Mixed messages

Abstract

Background:

More than 5 years ago, the Blueprint for Pharmacy developed a plan for transitioning pharmacy practice toward more patient-centred care. Much of the strategy for change involves communicating the new vision.

Objective:

To evaluate the communication of the Vision for Pharmacy by the organizations and corporations that signed the Blueprint for Pharmacy’s Commitment to Act.

Methods:

The list of 88 signatories of the Commitment to Act was obtained from the Blueprint for Pharmacy document. The website of each of these signatories was searched for all references to the Blueprint for Pharmacy or Vision for Pharmacy. Each of the identified references was then analyzed using summative content analysis.

Results:

A total of 934 references were identified from the webpages of the 88 signatories. Of these references, 549 were merely links to the Blueprint for Pharmacy’s website, 350 of the references provided some detailed information about the Blueprint for Pharmacy and only 35 references provided any specific plans to transition pharmacy practice.

Conclusion:

Widespread proliferation of the Vision for Pharmacy has not been achieved. One possible explanation for this is that communication of the vision by the signatories has been incomplete. To ensure the success of future communications, change leaders must develop strategies that consider how individual pharmacists and pharmacies understand the message.

Knowledge into Practice.

• Widespread proliferation of the Blueprint for Pharmacy’s vision has not yet been achieved.

• Complete communication of the Blueprint for Pharmacy has not been realized.

• Actionable steps, which may be undertaken by individual pharmacies and pharmacists, are needed to improve the success of communication of the Blueprint for Pharmacy.

Mise En Pratique Des Connaissances.

• Aucune diffusion à grande échelle du Plan directeur pour la pharmacie n’a encore été effectuée.

• Un plan de communication complet du Plan directeur pour la pharmacie n’a pas été réalisé.

• Des mesures pragmatiques, pouvant être appliquées par des pharmacies ou des pharmaciens individuels, sont requises pour accroître le succès de la diffusion du Plan directeur pour la pharmacie.

Background

The Urban Dictionary describes mixed messages as “[situations] in which a person is receiving verbal or nonverbal cues that seem to contradict each other.”¹ As a consequence of these “mixed messages,” people are often left feeling confusion, anger and a willingness to disengage from interaction with the offending party.¹ Within the context of organizational change, mixed messages can be considered communication failures between change leaders and those tasked with implementing the change. According to a growing body of communications literature, appropriate communication is the “medium in which change occurs” (p. 296).²

For many decades, pharmacists in Canada have been buffeted by calls for changes in how they perform their jobs. A new strategy for changing pharmacy practice in Canada was proposed by Tsuyuki and Schindel³ more than 5 years ago. This plan outlined 8 steps, borrowed from Harvard Business School researcher John Kotter, who has worked with numerous companies worldwide to change their business practices.⁴ The 8 steps are as follows: 1) establish a sense of urgency, 2) form a powerful guiding coalition, 3) create a vision, 4) communicate that vision, 5) empower others to act on the vision, 6) plan for and create short-term wins, 7) consolidate improvements and produce more change and 8) institutionalize new approaches (see Box 1 for details on each step).^3,4

In relating Kotter’s first step to pharmacy practice, Tsuyuki and Schindel³ pointed to some “crises” plaguing pharmacists at the time their article was published (2008), including the Transparent Drug System for Patients Act in Ontario and alterations to the reimbursement and reward strategies of pharmacists, which were supposed to instill a sense of urgency in the profession. Since that time, Ontario pharmacists have also lived through the implementation of Bill 16, which reduced the payout for generic drugs and removed all professional allowances.⁵ A similar sequence of events has recently taken place in Alberta, where the payout for generic drugs was reduced to 18% of name-brand products,⁶ and British Columbia, where generic prices were dropped to 25% of the name-brand version.⁷

In discussing Kotter’s second step, Tsuyuki and Schindel³ pointed to the creation of a pan-Canadian pharmacy task force, which at the time had just started discussing what would become the Blueprint for Pharmacy initiative. Since that time, the Blueprint for Pharmacy’s vision—“optimal drug therapy outcomes for Canadians through patient-centred care”—has been solidified, arguably achieving Kotter’s third step, “create a vision.”⁴ Once the vision had become finalized it was communicated to pharmacists across the country,⁸ which began the process of achieving Kotter’s fourth step, “communicate the vision.”⁴ Part of this communication strategy was the development of the Commitment to Act contract that was signed by individuals or organizations as an indication of their support of the Blueprint for Pharmacy and its vision for the profession.

Since communication plays a critical role in fostering change,^2,4 and poor communication may result in mixed messages being received by the intended audience, our research team became interested in how signatories of the Blueprint for Pharmacy’s Commitment to Act were communicating the Vision for Pharmacy.

Methods

Sample

The list of 88 signatories was obtained from Appendix 1 of the Blueprint for Pharmacy’s Vision for Pharmacy document.⁹ Each of the signatories was included as part of the data collection process. We focused specifically on the communication strategies of organizations, rather than individuals, for 2 reasons; first, because they represent most of the pharmacists across Canada, and second, because unlike individual signatories, these groups were likely to produce material that was accessible and available for data collection.

Data collection

The website of each signatory was identified using the Google Canada search engine. The name of the organization or corporation was entered into a search, and results were combed until the appropriate website was identified. The URLs for the provincial branches of the Canadian Society of Hospital Pharmacists (CSHP) were found by identifying the most reasonable URL from a list returned by Google by entering “CSHP” and the province’s name.

Upon obtaining the list of websites for each of the organizations, the search function within the website, which was often supported by Google, was used to search each website individually. The search terms “blueprint for pharmacy” AND “vision for pharmacy” were used in this search. For example, when searching the Canadian Pharmacists Association website, the search strategy terms were “blueprint for pharmacy” AND “vision for pharmacy.” However, only the protocol, server, domain and top-level domain portions of the URL were included in our search. All identified web pages or files (Microsoft Word, Microsoft Powerpoint or PDF documents) related to the Blueprint for Pharmacy were copied and saved to separate files for analysis. All data included herein were collected between August 8 and 12, 2012.

Analysis

All identified material was first analyzed quantitatively, providing counts of the number of Blueprint for Pharmacy–related results from the website searches. Webpages and files whose sole mention of the Blueprint for Pharmacy was a web-link titled “Blueprint for Pharmacy” were excluded from the qualitative analysis due to a lack of content specific to that particular organization, but a count of these mentions was made. Furthermore, duplicate files and webpages were excluded from analysis and were not enumerated.

Upon completion of the quantitative analysis, all remaining material was analyzed qualitatively using summative content analysis, a type of qualitative content analysis.¹⁰ Summative content analysis uses quantitative results, like those described above, as a starting place from which a latent content analysis is performed.¹⁰ Latent content analysis is an interpretation of the quantitative results, using knowledge of the context from which the data have been derived, to develop themes from the data.¹⁰ Two members of the research team independently performed the summative content analysis (CBC and MR). Discussion and consensus were used to address any discrepancies in the analysis and coding.

Results

A search of the websites of the 88 organization signatories revealed a total of 934 references to the Blueprint for Pharmacy (Figure 1). To examine these results more closely, the 88 signatories were then divided into 4 groups: educational organizations (universities and student groups), chain drug groups (franchises and chains), provincial organizations (advocacy and regulatory bodies) and national organizations. The total number of references contributed by each of these groups is reflected in Table 1.

Figure 1.

Flow chart of identified references to the Blueprint for Pharmacy or Vision for Pharmacy from signatories’ websites

Table 1.

Number of references contributed by signatory groups

Signatory breakdown	Number of references (%)
Educational organizations (n = 23)	463 (50%)
Chain drug groups (n = 20)	7 (1%)
Provincial organizations (n = 22)	115 (12%)
National organizations (n = 7)	349 (37%)
Total	934

Summative content analysis of these references revealed 3 thematic types: 1) references to the Blueprint for Pharmacy’s website (i.e., the link); 2) references containing details about the Blueprint for Pharmacy; and 3) references containing specific plans for advancing the adoption of advanced scopes of practice for pharmacists (see Table 2 for examples). Looking more specifically at the types of references to the Blueprint for Pharmacy offered by each of these groups, the great majority of responses from both the educational organizations and the national organizations were links to the Blueprint website. While provincial organizations contributed more detailed references to the Blueprint for Pharmacy, more than half of the references offered by chain drug groups were for strategies for advancing pharmacy practice (Table 3).

Table 2.

Examples of detailed references to the Blueprint for Pharmacy and specific plans using the Blueprint for Pharmacy

References containing details about the Blueprint for Pharmacy

References containing specific plans for advancing the adoption of advanced scopes of practice for pharmacists

“The Blueprint for Pharmacy is shaping the profession through its development of a Vision for the future of pharmacy in Canada” (Educational organization) “The Blueprint for Pharmacy will be asking pharmacy departments across Canada to commit” (Provincial organization) “The Blueprint for Pharmacy Implementation Plan outlines a pan-Canadian, collaborative strategy to facilitate the changes required to align pharmacy practice, including the reimbursement model for community pharmacy, with the health care needs of Canadians” (National organization)

“[The implementation of a] comprehensive medication management program that is being tested in 12 of a major chain pharmacy’s stores” (Chain drug group) “Co-lead on a number of deliverables as part of the implementation plan for the Blueprint for Pharmacy” (Provincial organization) “Basing the organization’s strategic plan upon the Blueprint” (Educational organization)

Table 3.

Breakdown of number of references by signatory groups (%)

	Web link references	Blueprint detail references	Action plan references
Educational organizations	326 (70%)	120 (26%)	17 (4%)
Chain drug groups	0 (0%)	3 (43%)	4 (57%)
Provincial organizations	7 (6%)	108 (94%)	0 (0%)
National organizations	216 (62%)	119 (34%)	14 (4%)

Examining the breakdown of references by thematic type reveals nearly 60% of the total references to the Blueprint for Pharmacy were links to the Blueprint website and only 4% of total references were those using the Blueprint for Pharmacy as a framework to develop a change strategy for pharmacy practice.

Discussion

While more than 900 references to the Blueprint for Pharmacy were made by the organizational signatories, the majority were links to the Blueprint for Pharmacy website. Only 4% of the total references were classified as using the Blueprint for Pharmacy to develop a specific plan of action to change pharmacy practice. While provincial organizations succeeded in providing more detailed information about the Blueprint for Pharmacy, chain drug groups offered a greater number of actionable plans for changing pharmacy practice.

According to Kotter,⁴ communication of the vision for change cannot be limited to merely telling people about the vision using a single communication medium, such as a link to the Blueprint for Pharmacy website (see Box 1). Rather, change leaders, like the organizational signatories discussed herein, must use multiple communication approaches and include detailed strategies for change.⁴ It is also important that change leaders demonstrate the vision in their day-to-day practice.⁴

Furthermore, some authors suggest that communication must convey not only knowledge about the change but information about how that change will influence the day-to-day work of those affected.¹¹ Through this delineation of the impact, any fears associated with the change can be mitigated.¹¹ Communication must also work to create a community among change recipients and change leadership based on mutual trust.¹¹ Authors also suggest that it is important for change leaders to communicate coherent narratives, or stories, to allow recipients to engage in sense-making about that change.^2,12 In particular, narratives help people to structure and give meaning to their experiences and prepare them for future enactments of their new role.²

As such, it may be argued that the type of communication undertaken to date, in the hopes of achieving the Vision for Pharmacy, has been insufficient to empower pharmacists to act on the vision.⁴ Further to this point, pharmacists working in the organizations of the signatories described herein may interpret the lack of actionable direction as “mixed messages,”¹ suggesting that change leaders are not as invested in the change as they claim.

Looking to some recent literature on the state of pharmacy practice across Canada, widespread success in achieving the vision of the Blueprint for Pharmacy has not been attained.¹³ While suggestions for making change are offered in the Blueprint for Pharmacy Implementation Plan, many of these are of a much larger scope (i.e., changing educational programs or developing new legislation) than would be possible for a single pharmacist or pharmacy to undertake.¹⁴ We propose that in addition to the items currently outlined in the Implementation Plan, specific examples of how additional clinical services can be integrated into a pharmacy setting be developed for use by pharmacists and pharmacies. For example, how might a pharmacy integrate medication reviews into daily practice, while also maintaining a high level of performance in other areas of the pharmacy? How do the pharmacy staff members who were able to make this change describe their new practice and the change process? If adequate attention is not paid to the integration and, perhaps more important, the operationalization of the Blueprint for Pharmacy’s Vision for Pharmacy, it is likely that this vision will not be realized.¹¹

One limitation of this study is that the data were limited to the information posted on the signatories’ websites. We acknowledge that webpages are just one avenue for the communication of a vision, and it is possible that we missed actionable Blueprint for Pharmacy strategies being communicated in other ways. However, this work does provide a snapshot of efforts being made to bring pharmacy practice more generally into line with the Blueprint for Pharmacy’s Vision for Pharmacy.

Conclusion

In terms of the model proposed by Tsuyuki and Schindel³ for facilitating practice change within pharmacy, communication of the Blueprint for Pharmacy has been incomplete. To enhance the success of future communications, change leaders must develop specific strategies and narratives that consider how individual pharmacists and pharmacies are taking up the message. This consideration not only will aid the implementation of advanced practices but also will act as a demonstration of change leaders’ commitment to the Vision for Pharmacy, thereby eliminating the proliferation of mixed messages. With these key components in place, efforts can then be refocused on the remaining steps in the change process. ■