study-with -regard to the pJ1} vision of comprehensive patient care empirically affect' behavioral intent in community pharmacists. 3- 5 This concept i' based on Ajzen and Fishbein's theory of re~d action,6 which refers to an assessment of the perceived and social pressures on individuals to perform a target behavior. I When professionals practice within organizational setting' professional values can conflict with organizational vaJues 71n community pharmacy practice, pharmacists must respond It' diverse and often conflicting influences. For example, a problen
Situational Factors
may arise when the time needed to counsel patients about medications conflicts with the time needed to dispense prescriptions. In this paper, I examine empirically the relative contribution of workload pressures and perceived normative values of significant others (managers and patients) on community pharmacists' clinical decision making.
Organizational Climate and Clinical D~cision Making Pharmaceutical care entails a fundamental shift for the pharmacy to a more cognitive, patient-centered focus. It is defined as "the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life."s Partly because of the individual and situational barriers to positive clinical behavior, pharmaceutical care has not yet become a reality for community pharmacy practice. Penna has identified several situational barriers faced by pharmacists to providing comprehensive patient care. 9 These include a drug product focus, lack of a serlice orientation, and lack of monetary incentives. Raisch reported ,that excessive workload, lack of privacy, patient attitudes, and store layout are the main impediments to pharmacists' providing I counseling services to their patients. 10 \ One way of increasing the likelihood of community pharmacists' engendering pharmaceutical care is to create an organizational climate conducive to its provision. Organizational climate (the shared beliefs, values, and assumptions within an organization ll ) indicates to its members the work behaviors important for 'organizational effectiveness.! These indications become manifest I in!he types of behaviors that the organization rewards, supports, Iand expects from its employees. The climate of an organization is inferred by its members. Such inferences are often organized around the goals that the organization pursues.! For example, does a pharmacy chain pursue a goal of maximizing market share Ija prescription volume, or does it pursue a goal of being a top "pharmaceutical care" chain? The climate of a pharmacy organization is likely to influence a pharmacist's clinical decision making in one very important way: itis often the reward system that contributes significantly to the O (erall climate of an organization.!2 Organizational reward sys[ems include both monetary and nonmonetary incentives, and they can drive organizational climates specifically because they Influence motivation. As a result, organizational reward systems Indirectly lead to perceptions about what the organization stands 'Or, believes in, and values. According to Kerr, the organizational reward system is often lied as a way of encouraging behaviors that the organization lieems important to its effectiveness. He states that employees of irganizations " ... seek information concerning what activities are 1Warded, and then seek to do (or at least pretend to do) those ,~ngs often to the virtual exclusion of activities not rewarded."13 If this statement holds true in community practice, then phar-
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RESEARCH
macists may generally gravitate toward providing services that the organization rewards. Since the pharmacy organization's primary revenue center is prescription dispensing, this is the behavior that is typically rewarded. Thus, an organization's reward system may contribute to pharmacists' emphasizing prescription dispensing. A primary reason for significant organizational climate influences has to do with strong and weak workplace settings. Most work settings are strong situations exerting substantial influences on individual attitudes and behaviors. I4-1 7 Strong organizational settings are characterized as having inherent situational pressures to behave in particular ways (e.g., emphasizing prescription dispensing) .!S Therefore, quite often, organizational participants adopt the attitudes and behaviors encouraged by the organization's climate regardless of their personal attitudes,IS The resulting incongruence between personal characteristics and the situation often leads to absenteeism, dissatisfaction, poor job performance, and tum over. 19 Unfortunately, the aforementioned climate influences appear to attenuate patient care activities in the community setting for the following reasons: • The major portion of the pharmacy organization's remuneration is derived from prescription dispensing, rather than patient care activities. Therefore, the organization often rewards prescription volume (i.e., through monetary bonuses or recognition awards). Thus, this may be the behavior exhibited most often by community pharmacists. • If the workplace setti ng is strong (as most organizational behavior literature suggests), situational pressures can be expected to dominate clinician decision making. Thus, community pharmacists can be expected to adhere to what they perceive as important to the company and its managers. Both organizational influences may act as barriers and thus help to explain why the provision of pharmaceutical care has not yet become a reality in the day-to-day operations of community pharmacies. 4 ,9,lo
Objective The objective of this study was to examine the influence of two situational pressures inherent in community practice on practitioners ' clinical decision making. These situational pressures are components of the organization's climate and specifically refer to workload pressures and the perceived normative beliefs of patients and employers relative to the provision of pharmaceutical care. 9,IO,20 Based on this rationale, the following hypothesis is advanced: The situational pressures of workload and perceived normative beliefs of patients and employers (significant others) will be significantly correlated and will account for a significant amount of the variance associated with community pharmacists' clinical decision making,
Journal of the American Phannaceutical Association
441
RESEARCH
Situational Factors
Methods This study was a component of a larger study that examined moral reasoning as a determinant of community practitioners' clinical performance. The two research instruments used addressed the two components of organizational climate--clinical decision making and social desirability. The social desirability scale was used as an external check on the validity of the clinical decision making questionnaire. These instruments were sent to a sampling frame comprising 450 systematic randomly sampled community pharmacists (chain and independent) in a large southeastern city. The sampling frame was obtained from the target city's state board of pharmacy and included community pharmacists exclusively. The independent variables of interest were (1) perceived normative beliefs of significant others toward the pharmacist providing a high level of patient care and (2) his or her workload. Perceived normative beliefs of the community pharmacist's employers and patients were gauged with a self-report measure that asked the extent to which employers and patients would approve or disapprove of pharmacists' provision of pharmaceutical care during the next six weeks . These items were modeled after a component of Odedina' s Behavioral Pharmaceutical Care Scale (BCPS) and were measured on a seven-point Likert-type scale ranging from approval to disapproval of the provision of pharmaceutical care.4 In an attempt to get a more precise measure of workload than merely prescriptions dispensed, additional help from other pharmacists and technicians was included in the model. The formula decided upon was modeled after Kirking's operationalization of workload 2: Workload = A/[(B/C) + 1] Where A = number of prescriptions dispensed per hour; B = number of hours worked by other pharmacists and all technicians during a typical day; and C = number of hours worked by the respondent during that day. For example, suppose two pharmacies each dispense 120 prescriptions during a 12-hour day . The first pharmacy (X) has one pharmacist and no technician or extra pharmacist help. The second pharmacy (Y) has one primary pharmacist, no extra pharmacist help, and technician help amounting to an average of 6 hours per day. By plugging the numbers into the above workload formula, pharmacy X's pharmacist has a workload value of 10, while the pharmacist working at pharmacy Y has a workload value of 6.67. The dependent variable in this investigation was clinical decision making. It was measured using the direct patient care dimension subset of the BPCS, which attempts to capture pharmacists' efforts to provide pharmaceutical care. 21 It asks respondents to examine their last five patients with chronic conditions and to report the extent to which they performed the following patient care activities: • Documentation • Patient assessment • Implementation of therapeutic objectives
448
Journal of the American Phannaceutical Association
• Patient counseling • Screening of patient records The 18 questions in this instrument yield possible scores on co lective dimensions from 0 to 90. Reliability estimates of the fi, domains range from 0.72 to 0.90, while content validity is 0.79. 1! Social desirability served as an external check of the validityc the BPCS. Specifically, because of the possibility of respondent. expressing socially acceptable norms rather than their true ani tudes and behaviors , a shortened version of Crowne and MID lowe's Social Desirability Index was used as an external measur, to control for responding to the BPCS in a socially desirable rna! nef. Included in the Marlowe- Crowne short form are items sud as, I am always courteous, even to people who are disagreeable,: A true response to this item would be considered a socially desu able one. The short-form version includes 13 true-or-false iteID of the original 33 items making up the Marlowe-Crowne Soci, Desirability Index .23 Seven items are reverse coded, and ear: socially desirable answer is assigned a point. This instrument m a Kuder-Richardson reliability of 0.76. Since the hypothesis posited that a significant correlation and, significant amount of the variance associated with clinical d ' sion making would be accounted for by the situational pressure of perceived normative beliefs and workload, a semipartial com lation was used within a multiple regression analysis usin: SPSS.24 For purposes of this investigation, the cutoff for signio, cance was ex. = 0.05 . The sernipartial correlation represents til unique relationship predicted by an independent variable after al predictions shared with all other independent variables an parceled out. 25 The semipartial correlation is useful for apportioo ing variances among the independent variables in a regressi~' equation. Thus , it provides a precise measure of a variable', unique contribution to the outcome measure (i.e., clinical decisi~ making). Squaring the sernipartial correlation results in the uniqUi variance associated with clinical decision making that can ~ explained by the situational pressures of workload and nonnatili' beliefs. Perceived normative beliefs of patients and employers weri combined for statistical analysis. This treatment of perceived n~ mative beliefs is consistent with those of previous studies. 3,4
Results Of 450 mailed questionnaires, 9 were returned as undeliwr able. To maximize response rates, a modified Dillman approad was used whereby three reminders, spaced two weeks apart, wer sent to sample pharmacists. 26 A chain pharmacy directed 29 0f ir.' pharmacists not to respond to the survey, for reasons that coui; not be ascertained. Of the remaining 412 surveys assumed to hal'; been delivered, 131 (31.8%) pharmacists responded. The mean age of the respondents was 40 years, and the numti of men (80) responding was more than twice the number of worr. en (33). Scores on the perceived normative belief scale rang l
July/August 1998 Vol. .18.~o '
from 4 to 14, with a mean of 10.99, while scores on the workload measure ranged from 2. 12 to 12, with a mean of 5.29. The scores on the clinical decision making instrument ranged from 9 to 69, with a mean of 37.34. Because of the possibility of systematic differences between those who responded and those who did not, nonresponse bias was assessed. Because late respondents may be similar to nonrespondents on variables of interest, a wave analysis was conducted whereby those responding to the initial mailing and the subsequent reminders were compared on the clinical decision making instrument. 27 Results of this wave analysis indicated that nonresponse bias did not appear to be a problem with this investigation. After control ling for social desirability, the situational pressure of workload did not account for a significant portion of the variance associated with a community pharmacists ' clinical decision making (Table 1). However, after controlling for social desirabilityand workload, perceived normative beliefs accounted for 7.6% of the variance associated with community pharmacists' clinical decision making (p = 0.003).
ing in this study may be because the workload measurement used was not sensitive enough to capture the true relationship. Since the workload measure used in this investigation did not take into account " time of day," the possibility exists for clinical performance to be high during slow times and poor during the busier times. Therefore, workload may have been a factor in the sampled pharmaci sts' clinical decision making, even though this study failed to detect any relationship. The present study demonstrated that the perceived normative beliefs of significant others about the provision of pharmaceutical care can significantly influence community pharmacists ' clinical decision making. However, these perceived normative beliefs accounted for only 7.6% of the variance associated with clinician decision making. Two explanations for this are possible. First, this investigation examined only two aspects of organizational climate. Examination of additional climate elements, such as autonomy, task orientation, and innovation, may increase the explained amount of variance associated with clinical decision making. As discussed previously, one element that often shapes the climate of an organization is the organizational reward system. 12 It, along with other climate elements, accounts for a significant amount of Discussion the variance associated with poor job performance. 31 ,32 Therefore, if community pharmacy organizations want their pharmacists to This investigation examined the relationship between two com- provide comprehensive patient care, their organizational climates ponents of organizational climate and community pharmacists ' must reflect this. The organizational reward system can be clinical decision making. Perceived normative beliefs of signifi- changed to elevate the importance of patient care activities cant others appeared to be a significant predictor of pharmacists' through monetary means (e.g., bonuses for detecting drug-drug decision making. On the other hand, workload pressures, at least interactions) or through nonmonetary means (e.g., recognition via a plaque for the pharmacist who detects the most drug or food in this study, did not significantly affect this variable. Perceived normative beliefs of significant others toward patient interactions). By doing this, community pharmacists might come care activities have been examined in previous studies. 3,4,28 In gen- to perceive that patient care activities are rewarded, and they will eral, our results corroborate those of past studies by supporting the likely begin to emphasize them. A second explanation is that individual differences were not contention that perceived normative beliefs of significant others examined. Such individual difference variables as moral reasoncan significantly influence pharmacists' patient care activities. Workload did not appear to influence community pharmacists' ing and self-efficacy have been shown to influence clinical deciclinical decision making. Although other studies, such as Berardo sion making in medical residents and pharmacists. 4,33,34 et ai., did not find a correlation between workload and patient care activities, research in other professions suggests that workload pressures can significantly influence behavior. 29 For exam- Limitations and Future Research ple, in accounting and auditing, it has been empirically demonSeveral limitations to this research can be identified. The sam. strated that when firms put budget pressures on auditors, their work quality suffers. 3o A plausible explanation for why workload ple of community pharmacists from only one city limits the genpressures were not significantly related to clinical decision mak- eralizability of the results. Only two situational pressures inherent
I
T:bl e 1. Unique Contribution of Situational Variables to Pharmacists' Clinical Decision Making
Va riable
R
R 2 Chang e
FChange
Signifi cance of FChange
S em ipartial Correlation Coefficient
~I desirability
0.006
0
0 .004
0 .952
0.021
Workload
0.039
0 .001
0 .165
0.686
0.065
Perceived normative beliefs
0.278
0 .076
9 .022
0.003*
0.275
.---------------------------------------------------------------------------------------------------'Significant at ex = 0.01 .
~,. IOl. l8,No.4 July/August 1998
Journal of the American Phannaceutical Association
449
RESEARCH
Situational Factors
in community practice were examined. Therefore, it is difficult to generalize the findings to represent a more detailed representation of organizational climate. Finally, despite efforts to assess nonresponse bias, those who responded to the survey could have been systematically different from those who did not. Despite these limitations, the result of this research suggests that the perceived normative beliefs of significant others is one determinant of community pharmacists' clinical decision making. To validate these results, future research should be pursued using broader dimensions of organizational climate and sampling of community pharmacists from different regions of the United States.
Conclusion This study examined the influence of two situational pressures inherent in community practice on pharmacists' clinical decision making: pharmacists' perceptions of the normative beliefs of significant others (patients and employers), and workload pressures. Only the perceived normative beliefs of patients and employers significantly influenced clinician decision making. Pharmacy organizations may wish to identify and resolve both perceived and real problems that impede the provision of pharmaceutical care by their pharmacists (i.e. , emphasizing and rewarding prescription volume and not the provision of pharmaceutical care).
References 1. Schneider B, Brief AP, Guzzo, RA. Creating a climate and culture for sustainable organizational change. Organ Dyn. 1996 (Spring):7-19. 2. Kirking DM. Pharmacists' Perceptions of Their Role in Outpatient Drug Therapy Counseling. Columbus, Ohio: Ohio State University; 1980. Dissertation. 3. Farris KB, Kirking DM. Predicting community pharmacists' intention to try to prevent and correct drug therapy problems. J Soc Adm Pharm. 1995;12:64-79. 4. Odedina FT. Implementation of Pharmaceutical Care in Community Practice: Development of a Theoretical Framework for Implementation. Gainesville, Fla: University of Florida; 1994. Dissertation. 5. Odedina FT, Segal R, Hepler CD, et al. Changing pharmacists' practice pattern: pharmacists' implementation of pharmaceutical care factors. J Soc Adm Pharm. 1996;13:74-88. 6. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980. 7. Sitkin SB, Sutcliffe KM . Dispensing legitimacy: the influence of professional, organizational, and legal controls on pharmacist behavior. Sociolog Organ. 1991;8:269-95. 8. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533-45.
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Journal of the American Phannaceutical Association
9. Penna RP. Pharmaceutical care: pharmacy's mission for the 1990s. A J Hasp Pharm. 1990;47:543-9. 10. Raisch DW. Barriers to providing cognitive services. Am Phaff 1993(Dec): NS33:54-8. 11. Johns G. Organizational Behavior. Glenview, III : Scott Forresmal 1988. 12. Lawler EE III. High-Involvement Management: Participative Stralegi, for Improving Organizational Performance. San Francisco, Cali Jossey-Bass, 1986. 13. Kerr S. On the folly of rewarding A while hoping for B. Acad Manage. 1975;18:769-83. 14. Bern DJ, Allen A. On predicting some of the people some of thetim, the search for cross-sectional consistencies in behavior. Psychol Re 1974;81 :506-20. 15. Davis-Blake A, Pfeffer J. Just a mirage: the search for disposition; effects in organizational research . Acad Manage Rev. 1989;14:385-4(( 16. Mischel W. Personality and Assessment. New York, NY: John Wiley, Sons; 1968. 17. Mischel W. The interaction of the person and the situation. In: Magnu: son D, Endler NS, eds. Personality at Crossroads: Current Issues i Interactional Psychology. Hillsdale, NJ: Erlbaum; 1977:333- 52. 18. Chatman JA. Improving interactional organizational research: a mod, of person-organization fit. Acad Manage Rev. 1989;14:333-49. 19. Jackofsky EF, Slocum JW. A longitudinal study of climates. Orga Behav. 1987;9:319-34. 20. Schommer J, Wiederholt JB. Pharmacists' perceptions of patient! needs for counseling. Am J Hosp Pharm. 1994;51:478-85. 21 . Odedina F, Segal R. Behavioral pharmaceutical care scale for measUi ing pharmacists' activities. Am J Health Syst Pharm. 1996;53:85&-S5. 22. Crowne DP, Marlowe D. The Approval Motive. New York: John Wile & Sons; 1960. 23. Reynolds WM . Development of reliable and valid short forms of th Marlowe-Crowne social desirability scale. J Clin Psychol. 198; 38:119-25. 24. SPSS 7.0 for Windows. Statistical Package for the Social Science! Chicago, III: SPSS Inc; 1995. 25. Hair JF Jr, Anderson RE, Tatham RL, et al. Multivariate Data Analysi! 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1994. 26. Salant P, Dillman D. How to Conduct Your Own Survey. New Yo~ John Wiley & Sons; 1994. 27. Churchill GA. Marketing Research: Methodological Foundations. Nell York: Holt, Rinehart and Winston; 1987. 28. Mason HL. Using attitudes and subjective norms to predict pharmaci~ counseling behaviors. Patient Couns Educ. 1983;4: 190-6. 29. Berardo DH, Kimberlin CL, Barnett CWo Observational researchOfi patient education activities of community pharmaCists. J Soc Adm Pharm. 1989;6:21 - 30. 30. Ponemon LA, Gabhart DRL. Ethical Reasoning in Accounting anD Auditing. Vancouver, BC: CGA-Canada Research Foundation; 1993. 31 . Jansen E, Eccles D. Innovation and restrictive conformity among hospital employees: individual outcomes and organizational considera tions. Hasp Health Serv Adm. 1994;39:63-80. 32. Prichard RD, Karasick BW. The effects of organizational climateon managerial job performance and job satisfaction. Organ Behav Hurr Perform. 1973;9:126-46. 33. Sheehan TJ , Husted SD, Candee D, et al. Moral judgment as a predic tor of clinical performance. Eval Health Prof. 1980;379-400. 34. Latif DA. The Relationship Between Community Pharmacists' Mora Reasoning and Components of Clinical Performance. Auburn, Ala Auburn University; 1997. Dissertation.
July/August 1998
Vol. 38,N.'
Situational Factors as Determinants of Community Pharmacists' Clinical Decision Making Behavior David A. Latif Objective: To examine the relative contribution of two work-related pressures, workload and perceived normative beliefs of signiff cant others, to community pharmacists' clinical decision making behavior. Design: Systematic random sample design. Setting: A large southeastern city. Participants: 450 independent and chain community pharmacists identified from the state board of pharma· cy list of licensed community pharmacists. Interventions: A mailed questionnaire asking about community pharmacists' workloao pressures and the perceived beliefs of their patients and employers (significant others) approving or disapproving of them providin! pharmaceutical care. Main Outcome Measures: Clinical decision making behavior, as measured using a subset of the Behavioral Pharmaceutical Care Scale. Results: Response rate was 31.8%. Workload was not significantly related to clinical decision makin!. After controlling for social desirability and workload, perceived normative beliefs of significant others was highly significant; it accounted for 7.6% of the variance associated with clinical decision making behavior. Conclusion: Workload pressures did no! appear to influence the provision of pharmaceutical care. Community pharmacists' perceived normative beliefs about their patients' and employer's approval or disapproval of the provision of pharmaceutical care should be further examined within the larger conte~ of the pharmacy organization's climate.
JAm Pharm Assoc. 1998;38:446-50,
As the pharmacy profession continues its paradigm shift toward comprehensive patient care, studies that examine the relative impact of the pharmacy organization's climate on pharmacists' patient care activities may help to explain and predict individual decisions made in the provision of this care. Climate is the atmosphere that employees perceive as a result of an organization's practices, procedures, and rewards. These perceptions are based on what actually happens in an organization-not what management, the company newsletter, and the annual report proclaim. l The type of climate in an organization fosters certain behaviors among employees. For example, the 3M Company has created and maintained a climate of innovation in which many informal meetings are held to discuss new product ideas. Similarly, in Received June 30, 1997, and in revised form September 29, 1997. Accepted for publication October 18, 1997. David A. Latif, PhD, MBA, is assistant professor of pharmacy administration, School of Pharmacy, Shenandoah University, Winchester, Va. At the time this article was accepted, Dr. Latif was assistant professor of pharmacy administration, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York. Correspondence: David A. Latif, PhD, MBA, School of Pharmacy, Shenandoah University, 1460 University Drive, Winchester, VA 22601 . Fax: (540) 665-1283.
the community pharmacy setting, a patient-centered climate C3l1 foster the provision of pharmaceutical care. Two situational fac· tors-{)r pressures-inherent in community practice are components of a pharmacy organization's climate: workload pressurel and the perceived normative beliefs of managers and patientl about the provision of comprehensive patient care. Pharmacists who experience high workload pressures, such al routinely dispensing a high volume of prescriptions per day,mal provide patients with a different level of care than those pharma· cists with more time available for interactions with patients Workload pressure is affected by the availability of assistance from technicians and other pharmacists. 2 The extent to which community pharmacists perceive theW port or disapproval of employers, managers, and patientstermed "significant others" in this study-with -regard to the pJ1} vision of comprehensive patient care empirically affect' behavioral intent in community pharmacists. 3- 5 This concept i' based on Ajzen and Fishbein's theory of re~d action,6 which refers to an assessment of the perceived and social pressures on individuals to perform a target behavior. I When professionals practice within organizational setting' professional values can conflict with organizational vaJues 71n community pharmacy practice, pharmacists must respond It' diverse and often conflicting influences. For example, a problen
Situational Factors
may arise when the time needed to counsel patients about medications conflicts with the time needed to dispense prescriptions. In this paper, I examine empirically the relative contribution of workload pressures and perceived normative values of significant others (managers and patients) on community pharmacists' clinical decision making.
Organizational Climate and Clinical D~cision Making Pharmaceutical care entails a fundamental shift for the pharmacy to a more cognitive, patient-centered focus. It is defined as "the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life."s Partly because of the individual and situational barriers to positive clinical behavior, pharmaceutical care has not yet become a reality for community pharmacy practice. Penna has identified several situational barriers faced by pharmacists to providing comprehensive patient care. 9 These include a drug product focus, lack of a serlice orientation, and lack of monetary incentives. Raisch reported ,that excessive workload, lack of privacy, patient attitudes, and store layout are the main impediments to pharmacists' providing I counseling services to their patients. 10 \ One way of increasing the likelihood of community pharmacists' engendering pharmaceutical care is to create an organizational climate conducive to its provision. Organizational climate (the shared beliefs, values, and assumptions within an organization ll ) indicates to its members the work behaviors important for 'organizational effectiveness.! These indications become manifest I in!he types of behaviors that the organization rewards, supports, Iand expects from its employees. The climate of an organization is inferred by its members. Such inferences are often organized around the goals that the organization pursues.! For example, does a pharmacy chain pursue a goal of maximizing market share Ija prescription volume, or does it pursue a goal of being a top "pharmaceutical care" chain? The climate of a pharmacy organization is likely to influence a pharmacist's clinical decision making in one very important way: itis often the reward system that contributes significantly to the O (erall climate of an organization.!2 Organizational reward sys[ems include both monetary and nonmonetary incentives, and they can drive organizational climates specifically because they Influence motivation. As a result, organizational reward systems Indirectly lead to perceptions about what the organization stands 'Or, believes in, and values. According to Kerr, the organizational reward system is often lied as a way of encouraging behaviors that the organization lieems important to its effectiveness. He states that employees of irganizations " ... seek information concerning what activities are 1Warded, and then seek to do (or at least pretend to do) those ,~ngs often to the virtual exclusion of activities not rewarded."13 If this statement holds true in community practice, then phar-
.,~"
" ,No.4 July/August 1998
RESEARCH
macists may generally gravitate toward providing services that the organization rewards. Since the pharmacy organization's primary revenue center is prescription dispensing, this is the behavior that is typically rewarded. Thus, an organization's reward system may contribute to pharmacists' emphasizing prescription dispensing. A primary reason for significant organizational climate influences has to do with strong and weak workplace settings. Most work settings are strong situations exerting substantial influences on individual attitudes and behaviors. I4-1 7 Strong organizational settings are characterized as having inherent situational pressures to behave in particular ways (e.g., emphasizing prescription dispensing) .!S Therefore, quite often, organizational participants adopt the attitudes and behaviors encouraged by the organization's climate regardless of their personal attitudes,IS The resulting incongruence between personal characteristics and the situation often leads to absenteeism, dissatisfaction, poor job performance, and tum over. 19 Unfortunately, the aforementioned climate influences appear to attenuate patient care activities in the community setting for the following reasons: • The major portion of the pharmacy organization's remuneration is derived from prescription dispensing, rather than patient care activities. Therefore, the organization often rewards prescription volume (i.e., through monetary bonuses or recognition awards). Thus, this may be the behavior exhibited most often by community pharmacists. • If the workplace setti ng is strong (as most organizational behavior literature suggests), situational pressures can be expected to dominate clinician decision making. Thus, community pharmacists can be expected to adhere to what they perceive as important to the company and its managers. Both organizational influences may act as barriers and thus help to explain why the provision of pharmaceutical care has not yet become a reality in the day-to-day operations of community pharmacies. 4 ,9,lo
Objective The objective of this study was to examine the influence of two situational pressures inherent in community practice on practitioners ' clinical decision making. These situational pressures are components of the organization's climate and specifically refer to workload pressures and the perceived normative beliefs of patients and employers relative to the provision of pharmaceutical care. 9,IO,20 Based on this rationale, the following hypothesis is advanced: The situational pressures of workload and perceived normative beliefs of patients and employers (significant others) will be significantly correlated and will account for a significant amount of the variance associated with community pharmacists' clinical decision making,
Journal of the American Phannaceutical Association
441
RESEARCH
Situational Factors
Methods This study was a component of a larger study that examined moral reasoning as a determinant of community practitioners' clinical performance. The two research instruments used addressed the two components of organizational climate--clinical decision making and social desirability. The social desirability scale was used as an external check on the validity of the clinical decision making questionnaire. These instruments were sent to a sampling frame comprising 450 systematic randomly sampled community pharmacists (chain and independent) in a large southeastern city. The sampling frame was obtained from the target city's state board of pharmacy and included community pharmacists exclusively. The independent variables of interest were (1) perceived normative beliefs of significant others toward the pharmacist providing a high level of patient care and (2) his or her workload. Perceived normative beliefs of the community pharmacist's employers and patients were gauged with a self-report measure that asked the extent to which employers and patients would approve or disapprove of pharmacists' provision of pharmaceutical care during the next six weeks . These items were modeled after a component of Odedina' s Behavioral Pharmaceutical Care Scale (BCPS) and were measured on a seven-point Likert-type scale ranging from approval to disapproval of the provision of pharmaceutical care.4 In an attempt to get a more precise measure of workload than merely prescriptions dispensed, additional help from other pharmacists and technicians was included in the model. The formula decided upon was modeled after Kirking's operationalization of workload 2: Workload = A/[(B/C) + 1] Where A = number of prescriptions dispensed per hour; B = number of hours worked by other pharmacists and all technicians during a typical day; and C = number of hours worked by the respondent during that day. For example, suppose two pharmacies each dispense 120 prescriptions during a 12-hour day . The first pharmacy (X) has one pharmacist and no technician or extra pharmacist help. The second pharmacy (Y) has one primary pharmacist, no extra pharmacist help, and technician help amounting to an average of 6 hours per day. By plugging the numbers into the above workload formula, pharmacy X's pharmacist has a workload value of 10, while the pharmacist working at pharmacy Y has a workload value of 6.67. The dependent variable in this investigation was clinical decision making. It was measured using the direct patient care dimension subset of the BPCS, which attempts to capture pharmacists' efforts to provide pharmaceutical care. 21 It asks respondents to examine their last five patients with chronic conditions and to report the extent to which they performed the following patient care activities: • Documentation • Patient assessment • Implementation of therapeutic objectives
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• Patient counseling • Screening of patient records The 18 questions in this instrument yield possible scores on co lective dimensions from 0 to 90. Reliability estimates of the fi, domains range from 0.72 to 0.90, while content validity is 0.79. 1! Social desirability served as an external check of the validityc the BPCS. Specifically, because of the possibility of respondent. expressing socially acceptable norms rather than their true ani tudes and behaviors , a shortened version of Crowne and MID lowe's Social Desirability Index was used as an external measur, to control for responding to the BPCS in a socially desirable rna! nef. Included in the Marlowe- Crowne short form are items sud as, I am always courteous, even to people who are disagreeable,: A true response to this item would be considered a socially desu able one. The short-form version includes 13 true-or-false iteID of the original 33 items making up the Marlowe-Crowne Soci, Desirability Index .23 Seven items are reverse coded, and ear: socially desirable answer is assigned a point. This instrument m a Kuder-Richardson reliability of 0.76. Since the hypothesis posited that a significant correlation and, significant amount of the variance associated with clinical d ' sion making would be accounted for by the situational pressure of perceived normative beliefs and workload, a semipartial com lation was used within a multiple regression analysis usin: SPSS.24 For purposes of this investigation, the cutoff for signio, cance was ex. = 0.05 . The sernipartial correlation represents til unique relationship predicted by an independent variable after al predictions shared with all other independent variables an parceled out. 25 The semipartial correlation is useful for apportioo ing variances among the independent variables in a regressi~' equation. Thus , it provides a precise measure of a variable', unique contribution to the outcome measure (i.e., clinical decisi~ making). Squaring the sernipartial correlation results in the uniqUi variance associated with clinical decision making that can ~ explained by the situational pressures of workload and nonnatili' beliefs. Perceived normative beliefs of patients and employers weri combined for statistical analysis. This treatment of perceived n~ mative beliefs is consistent with those of previous studies. 3,4
Results Of 450 mailed questionnaires, 9 were returned as undeliwr able. To maximize response rates, a modified Dillman approad was used whereby three reminders, spaced two weeks apart, wer sent to sample pharmacists. 26 A chain pharmacy directed 29 0f ir.' pharmacists not to respond to the survey, for reasons that coui; not be ascertained. Of the remaining 412 surveys assumed to hal'; been delivered, 131 (31.8%) pharmacists responded. The mean age of the respondents was 40 years, and the numti of men (80) responding was more than twice the number of worr. en (33). Scores on the perceived normative belief scale rang l
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from 4 to 14, with a mean of 10.99, while scores on the workload measure ranged from 2. 12 to 12, with a mean of 5.29. The scores on the clinical decision making instrument ranged from 9 to 69, with a mean of 37.34. Because of the possibility of systematic differences between those who responded and those who did not, nonresponse bias was assessed. Because late respondents may be similar to nonrespondents on variables of interest, a wave analysis was conducted whereby those responding to the initial mailing and the subsequent reminders were compared on the clinical decision making instrument. 27 Results of this wave analysis indicated that nonresponse bias did not appear to be a problem with this investigation. After control ling for social desirability, the situational pressure of workload did not account for a significant portion of the variance associated with a community pharmacists ' clinical decision making (Table 1). However, after controlling for social desirabilityand workload, perceived normative beliefs accounted for 7.6% of the variance associated with community pharmacists' clinical decision making (p = 0.003).
ing in this study may be because the workload measurement used was not sensitive enough to capture the true relationship. Since the workload measure used in this investigation did not take into account " time of day," the possibility exists for clinical performance to be high during slow times and poor during the busier times. Therefore, workload may have been a factor in the sampled pharmaci sts' clinical decision making, even though this study failed to detect any relationship. The present study demonstrated that the perceived normative beliefs of significant others about the provision of pharmaceutical care can significantly influence community pharmacists ' clinical decision making. However, these perceived normative beliefs accounted for only 7.6% of the variance associated with clinician decision making. Two explanations for this are possible. First, this investigation examined only two aspects of organizational climate. Examination of additional climate elements, such as autonomy, task orientation, and innovation, may increase the explained amount of variance associated with clinical decision making. As discussed previously, one element that often shapes the climate of an organization is the organizational reward system. 12 It, along with other climate elements, accounts for a significant amount of Discussion the variance associated with poor job performance. 31 ,32 Therefore, if community pharmacy organizations want their pharmacists to This investigation examined the relationship between two com- provide comprehensive patient care, their organizational climates ponents of organizational climate and community pharmacists ' must reflect this. The organizational reward system can be clinical decision making. Perceived normative beliefs of signifi- changed to elevate the importance of patient care activities cant others appeared to be a significant predictor of pharmacists' through monetary means (e.g., bonuses for detecting drug-drug decision making. On the other hand, workload pressures, at least interactions) or through nonmonetary means (e.g., recognition via a plaque for the pharmacist who detects the most drug or food in this study, did not significantly affect this variable. Perceived normative beliefs of significant others toward patient interactions). By doing this, community pharmacists might come care activities have been examined in previous studies. 3,4,28 In gen- to perceive that patient care activities are rewarded, and they will eral, our results corroborate those of past studies by supporting the likely begin to emphasize them. A second explanation is that individual differences were not contention that perceived normative beliefs of significant others examined. Such individual difference variables as moral reasoncan significantly influence pharmacists' patient care activities. Workload did not appear to influence community pharmacists' ing and self-efficacy have been shown to influence clinical deciclinical decision making. Although other studies, such as Berardo sion making in medical residents and pharmacists. 4,33,34 et ai., did not find a correlation between workload and patient care activities, research in other professions suggests that workload pressures can significantly influence behavior. 29 For exam- Limitations and Future Research ple, in accounting and auditing, it has been empirically demonSeveral limitations to this research can be identified. The sam. strated that when firms put budget pressures on auditors, their work quality suffers. 3o A plausible explanation for why workload ple of community pharmacists from only one city limits the genpressures were not significantly related to clinical decision mak- eralizability of the results. Only two situational pressures inherent
I
T:bl e 1. Unique Contribution of Situational Variables to Pharmacists' Clinical Decision Making
Va riable
R
R 2 Chang e
FChange
Signifi cance of FChange
S em ipartial Correlation Coefficient
~I desirability
0.006
0
0 .004
0 .952
0.021
Workload
0.039
0 .001
0 .165
0.686
0.065
Perceived normative beliefs
0.278
0 .076
9 .022
0.003*
0.275
.---------------------------------------------------------------------------------------------------'Significant at ex = 0.01 .
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RESEARCH
Situational Factors
in community practice were examined. Therefore, it is difficult to generalize the findings to represent a more detailed representation of organizational climate. Finally, despite efforts to assess nonresponse bias, those who responded to the survey could have been systematically different from those who did not. Despite these limitations, the result of this research suggests that the perceived normative beliefs of significant others is one determinant of community pharmacists' clinical decision making. To validate these results, future research should be pursued using broader dimensions of organizational climate and sampling of community pharmacists from different regions of the United States.
Conclusion This study examined the influence of two situational pressures inherent in community practice on pharmacists' clinical decision making: pharmacists' perceptions of the normative beliefs of significant others (patients and employers), and workload pressures. Only the perceived normative beliefs of patients and employers significantly influenced clinician decision making. Pharmacy organizations may wish to identify and resolve both perceived and real problems that impede the provision of pharmaceutical care by their pharmacists (i.e. , emphasizing and rewarding prescription volume and not the provision of pharmaceutical care).
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9. Penna RP. Pharmaceutical care: pharmacy's mission for the 1990s. A J Hasp Pharm. 1990;47:543-9. 10. Raisch DW. Barriers to providing cognitive services. Am Phaff 1993(Dec): NS33:54-8. 11. Johns G. Organizational Behavior. Glenview, III : Scott Forresmal 1988. 12. Lawler EE III. High-Involvement Management: Participative Stralegi, for Improving Organizational Performance. San Francisco, Cali Jossey-Bass, 1986. 13. Kerr S. On the folly of rewarding A while hoping for B. Acad Manage. 1975;18:769-83. 14. Bern DJ, Allen A. On predicting some of the people some of thetim, the search for cross-sectional consistencies in behavior. Psychol Re 1974;81 :506-20. 15. Davis-Blake A, Pfeffer J. Just a mirage: the search for disposition; effects in organizational research . Acad Manage Rev. 1989;14:385-4(( 16. Mischel W. Personality and Assessment. New York, NY: John Wiley, Sons; 1968. 17. Mischel W. The interaction of the person and the situation. In: Magnu: son D, Endler NS, eds. Personality at Crossroads: Current Issues i Interactional Psychology. Hillsdale, NJ: Erlbaum; 1977:333- 52. 18. Chatman JA. Improving interactional organizational research: a mod, of person-organization fit. Acad Manage Rev. 1989;14:333-49. 19. Jackofsky EF, Slocum JW. A longitudinal study of climates. Orga Behav. 1987;9:319-34. 20. Schommer J, Wiederholt JB. Pharmacists' perceptions of patient! needs for counseling. Am J Hosp Pharm. 1994;51:478-85. 21 . Odedina F, Segal R. Behavioral pharmaceutical care scale for measUi ing pharmacists' activities. Am J Health Syst Pharm. 1996;53:85&-S5. 22. Crowne DP, Marlowe D. The Approval Motive. New York: John Wile & Sons; 1960. 23. Reynolds WM . Development of reliable and valid short forms of th Marlowe-Crowne social desirability scale. J Clin Psychol. 198; 38:119-25. 24. SPSS 7.0 for Windows. Statistical Package for the Social Science! Chicago, III: SPSS Inc; 1995. 25. Hair JF Jr, Anderson RE, Tatham RL, et al. Multivariate Data Analysi! 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1994. 26. Salant P, Dillman D. How to Conduct Your Own Survey. New Yo~ John Wiley & Sons; 1994. 27. Churchill GA. Marketing Research: Methodological Foundations. Nell York: Holt, Rinehart and Winston; 1987. 28. Mason HL. Using attitudes and subjective norms to predict pharmaci~ counseling behaviors. Patient Couns Educ. 1983;4: 190-6. 29. Berardo DH, Kimberlin CL, Barnett CWo Observational researchOfi patient education activities of community pharmaCists. J Soc Adm Pharm. 1989;6:21 - 30. 30. Ponemon LA, Gabhart DRL. Ethical Reasoning in Accounting anD Auditing. Vancouver, BC: CGA-Canada Research Foundation; 1993. 31 . Jansen E, Eccles D. Innovation and restrictive conformity among hospital employees: individual outcomes and organizational considera tions. Hasp Health Serv Adm. 1994;39:63-80. 32. Prichard RD, Karasick BW. The effects of organizational climateon managerial job performance and job satisfaction. Organ Behav Hurr Perform. 1973;9:126-46. 33. Sheehan TJ , Husted SD, Candee D, et al. Moral judgment as a predic tor of clinical performance. Eval Health Prof. 1980;379-400. 34. Latif DA. The Relationship Between Community Pharmacists' Mora Reasoning and Components of Clinical Performance. Auburn, Ala Auburn University; 1997. Dissertation.
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