Life in a Fishbowl: Accountability and Integrity in Pharmacy Leadership

Abstract

The Director’s Forum is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems by providing practical information on various leadership topics. Pharmacists are bound to practice in the best interest of the patient and are obligated to act with integrity and in an ethical manner. Pharmacy directors and their leadership staff are additionally bound to manage their department with integrity. Staff often scrutinize the pharmacy director’s actions, giving the director a feeling of “life in a fishbowl.” Every action of the leader is judged in the context of personal integrity or their individual commitment to moral, spiritual, and ethical values. The objective of this article is to describe how a pharmacy leader manages this responsibility. This article addresses the pharmacy leader’s obligations to act with integrity, reviews key integrity concerns in pharmacy leadership, and provides guidance for leading and managing in the context of ethics and integrity. Pharmacy directors must always be aware that they are open to both department and public scrutiny if they do not conduct themselves in a professional manner. Being accountable for their actions and maintaining a high standard of integrity, leaders can keep the focus of their departments on the goal of patient-centered pharmacy services.

Introduction

Directors of pharmacy and their staff must manage their life choices with personal integrity while adhering to the highest professional ideals.¹ The choices that a person makes in life affect his or her leadership abilities in very real ways. Leaders are often looked to as both personal and professional role models. The pharmacy directors’ position of authority and their local, national, and even international notoriety create a “life in a fishbowl,” demonstrated by the following examples.

A pharmacy director often takes business trips on behalf of the hospital. These trips are legitimate, but the pharmacy director routinely leaves a day earlier than expected and always arrives back a few days after the official business meeting has ended. Further, the business staff of the department notices that the director codes the timesheet for these additional days as business leave, instead of vacation or personal time. The director’s actions are upsetting to the pharmacy’s business staff, and soon other department employees begin to notice this pattern. The staff gossips and jokes about it behind the director’s back, and the department begin to focus on the director’s behavior instead of its patient care mission.

In another example, a director of pharmacy is stressed by new hospital initiatives that require budget reductions involving clinical pharmacists. The director turns to alcohol for relief. After a night of drinking on a business trip in South Carolina, the director decides to go for a walk to get some fresh air. A police officer notices the director stumble and asks him if he has had a little too much to drink. Knowing that there are strict laws in regard to public intoxication, the director says he is fine and keeps walking under the assumption the officer will leave him alone. After being asked to stop again, the director yells at the police officer and begins to run, falling and injuring his face. Because he ran from the situation, he is taken into the county jail for public intoxication and resisting arrest; his arrest photo shows a disheveled man with a black eye. His drinking behavior led the pharmacy director to overreact to the police officer, with the unintended consequences of his arrest and his mug shot being seen by his staff on the Internet. Other examples of personal choices that damage a leader’s integrity include using business funds to pay for nonbusiness activities, flirting with pharmacy staff, cheating on continuing education credits, and using company technology to access pornography.

For leaders, “life in a fishbowl” means that staff will watch, scrutinize, and judge them on both job performance and personal lifestyle choices. Staff will analyze the personal integrity of their leaders, regardless of their success in the business world. Leaders’ personal integrity is shaped out of their commitment to moral, spiritual, and ethical values that guide their decisions and direct the way in which they live.

The objective of this article is to provide practical tips on how a pharmacy leader manages the “life in a fishbowl.” This article addresses leadership obligations, reviews key professional behaviors, and provides guidance for leading and managing in the context of acting with integrity and professionalism. Pharmacy directors must always be aware that they are open to both department and public scrutiny when they do not conduct themselves in an ethically accountable manner.² By effectively managing their “life in a fishbowl,” pharmacy directors can avoid unnecessary distractions from their goal of implementing patient-centered pharmacy services.

Integrity and Phar Macy Leadership Obligations

Pharmacists in leadership positions must exhibit stellar behavior and adopt good values when they are at work or in the community, because they are constantly being observed. They must effectively influence the behavior of administrators, physicians, nurses, pharmacy technicians, residents, interns, support staff, patients and their families to optimize medication safety and produce positive patient outcomes that will shape the future of the pharmacy profession.¹ Personal character is often judged by its results; new practitioners emulate the actions of pharmacy leaders as they develop their own personal ethics. Leadership is the professional obligation of all pharmacists and is not exclusive to those who hold formal titles. Emotional intelligence, authenticity, communication, and conflict management (Table 1) apply directly to pharmacy leadership behavior.³

Table 1. Principles of pharmacy leadership that lead to effective management³.

Principle	Competency	Example
Emotional intelligence	Practicing self-evaluation through reflection; utilizing peer feedback for continued awareness	Understanding and controlling how you respond when an employee constantly challenges your management style in front of other employees
Demonstrating authenticity	Displaying integrity through decision making while establishing shared goals with others; identifying weaknesses and improving upon them	Being open to employees about the potential for overtime reductions even if that means they will initially be upset with pharmacy leadership
Communication strategies	Portraying a professional message to others so that they can align their goals with department needs	Sharing with pharmacy staff via e-mail the importance of medication errors and showing that their participation in safety solutions can directly improve the delivery of medications to patients
Handling conflict	Identifying opposing viewpoints, and formulating an informed response to the situation	Having hospital administration revoke pharmacy full-time equivalents due to budget cuts, and responding by utilizing current staff to keep meeting organizational goals

Emotional Intelligence

Emotional intelligence is used to describe the relationship between feelings and intellect and the ability to monitor one’s emotions in order to guide thinking and actions. Leaders that display this principle are keenly aware of their emotional self and those around them through their self-awareness lens. They know how damaging aggressive behavior can be in the workplace, so they are able to filter their emotions. These emotionally intelligent pharmacy leaders have an innate ability to respond positively to those in their environment even when challenges arise. Pharmacy leaders must utilize the ability to show that they are comfortable and self-aware with their skillsets, goals, and visions. They must be reflective listeners to their staff and show a genuine interest in patient care. Emotionally intelligent leaders are nonthreatening and approachable because they do not use power to manipulate their followers, but instead are available and lead by serving others. Pharmacy leaders have to earn respect and trust from their staff; being emotionally intelligent is an effective way to accomplish this goal. ⁴

Pharmacists will often look to their leader in times of difficulty to see how they respond to adversity. These situations may arise due to a significant medication error, staff reductions, pharmacy budget discrepancies, or antagonistic medical staff. Although the expression of natural human emotion is important to help demonstrate genuineness, it is also important to manage our impulses and make informed decisions. This often means not reacting to situations without gathering all the information and using this evidence to make a decision that will best benefit the organization and patients we serve. Those leaders that do what is best for their patients and staff often have the most success and are able to gain widespread support.

Demonstrating Authenticity

Regardless of the situation, a pharmacy leader must be authentic and portray a clear message to employees. It is not good enough that a leader sets clear objectives in the workplace; he or she must also be knowledgeable on a variety of clinical and administrative topics. This knowledge is important in determining how to best implement new ideas and understanding the ramifications of all decisions. Pharmacy leaders will be better equipped to collaborate with medical and nursing colleagues when they understand the topic themselves. Staff have a keen sense for understanding when a leader may not be telling the complete truth or is speaking from a perspective that lacks understanding. Without knowing their boundaries in patient care and leadership, leaders can receive resistance to the adoption of an idea or not receive “buy-in” from the pharmacy staff. In times of difficulty, it is the leader that has earned the most trust from the organization who will be the most successful.

When faced with the prospect of delivering difficult announcements or being asked to comment on a confidential matter, it may be tempting to limit information and tell partial truths. But by not being forthright with employees, leaders can limit their effectiveness and lose organizational momentum. Leaders may fail to receive critical information from employees because of mistrust between leadership and staff. This could reduce the amount of preventable errors that can be addressed in both patient care and management settings. By setting a precedent of authenticity, leaders not only gain the trust of their staff, but also have a strong influence on organizations and their ability to be effective. Leaders need to recognize that staff are constantly watching them and evaluating their authenticity in a variety of settings both in and out of the workplace.³

Communication Strategies

Pharmacy leaders must not only communicate professionally, but also be able to articulate a compelling vision for the future. The most successful leaders are able to communicate with a variety of individuals regardless of background. They must effectively communicate a commitment to organizational goals, provide a purpose to work activities, and link current objectives to future accomplishments while promoting change within pharmacy. If leaders cannot convey their ideas to others, they tend to achieve poor results and have staff who are disengaged with their work.

In addition to communicating a clear vision to others, it is essential that pharmacy leaders communicate professionally. This includes sending e-mails that do not contain inappropriate language or emotion. Employees and other colleagues often observe the way leaders communicate verbally and in writing and hold them to a high standard. If professionalism is not maintained irrespective of the conversation topic, staff will judge their leader for their actions. In our current culture, pharmacy leaders may choose to communicate through social media. They need to remember the impact their words can have on the organization and profession they represent. Any form of communication they use can impact their leadership influence regardless of unintended meaning.

Handling Conflict

It is inevitable that conflict will arise within an organization. It is not necessarily the conflict that causes most problems for pharmacy leaders, but it is the way they respond to this adversity.⁵ Often the natural instinct is to get angry in a situation of conflict, but leaders must temper this anger so that other pharmacy staff remain calm. A common example of this conflict may be when an administrator reduces the pharmacy budget after jobs have been promised to incoming staff. Once those jobs are no longer available, it will cause more stress on the department to keep filling those roles by stretching current staff and disappointing incoming staff by revoking the job offer. In this situation, it may be easy to lash out at administration because of the situation they put pharmacy leadership in, however, it is better to accept these changes for the time being and return with a request once administration has had time to reflect. Pharmacy leaders manage conflict not by avoidance, but in their response to resolve the issue through strategy and perseverance.

Guidelines For Managing Leadership Integrity

Leaders in pharmacy must always consider the consequences of their actions for themselves and for the employees and organizations they represent. Ethics provide the framework through which leaders can make decisions and react to situations (Table 2).¹ Many times, leaders must make a conscience decision not to partake in specific activities that have the potential to harm the organization or their personal integrity. We offer the following guidelines for managing behavior in some key areas of leadership. Much of the advice is common sense, but it is important to help leaders avoid potentially embarrassing or legal consequences.

Table 2. Four-step process for ethical decision making¹.

Action	Implementation	Example
Recognize a moral issue	Evaluate the situation in terms of the moral issues and identify the risks, benefits, and consequences of each action.	Recognize that accepting a drug representative’s invitation to a sporting event may create the appearance of impropriety or raise issues of conflict of interest
Make a moral judgment	Determine ahead of time how you will respond both personally and professionally to situations.	Even though you know that you will not be influenced by accepting the invitation, you decide that these types of situations could be perceived as questionable so it is best to avoid them.
Resolve to place moral concerns ahead of others concerns	Identify the risks, benefits, and consequences of each action.	You know that a strong relationship with this vendor will benefit your organization, but you place the goal of preserving the organization’s integrity above any financial gain.
Act on the moral concern	Act in accordance to your ethical principles.	You do not accept the offer and make it a department policy for all staff to decline invitations from vendors and customers.

Managing Business Leave and Work Schedule

Leaders are often asked to speak at professional societies, lead advisory boards, or offer consultative services. These extracurricular opportunities are important for emerging leaders, but they must be undertaken with integrity. Leaders should only take time off work when necessary. When traveling on business, leaders should request vacation time for any leave not directly related to working activities. When at work, leaders must be honest in scheduling their time and not take advantage of the flexibility of their schedule.

Interactions with Peers and Direct Reports

Interacting with employees from a level of authority allows leaders to set out clear expectations. With this perspective, leaders have the responsibility to maintain professional relations with peers and direct reports. This professional behavior extends into personal friendships. When leaders interact with employees of the same or different sex, they should not make them feel uncomfortable through their words or actions. Leaders who overstep employees’ personal boundaries, either physically or emotionally, may make them feel violated. Other employees pick up on this behavior, and the leader can gain a reputation for these inappropriate actions. Although a shoulder rub or hug might seem innocent, everyone perceives workplace behavior differently; for that reason, leaders must always keep a professional demeanor. One small error in behavior in interacting with peers can have lasting effects on a leader’s reputation and effectiveness.

Interactions With Vendors and Customers

Vendors play an integral role in the profession of pharmacy, and pharmacy directors must establish working relationships with these entities. It is important to have vendors or customers as allies when entering contract negotiations, as positive working relationships will be recognized for their value.⁶ Most organizations have policies on appropriate vendor interactions, and these polices serve to keep these relationships in check. As leaders in pharmacy, the directors’ primary responsibility is to the organization and to provide unbiased information to them. Often vendors or customers will offer opportunities for leaders to attend nonwork functions, such as sporting events, concerts, or dinners. Although it may be tempting to accept these offers, individuals outside of the department could perceive this behavior as influencing the directors’ professional judgment. It is important that leaders recognize the potential conflict of interest and not attend functions in which vendors or customers pay for their attendance. They should eliminate all conflicts of interest, even if it means turning down a great opportunity for personal enjoyment. By deciding ahead of time that they will not participate in any outside activities with vendors, pharmacy leaders will set a moral standard that is in the best interest of the organizations in which they are employed.

Social Interactions and Behavior

Often leaders will be put into situations where their professional and social lives intersect, such as professional meetings or unofficial employee functions. Although it is important for leaders to interact with employees inside and outside of work, they must always behave in a professional manner. Employees are constantly watching their leaders to see how they react in social settings. They note how much the leaders drink, what type of language they use, and any risky behavior they engage in. Leaders cannot let their guard down, even outside of the work setting. Since they are living “life in a fishbowl,” they must make moral choices that set a good example for peers and employees alike.

Managing Conflicts of Interest

Pharmacy leaders must carefully review and monitor potential conflicts of interest. These include ownership of stock, business interests similar to their job functions, and personal relationships with members of the industry. Most institutions have policies that govern conflicts, but these policies can be easily violated and “covered up” by leaders and the industry alike. One area of risk is the undue influence of personal relationships in formulary review of medications. It is essential for pharmacy directors to manage this process in a transparent and professional manner; all conflicts of interest should be disclosed to all members of a group making formulary decisions.³ Several other areas related to conflict of interest can cause issues for pharmacy leaders, for example, if ownership of pharmaceutical company stock is omitted on a conflict of interest reporting form or if an industryfunded lunch, golf trip, or vacation is noted as business even though no business topics were discussed. Leaders must establish professional relationships with industry but not overstep boundaries. When attending professional meetings, pharmacy leaders must continually be aware of how their social interactions with the industry will be perceived. When attending dinners with the industry personnel at meetings, leaders should insist on paying for themselves and their staff. When at advisory boards, nonbusiness activity should be paid for by the leaders and not the industry. Finally, the leaders should decline any gifts of any nature and value from industry.

Conclusion

It is important for pharmacy leaders to remember that they live “life in a fishbowl,” whether they are at work or in a social setting. Their actions will be scrutinized and discussed regardless of their intention or the reality of the situation. After reading this article, we hope pharmacy leaders understand some of the pitfalls that can happen. They must always hold themselves to standards greater than those to which they hold their employees and not fall into the temptation of living life outside of their ethical framework.

We urge all leaders to remember the impact they have on their pharmacy staff and patients in the delivery of care in an ethical and respectful manner. Leaders must understand how their actions can impact the lives of those with whom they work.⁶ By basing each decision and action on their ethical structure, pharmacy leaders can establish a legacy that is focused on personal integrity, patient care, organizational improvement, employee development, and individual growth.