An international portrait of pharmacists' professional role identities: A Q-methodology innovative study

Abstract

Background

Professional identities shape who pharmacists are, what they do, and what they stand for as professionals. Novel research methodologies have potential to illuminate pharmacists' professional identity and roles in new and innovative ways. This study aimed to explore international pharmacists' identity through reflection on their professional roles.

Methods

Q Methodology, which uses quantitative techniques to systematically study subjectivity, was used to allow for an in-depth analysis of professional identity. The participants were self-identified pharmacists working in patient-facing roles who attended the International Pharmaceutical Federation (FIP) Congress in Brisbane, Australia, from September 24–28, 2023. They completed Q methodology online activities to sort the Q-Set within a fixed quasi-normal distribution grid.

Results

Twenty participants completed the Q-Sort activity. Participants came from 10 countries (five of the six World Health Organization regions), two thirds identified as women and approximately one third practiced in hospital and community pharmacy settings, respectively. Three factor arrays are described, which explain 52 % of the variance; Factor 1: Pharmacists as autonomous healthcare providers AND clinical team members; Factor 2: Pharmacists as healthcare providers for individual patients; and Factor 3: Pharmacists as managers first, then healthcare providers.

Conclusion

This study offers a new perspective, revealing how various roles may converge to form a pharmacist's professional role identity: for example, autonomous healthcare providers AND clinical team members AND patient-focused practitioners AND leaders mindful of management responsibilities. Viewing the Q Methodology with a systems thinking lens illuminates pharmacists' professional identities as neither a mere sum of the roles and services they provide, nor represented by a singular aspect of their professional work. Recognizing the complexity of the pharmacists' identities as individuals helps to break free from the cognitive dissonance that has plagued the profession suggesting that professional identity is represented by singular or often competing roles as the scope of pharmacy practice evolves.

Introduction

Professional identities shape who pharmacists are, what they do, and what they stand for as professionals.^1,2 Professional role identity represents how professionals see themselves in relation to their roles leading to understanding who they are and how they should act.3, 4, 5 Professional role identity is theorized as iterative, evolving with new or changing roles,^6,7 changing work environments,³ and extreme events (such as the COVID-19 pandemic).⁸ Previous literature has suggested that pharmacists identify with and perform many roles.^1,2,9, 10., 11 “Dispenser of medicine” has been the primary and universal way in which pharmacists have viewed themselves.^1,12 “Medicine advisor”, “social carer”, or “manager/businessperson” were other ways that pharmacists have traditionally regarded themselves.² More recently, other identities are noted as “clinical decision-maker”,¹³ “clinician”,^11,14,15 or “multifaceted professional¹⁶ as pharmacists' roles evolve to fulfill their scope of practice. These professional role identities are visible at the individual or micro-level, as pharmacists are influenced in how they see themselves based on their environment (e.g., practice setting, legislation and policies, regulatory and advocacy bodies, or education). A 2021 scoping review of pharmacists' professional identity highlights a disconnect between their aspirations as clinicians and the realities of their workplace duties. The “clinician” identity is strongly promoted within pharmacy education programs but does not dominate in global pharmacy practice, with many feeling tied to the transactional “dispenser” in community pharmacies.¹⁷ Similar sentiments are shared for other healthcare providers like physicians, whereby their practice environment influences their professional role identity. Reay et al. (2017) outlines how new roles and expectations can result in changes in collective professional role identity of physicians.¹⁸ It is suggested that when multiple role identities interplay, it is up to the individual to understand the impact on their identity formation and how it translates into their practice environment.¹⁹ The literature documents the possibility of multiple professional role identities among professionals, including pharmacists.^2,7 This study sought to understand the nature and complexity of multiple identities using an innovative research methodology. Such exploration will provide valuable insight into the evolution of practice since the start of the latest extreme event (the COVID-19 pandemic), shed some light on the ways to deploy and sustain change in practice, and act as the base for curriculum evolution and professional identity formation.^11,16 Indeed, a better understanding of the complexity of pharmacists' professional identity and roles using different methodologies could provide insight into practice change.

Q Methodology is an innovative methodology that has been explored in healthcare to unpack complex topics, like professional role identity. A 2021 scoping review of its use in healthcare (from 1966 to 2019) identified 289 studies that utilized this method, with a noticeable increase in the last 5 years, suggesting a growing interest in this approach.²⁰ It has been used to investigate the subjectivity of various healthcare topics, such as nurses' practices in stroke rehabilitation, mental healthcare, resource allocation, end of life care, as well as gender, sexual and reproductive health topics.²⁰ It is also acknowledged as a rigorous way of exploring complex or contentious topics from different perspectives. Q Methodology combines qualitative and quantitative techniques to study subjectivity. Despite its recent popularity, Q Methodology was originally developed in the 1930s by William Stephenson, a physicist and psychologist.^21,22 Q Methodology allows researchers to identify and describe the shared viewpoints that exist on a topic, revealing areas of consensus and disagreement across these views. It starts with Q-sorting, where individuals articulate their own viewpoint by ranking a set of statements (the Q-set) about a particular issue based on some defined dimension, for example, level of agreement or perceived importance.^20,22 This is followed by a factor analysis to identify clusters of shared viewpoints that can then be interpreted. The qualitative aspects of Q Methodology allow participants to express their subjective opinions, while the quantitative aspects use factor analytic data-reduction and induction to provide insights into opinion formation as well as to generate testable hypotheses. Q Methodology research emphasizes the qualitative how and why people think the way they do.²³ As such, it is an ideal method to study the complexity of pharmacists' roles and professional identities from around the globe.²⁴ We explored professional role identity based on two questions:,²⁵

• •“How do I act?” (What pharmacists do in their practice), and
• •“Who am I?” (How pharmacists define themselves in terms of the work they do).

This study aimed to (1) describe the use of Q Methodology within a pharmacy context and (2) explore international pharmacists' professional role identity through their reflection on their professional roles. The objectives were (1) to describe the process and challenges of using Q Methodology in a pharmacy context, (2) to explore how pharmacists conceptualize their roles, and (3) how their roles differ by practice environment. This study was underpinned by the hypotheses that there is a shared professional role identity composed of roles broadly shared by pharmacists practicing in similar areas, the differences over roles can be identified, explained, and managed within the bounds of the profession and practice or regulatory environments and that pharmacists' roles match with multiple role identity categories.

Methods

Study design

Q Methodology was used for this study following the guidance outlined by Watts and Stenner.²² This approach allowed for the in-depth analysis of the subjectivity of professional identity with an objective lens using Q Methodology. It also allowed for the separation of possible researcher influences or biases. The statements that make up the Q-Sort incorporated photographs to utilize visual art based methods to probe the exploration of the subjective understanding²⁶ of roles and professional identities for pharmacists. The details of how photographs were sourced and used are outlined below.

Participants and recruitment

Participants were self-identified pharmacists working in practice with a patient-facing role who attended the International Pharmaceutical Federation (FIP) Congress in Brisbane, Australia, from 24 September to 28 September 2023. Pharmacists working in non-patient facing roles, pharmacy technicians, pharmacy assistants, and pharmacy students/interns were not eligible to take part in this study. This decision was made as the professional roles and, thus identity would differ greatly between these groups. Therefore, this study focused specifically on patient-facing roles across the various pharmacy practice settings.

Participants were recruited through flyers, emails, and on-site research team members attending the FIP congress during networking events and the exhibit hall. The study recruitment material was also shared by FIP in the post-congress follow-up email sent to attendees. Ethics approval was provided by the Health Research Ethics Board of the University of Alberta (Pro00131961). Participants provided their informed consent at the beginning of the study activities, and all data that was collected was anonymous.

Data collection and analysis

The Q Methodology survey activities were displayed and housed on the online Q Methodology software platform developed by Lutfallah and Buchanan.²⁷ The platform allowed for the collection of the demographic and post-reflection questionnaires, as well as the Q-sort activity, all within one online platform. These additional data were used to contextualize the Q-sort results and provide deeper insights into participants' professional identities.

Four key phases were undertaken in this study; (1) definition of the concourse, (2) development of the Q-Set, (3) Q-sorting, and (4) analysis and interpretation. Following the methodology outlined by Watts and Stenner,²² the results are presented as a detailed narrative in table form for each factor array or viewpoint. Within the tabulated narrative, reference is provided to crossreference the Q Sort statement number (refer to appendix) and the overall ranking that the statement received within the viewpoint.

Phase I - concourse development

For this study, we used a combination of pharmacist role categories with descriptions/definitions and photos representing one of the roles as the Q-Set concourse (Appendix A). This concourse was initially developed and piloted in a Canadian study exploring the impact of the COVID-19 pandemic on pharmacists' professional role identity,²⁸ using the international joint FIP/World Health Organization (WHO) guidelines for good pharmacy practice.²⁹ There were originally 16 role categories from the photo concourse that were used for the Canadian study.²⁸ This was expanded based on the international joint FIP/WHO guidelines for good pharmacy practice²⁹ to 28 role categories. With the use of photos in an international study, the team paid particular attention to ensuring the photos were representative of different practice settings, countries, and equity, inclusion, diversity, accessibility, and antiracism (EDIAA) considerations.

Phase 2 - Q-set validation

The Q-set is a subset of statements which are drawn from the concourse, to be presented to the participants. This study used statements that included a photo, role category heading, and examples of roles within that category (Appendix A).

The photo concourse was reviewed with 16 individuals with a pharmacy background and included members of FIP who work at the international level of pharmacy. The feedback concluded that the photos clarified what the researcher's meant with the role categories and made the tasks less tedious than a list of text written only in English. These 16 participants gave helpful suggestions on roles that were missing and where role categories needed to be split. They also provided their insights into whether the EDIAA representation was appropriate for an international audience. A formal EDIAA assessment was also conducted by the University of Alberta Equity and Human Rights Department of the Office of the Provost and the FIP organization. The EDIAA assessments reported that the Q-Set needed more representation of different pharmacy practice settings (alternate to western community pharmacy layout), power dynamics by sex, and countries (alternate to high-income). As such, the research team strategically reached out to their contacts through FIP to obtain other photos of pharmacists' roles that reflected the missing representation specifically from non-western backgrounds. The Q-set was updated accordingly, resulting in a final 40 statements/photos set. Explicit permission was obtained for photos that the research team did not own for the use within the study and publication, this was posted within the online platform for participants to see and is published as the last page in the online supplementary material, which provides the final Q-Set statements and photos that was used in the study.

Phase 3 - Q-sort activity

Q-Sorting involves participants ranking the provided Q-Set using a fixed quasi-normal distribution grid. A fixed quasi-normal distribution grid is a structured arrangement of data points that follows a pattern similar to a normal (bell-shaped) distribution but with some modifications. It remains unchanged once set and ensures well-spaced data points for calculations or simulations. This step was completed online using the Q Methodology software.²⁷ The participants were introduced to the Q Sort in a pre-sorting activity where they viewed each individual statement and gave it a thumbs up, down or question mark. This meant that for the Q sorting activity, the participants had already seen the statements, and they were helpfully grouped into the three categories (thumbs up, down or question mark) to assist them with the sorting task. Participants ranked the Q-set statements using the fixed quasi-normal distribution grid, where they assigned each statement, a position ranging from most to least reflective of their professional identity. Anchors such as ‘most like my role’ and ‘least like my role’ were used to guide the sorting process. Following completion of their Q-sort, participants were asked post-sorting questions about the process, as well as their background and experience related to their roles in general. Questions included country, practice setting, job title, qualifications, gender, what did they like and dislike about the Q Sorting activity, were there any roles not represented that they identified with, rationale as to why, and if the photos helped or hindered their sorting.

Phase 4 - analysis & interpretation

The data analysis of the Q sorts was performed using the Q Methodology software.²⁷ Technical aspects of analysis in Q Methodology are similar to traditional factor analysis.²⁰ Factor extraction was performed using principal component analysis, followed by varimax rotation to enhance clarity and maximize the variance explained by each factor or viewpoint. These methods were selected to improve interpretability while preserving the distinctiveness of each factor. To aid qualitative interpretation, viewpoint arrays were constructed by computing ideal Q-sorts based on the weighted average of participant responses associated with each viewpoint. By analyzing participants' rankings, shared patterns emerged and were grouped into Factors, representing distinct perspectives. A factor array serves as a model ranking that reflects how an individual with a particular perspective would ideally prioritize all statements.

The overall configuration of statements in a viewpoint array is more important than the placement of a few particular items. Interpretation involves developing qualitative narratives for each viewpoint that incorporates as many statements from the viewpoint array as possible and draws on other data about the participants from participants' post-sorting reflections who loaded on that viewpoint.²⁰ The qualitative phase involves analyzing these factors to understand the perspectives they represent. Two researchers (KEW and TJS) examined the factor arrays (ideal rankings for each perspective) and use participants' comments, demographics, and contextual knowledge to interpret the meaning behind each factor. The goal is to construct a narrative that explains the key themes, values, and beliefs underlying each perspective, ensuring the interpretation aligns with the data. Additionally, the two researchers used content analysis to group participants post-sorting open-ended questions about their experience of the Q Sorting activity and their rationale as to why, they selected specific roles that they most and least identified with.

Sample size

Q Methodology studies aim to establish the existence of particular viewpoints and to understand and compare them.²² Q Methodology research emphasizes the qualitative how and why people think the way they do; the methodology does not count how many people think a certain way.²³ Thus, no sample size could be determined a priori. The focus is on capturing diverse perspectives rather than achieving statistical generalizability. The key principle is that the number of participants should be fewer than the number of Q statements to allow for meaningful factor extraction and interpretation. The goal of Q Methodology is, first and foremost, to uncover different patterns of thought rather than their numerical distribution among the larger population. Studies using the Q Methodology typically use small sample sizes (∼10–40 people).²³

Results

Participants and recruitment approach

There were 325 people who clicked the study link, of whom 83 people started the questionnaire. This is a uptake rate of 25.5 %, which proves to be a promising recruitment method to recruit participants at an international conference. However, major technical issues were identified during data collection at the conference using a touchscreen device. The platform would glitch and freeze, preventing people from finishing their questionnaire responses. Unfortunately, these issues prevented many from completing the questionnaire, giving up in frustration, and only 21 people submitted a completed Q sort. One participant did not meet the eligibility screening question of being in a direct patient-facing pharmacist role and thus was removed from the analysis. This technical issue was not identified in the testing and piloting of the platform and interface. To overcome this technical issue, participants were invited to complete the questionnaire in the post-conference email sent by FIP and advised to use a computer to complete the questionnaire.

Of these 20 people, 18 elected to complete the demographic questions at the end of the online questionnaire (Table 1). Two-thirds (66.7 %) of the participants identified as women and approximately one third practiced in hospital and community pharmacy settings, respectively (Table 1). Five of the six WHO regions, except the Eastern Mediterranean region, were represented by individual countries, including Canada, Malawi, Kenya, Australia, USA, Malaysia, Portugal, UK, Indonesia, and Nigeria.

Table 1.

Participant characteristics.

Gender (n = 18)
Woman	12
Man	6
WHO region (n = 18)
Africa	4
Americas	2
Eastern Mediterranean	0
Europe	4
South-East Asia	1
Western Pacific	7
Years in Practice (n = 18)
1–5 years	4
6–10	4
11–15	2
16–20	3
21–25	0
26–30	2
31+	3
Practice setting (multiple self-selection, n = 24)
Hospital	7
Outpatient	2
Community pharmacy	6
Academia	3
Primary care	2
Pharmacy association	1
Other (not specified)	3
Pharmacy qualification (multiple self-selection, n = 25)
BPharm	12
PharmD	3
PhD	2
MBA	3
MSc	3
Hospital residency	2

* Two participants chose not to provide demographic information.

Q sort activity

Most of the participants found the photos were useful in completing the Q sort activities and described them as complimentary for understanding some of the role categories as well as making the activity more engaging and visually appealing. It took participants an average of 17 min to complete the activities, and they found the instructions provided were clear and easy to follow.

Participants commented on what they found easy about the Q Sorting activity.

“I was able to understand the definitions of the roles of the pharmacist without having a descriptor apart from the title.”

“The images simplify the choices.”

Unsurprisingly, when asked what was challenging about the task, many of the participants referred to the technology issues, as well as the statements were hard to see on their mobile devices. Additional challenges related to the task were the difficulties in deciding where to place roles and what rankings to use, as all roles had to be placed on the grid, and some described that they wanted to give equal weighting to several roles. However, this is the nature and science behind the Q Methodology to get at the micro-differences within people's viewpoints.

“I only have a laptop and the tiles were tiny in the main sorting activity once they were in the grid, so more difficult to shuffle about.”

“So many of the roles are interconnected (e.g., counselling and assisting in chronic disease management) trying to separate these was difficult.”

Viewpoint interpretations

The Factor Analysis and Eigenvalues (the sum of squared factor loadings for each viewpoint) are presented in Table 2. Initially, 80 % of the variance was explained by eight viewpoints. However, following the methodology outlined by Watts and Stenner,²² we rotated and carried forward only the first three viewpoints, explaining 52 % of the variance and that had stronger eigenvalues. Viewpoints 4–8 only had one participant significantly identify with the factor array and did not give confidence that it was an accurate reflection of the international pharmacist population.

Table 2.

Factor analysis and eigenvalues.

	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Factor 6	Factor 7	Factor 8
Eigenvalues	5.7	2.8	1.9	1.6	1.3	1.2	0.9	0.8
% Explained Variance	28	14	10	8	6	6	4	4
Cumulative % Explained Variance	28	43	52	60	67	72	77	80
Standard Error	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2

* After analyzing participants rankings, patterns were determined and collated as Viewpoints, which represent shared perspectives. A factor array is a model ranking that best represents each group's way of thinking. It shows how someone with that perspective would ideally rank all the statements.

The participants in this study shared commonalities of their professional role identity which is presented in the viewpoint interpretation for Viewpoints 1, 2, and 3 are provided in Table 3. The shared commonalities were derived from the objective analysis of the participants Q Sort rankings of their individual roles and their subjective comments supporting/explaining their rankings, confirming the hypothesis that participants roles and their practice setting influence their professional role identity.

Table 3.

Viewpoints.

Viewpoint 1: Pharmacists as autonomous healthcare providers AND clinical team members. These pharmacists strongly value being part of a multidisciplinary team (2: +5)*, where they advise colleagues (15: +1) providing expert opinion (36: 0) after assessing and monitoring patients (28: +4; 38: +2). This collegial nature does not diminish their perception of their autonomy as a healthcare provider, leader, and an independent prescriber (1: +3; 13: +6) that makes significant contributions to a patient's healthcare team. This was true even for the participants, who were from countries that do not currently have specific pharmacist independent prescribing within their scope of practice. This viewpoint conveys that these two concepts are not mutually exclusive for pharmacists. These pharmacists see themselves as valuable team members whilst maintaining their unique expertise. They believe it is fundamentally important for them to participate in policy and governance (30: +5) to support the profession, but they do this through other avenues and not advocating - which they see more of a collective profession role and less of an individual pharmacist role (31: −1). Information was a strong identifier for these participants, specifically in two categories. Firstly, the acquisition of information (17: +2) including conducting research (25: +3), specialising (33: 0), combating misinformation (15: 0), and to a lesser extent continuing professional development (5: −2). Secondly, the sharing of evidence-based information through coaching, teaching, precepting, and counselling patients (23: +3; 18: +2; 16: +1; 14: +4), as well as with colleagues (15: +1; 36: 0). Pharmacists are important service providers in the community, even for these participants that predominantly work in tertiary care style settings. Primary care services like point-of-care testing, supporting self-care for acute illnesses, managing chronic conditions, vaccinations, outreach, and remote care were deemed important roles (6: +2; 22: +1; 27: +1; 3: 0; 24: −1; 8: +1) and thus, part of how these pharmacists see themselves andthe profession. Public health services and health emergency preparedness were ranked higher in Viewpoint 1 compared to the other viewpoints (29: −1; 27: −2; 26: −3) but were seen as perhaps less important than primary care services. With larger pharmacy teams and perhaps more technology and resources available, these pharmacists delegate the dispensing (10: −4), supply (9: −3), and inventory management (32: −5) to others within their pharmacy team. Additionally with their ability to delegate, they ranked lower than other viewpoints, the roles and identities of assessing drug quality (35: 0), coordinating antimicrobial stewardship (39: −1), and providing veterinary medicines (34: −4). These participants did not identify with aspects of business management (20: −5; 7: −3) and rejected the idea of pharmacists being responsible for merchandising or retail management (21: −6).

Viewpoint 2: Pharmacists as healthcare providers for individual patients. The pharmacist participants associated with Viewpoint 2 strongly associate themselves with the mission of community pharmacy to provide prescription services (12: +6)*, dispensing (10: +4), and supply medicines (9: +5) to individual patients. Meeting the needs of individual patients is the core ideal for these pharmacists. They demonstrate this through the value and importance they place on the primary care services that they provide through monitoring patients (38: +2), supporting self care of acute illness (8: +4), providing point-of-care testing (37: +1), and managing chronic conditions (6: +2). Other primary care services that were ranked higher compared to the other viewpoints included: compounding medicines (11: 0), providing veterinary medicines (34: −1), community outreach (3: 0), assessing drug quality (35: +1), and coordinating antimicrobial stewardship (39: 0). Information is still considered a vital component of these pharmacists' identities, but the roles have shifted from various audiences (as in Viewpoint 1) to the flow of information bidirectionally centering solely on patients. This was illustrated through the participants acquiring information (17: +1) but directly from patients for medication reconciliation (4: +3), counselling patients (14: +5), coaching them (23: +3), and combating misinformation for them (15: +3). Information, education, research, or teaching roles relating to other audiences like pharmacy staff, other colleagues, or the wider community were ranked lower than the other viewpoints (31: −2; 25: −3; 36: −3; 18: −5). Surprisingly even precepting, the teaching of future pharmacists working in community pharmacies was ranked lower than other viewpoints (16: 0). Public health services (29: −2), where the benefit is seen at the population or community level were ranked lower for these pharmacists compared to the other viewpoints. This included vaccination and the administering of medications by injection (22: −2) and performing pharmacoeconomic evaluations (4: −4). These participants see themselves as generalists, not specialising in any particular area of medicine (33: −1). With their focus being solely on individual patients and the mission of community pharmacy services, these pharmacists do not associate themselves with the business and retail management aspects of community pharmacy (20: −5; 21: −6). Given the more siloed nature of community pharmacy, these pharmacists feel their roles in leading and participating in multidisciplinary teams are less important compared with the other viewpoints (1: 0; 2: 0).

Viewpoint 3: Pharmacists as managers first, then as healthcare providers Unsurprisingly these pharmacists, given their job descriptions, had a strong association with managing or owning a pharmacy or pharmacy department (7: + 6; 20: +5)*. The roles they deemed most important in how they see themselves compared to the other viewpoints, focused on the business and running aspects of pharmacy – managing inventory (32: +3), dispensing (10: +5), managing chronic conditions (6: +3), and merchandising (21: −2). Information was an important component for these participants, but again had a distinct difference compared to the other viewpoints. These pharmacists valued continuing professional development (5: +4), focusing on advising others (19: +3), precepting pharmacy students (16: +1), and using their position to advocate for the profession (31: 0). However, they do not associate their advocating with the role of participating in policy and governance (30: −3). The individual patient information roles of counselling, coaching, medication reconciliation, and acquiring information were ranked lower for these participants than the other viewpoints (14: +4; 23: +2; 4: −1). While these pharmacists see it as important to provide public health services (29: −1) with a particular focus on coordinating antimicrobial stewardship (39: 0), they did not rank the roles of administering injections (22: −2), providing community outreach (3: −1), and participating in health emergency preparedness (27: −5) highly when compared to other viewpoints. These pharmacists identified less with the individual patient care roles: independently prescribing (13: +1), monitoring patients (38: −1), assessing patients (28: −2), providing prescription services (12: −3), compounding medicines (11: −4), providing remote care (24: −4), point-of-care testing (37: −5), and providing emergency care (26: −6).

* The first number refers to the statement number that represents the photo and role category (see appendix). The second number with a + or – is the ranking that statement received within the viewpoint.

Viewpoint 1: pharmacists as autonomous healthcare providers AND clinical team members

Viewpoint 1 had an eigenvalue of 5.7 and explained 28 % of the study variance. Eight participants significantly associated with viewpoint 1. They were from Australia, Canada, Malaysia, the UK, and the USA. They worked in hospitals, academia, and multidisciplinary clinics. Five of them had over 20 years of experience and three had under 10 years. Majority were women and one identified as a man. In Viewpoint 1 (Fig. 1), participants strongly value being part of a multidisciplinary team. Yet, this collegial nature does not diminish their perception of their autonomy as a healthcare provider, a leader, and an independent prescriber. This professional role identity was irrespective of their scope of practice including independent prescribing or not. The Factor array highlights the mutual professional role identity of being a team member and an autonomous healthcare provider, valuing teamwork while maintaining their unique expertise. Their priority is primary care services while also placing importance on their public health duties.

Fig. 1.

Representative Q Sort for Viewpoint 1: Pharmacists as autonomous healthcare providers AND clinical team members.

Viewpoint 2: pharmacists as healthcare providers for individual patients

Viewpoint 2 had an eigenvalue of 2.8 and explained 14 % of the study variance. Six participants significantly associated with the viewpoint. Two elected not to complete the demographic survey and no information is known about them. The other four were from Australia, Portugal, Nigeria, and Malaysia. Three were community pharmacists, two with management positions, and the fourth worked in outpatient clinics. Of the four, two identified as women and two as men. Their experience in practice ranged from 7 to 32 years. In Viewpoint 2 (Fig. 2) meeting patients' needs is the prime value and mission of the participants' roles and professional role identity as a pharmacist. They see themselves as generalists, morphing to whatever the need of their patient is. The tangible artifact of this pharmacist professional role identity is that the patient leaves with the dispensed medicine, or new knowledge, point-of-care test, vaccination, recommendations, or referrals; but the pharmacist's purpose is the individual patient. Looking at the information roles which are still a core element, but the audience is solely patients. Even precepting, which is an important role for community pharmacists, was ranked as a low priority.

Fig. 2.

Representative Q Sort for Viewpoint 2: Pharmacists as healthcare providers for individual patients.

Viewpoint 3: pharmacists as managers first, then as healthcare providers

Viewpoint 3 had an eigenvalue of 1.9 and explained 10 % of the study variance. Six participants significantly associated with the viewpoint. They were from Kenya, Portugal, Indonesia, and Malawi. Three were community pharmacists in management positions, two were hospital pharmacists with management positions, and one was in a management position for a pharmacy organization. There was an even split with three identifying as women and men, respectively. Four had under 6 years of experience and the other two had 13 and 30 years. In Viewpoint 3 (Fig. 3), the pharmacist professional role identity differs from the other two factor arrays. These pharmacists are in positions of management, and thus, this influences how they see themselves as pharmacists. Given their day-to-day activities, they associate themselves less with patient care services and roles and focus on running the pharmacy or pharmacy department, managing staff, and advocating for the profession.

Fig. 3.

Representative Q Sort for Viewpoint 3: Pharmacists as managers first, then as healthcare providers.

Discussion

Micro-level professional role identity

The findings of this study illustrate the complexity and diversity of pharmacists' professional identities, highlighting both individual and role-based differences (micro-level), whilst also revealing commonalities in how pharmacists perceive themselves and differences in how they enact their roles based on their practice settings (meso-level). Our findings showed that pharmacists held multiple identities based on their roles and practice settings and depending on their professional role identity or the meaning they attributed to the roles, the same roles were enacted differently. For example, pharmacists who identified most closely as community pharmacists (Viewpoint 2) emphasized roles such as prescription services, dispensing, and supplying medicines. These roles were enacted in line with their professional role identity as healthcare providers for individual patients, aiming to meet their needs. These pharmacists did not identify specifically as “dispensers” in their professional role identity. A label like “dispenser,” based on a single role, did not adequately capture the complex meaning the participants in this study attached to the enactment of their roles within their professional identity. Additionally, this work builds on previous research suggesting that pharmacists' individual professional role identities are influenced by their practice settings and the roles they perform.⁸ While this is the first study to explore pharmacists' professional role identity using Q Methodology, it aligns with others that have explored professional identity for physicians using Q Methodology, reinforcing a theoretical conceptualisation within identities research whereby identities are multiple and intersecting.^30,31Future studies using this methodology could reveal more aspects of diversity in pharmacists' individual professional role identities, as well as other commonalities or shared identities based on various environmental and contextual factors.

Macro-level professional identity

Embracing a systems thinking approach opens up opportunities for the pharmacy profession to support a unified professional identity centered on broad concepts such as the purpose, values and norms of the profession (macro-level) rather than individual interpretations of pharmacists' individual roles (micro-level). For example, the concept of medicines has formed the basis of a unified professional role identity for pharmacists.²⁹ For some, a broad recognition of medicines may involve roles associated with independent prescribing and a strong clinical professional role identity (Viewpoint 1). For others, it could mean engaging in research and development of new medicines through pharmaceutical science, educating others about medicines, or dispensing and supplying medicines during health emergencies to prevent exacerbations of chronic conditions (Viewpoint 2). These professional role identities or role labels should not be viewed hierarchically, as the profession (macro-level) continues to evolve to encompass many facets of pharmacists' professional work.

To drive meaningful change, a systems thinking lens has the potential to reveal new ways to view the complexity and diversity in professional role identity and its potential to support the continued evolution of pharmacy practice. The fundamental basis of systems thinking is understanding that multiple parts make up any one system, and the system is not just a collection of parts but a functioning unit.^32,33 This has been acknowledged as a foundational construct for healthcare professionals, who are expected to work within systems (e.g., hospitals, community pharmacies) and provide system-based care.³⁴ Each of these systems is connected via individuals and teams, regulations and rules, and technology. Pharmacists' self-perception is influenced by their environment (e.g., the practice setting in which they work), the roles and services required by their patients, their scope of practice, their colleagues, advocacy and regulatory bodies, and professional organizations. A systems thinking perspective moves our thinking beyond viewing professional role identity through the lens of singular and sometimes competing roles or labels like “dispenser” or “clinician.” By adopting a systems thinking approach, pharmacists' professional identities are neither simply the sum of their roles and services they provide nor represented by a singular aspect of their professional work. Pharmacist professional role identity labels need to encompass the diverse and complex nature of pharmacists' professional work and how multiple roles collectively inform pharmacists' self-perception or their professional role identity.

At the macro-level, professional identity transcends the individual roles of pharmacists. It is not about the specific tasks they perform, but rather about the profession's core values and how members embody the collective vision and mission of the profession. According to the 2011 FIP/WHO guidelines for good pharmacy practice, the mission of pharmacy practice is to “contribute to health improvement and to help patients with health problems to make the best use of their medicines”.²⁹ At a macro-level, this mission translates into ensuring the safe and effective use of medicines to improve patient outcomes, recognizing patients and positioning pharmacists as key contributors within the healthcare system. To achieve this mission at the micro-level, individual pharmacists interpret their professional role identity enacted through their roles and services based on their environment, practice setting, and context. In contemplating a macro-level professional role identity for the pharmacy profession, a systems thinking approach may support the acknowledgement of newer clinical roles associated with medicine use in ways that do not minimize the importance of historical roles associated with medicine supply.³⁵ The FIP Global Advanced Development Framework³⁶ reports that pharmacists are the key to optimizing safe and effective use of medicines to address the Sustainable Development Goal 3 ‘Ensure healthy lives and promote well-being for all at all ages’.³⁷ Additionally, the Framework suggests that pharmacists' roles, skills, experiences, and competencies evolve throughout their career.³⁶ The FIP Global Advanced Development Framework outlines the advancement of the development of professional autonomy for pharmacists, from following policies and procedures to being able to take action on their own interpretation and development of standards. The 2011 FIP/WHO guidelines for good pharmacy practice outline four role categories where pharmacists' are expected to be involved by society and individuals - (1) medicine supply, (2) effective medication management, (3) information, and (4) contribute to public health.²⁹ This is similar to the role categorization recently developed for this study.^8,28 While all of these role categories are accepted in the global portrait of pharmacy, this study has highlighted the nuances between pharmacists and how they see themselves, depending on where they practice and work. The diverse professional identities of pharmacists in this study—including roles such as autonomous healthcare providers, clinical team members, patient-focused practitioners, and leaders—reflect a global movement towards workforce transformation. The FIP Brisbane Call to Action advocates for the implementation of competency-based training programs that empower pharmacists to meet population health challenges more effectively.³⁸ It encourages the full utilization of pharmacists' skills, including potential prescribing authority, and the optimization of skill sets within clinical environments.³⁸ FIP's 2030 strategy further supports this approach by recognizing the varying stages of pharmacist role development worldwide and promoting sustainable strategies tailored to regional contexts. This strategic framework ensures that workforce evolution is responsive to local healthcare needs.³⁹ The findings of our study highlight the complex and evolving nature of pharmacists' roles across different settings, reinforcing FIP's vision of a globally competent and adaptable pharmacy workforce.

Strengths and limitations

To our knowledge, this is the first study to use Q Methodology in identifying the shared viewpoints of international pharmacists on their roles and professional role identity. Q Methodology is described as an ideal method for exploring complex topics or topics that are likely to elicit strong opinions and differing perspectives, such as the professional roles of pharmacists. This study combines the richness of qualitative data with the rigour of quantitative analysis and allows participants to express their own perspectives while reducing the impact of assumptions or potential biases.

This study has the potential to contribute to the field of study of how pharmacists' roles influence their professional identity. Additionally, this study will collate the various perspectives from different scopes of practice of pharmacists around the world. We hope that this will lead to new insights with respect to evolving roles, professional identity, and practice change. Also, this study could be used as an evidence-based foundation for an update to the FIP/WHO good pharmacy practice guidelines,²⁹ leveraging the complexity of professional role identity and the commonalities based on practice setting.

We have contributed to the method of Q Methodology with the combination of photos along with the statements, while this is not new for the field, our intentional approach to EDIAA in representing pharmacists' roles was novel. While we undertook extensive EDIAA assessment and review, there is the potential that participants did not see themselves reflected in the presented images, which may have impacted their ability to identify with the role category. Another possible limitation of this study relates to the specialization of some pharmacists who may have a narrower scope of practice and/or professional role identity. For Q Methodology and this study, participants are required to rank all statements, which may be challenging for pharmacists who have specialized in a particular area of healthcare.

Q Methodology provided an objective framework to explore pharmacists' subjective perspectives on their professional roles, minimizing the risk of researcher bias. Future studies could confirm and expand on the points discussed in this paper. The portrait of pharmacy is not fully formed. Studies including pharmacists from different practice settings (e.g., industry, government) and all six WHO regions might yield additional Factors. Additionally, this study specifically recruited pharmacists attending the FIP congress in Brisbane, Australia, many of whom are academics, managers, or involved in the FIP itself (and are perhaps not “average” pharmacists). The perspectives of pharmacists that do not attend this congress were not included in this study. Thus, this study is a foundation for further exploration for a wider international or global representation of the pharmacy workforce.

Conclusions

This study offers new perspectives, revealing how various roles may converge to form professional role identities for pharmacists: autonomous healthcare providers, clinical team members, patient-focused practitioners, and leaders mindful of management responsibilities. Combining the Q Methodology results with a systems thinking lens illuminates pharmacists' professional identities as neither a mere sum of the roles and services they provide, nor represented by a singular aspect of their professional work. Recognizing the complexity of individual pharmacists' identities helps to break free from the cognitive dissonance that has plagued the profession for decades, suggesting that professional identity is represented by singular or often competing roles as the scope of pharmacy practice evolves. There is no need to dismiss the part of ourselves that identifies as dispenser of medicine to be considered clinical but perhaps gives us a new lens in which to see how all these identities work together to form a comprehensive collective professional role identity as autonomous healthcare providers AND clinical team members AND focused on individual patients AND also mindful of leadership and management responsibilities.

CRediT authorship contribution statement

Kaitlyn E. Watson: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Theresa J. Schindel: Writing – review & editing, Methodology, Investigation, Formal analysis, Conceptualization. Sherly Meilianti: Writing – review & editing, Resources. Ross T. Tsuyuki: Writing – review & editing, Conceptualization. Yazid N. Al Hamarneh: Writing – review & editing, Conceptualization.

Funding

This work was supported through Dr. Kaitlyn Watson's 2023 Research Award from the FIP Social and Administrative Pharmacy Section (SAPS).

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Kaitlyn Watson reports administrative support and travel were provided by the International Pharmaceutical Federation through the 2023 Research Award provided by the FIP Social and Administrative Pharmacy Section (SAPS). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Ross Tsuyuki has received investigator-initiated, arm’s length grant funding from Merck, AstraZeneca, Pfizer, and Sanofi. He has consulted for Merck, Sanofi, Emergent Biosolutions, and Shoppers Drug Mart in the past, unrelated to this submission.

Appendix A. Supplementary data

Supplementary material