Community pharmacists’ attitudes, opinions and beliefs about leadership in the profession: An exploratory study

Abstract

Background:

The profession of pharmacy needs effective leaders to navigate change. Indirect indicators suggest there are insufficient numbers of pharmacists who actually want to be leaders. A paucity of research limits our understanding of what motivates and demotivates pharmacists to be leaders. This exploratory study was undertaken to investigate community pharmacists’ attitudes, opinions and beliefs about leadership.

Methods:

Interviews with 38 pharmacists were conducted either in person or using telecommunication applications such as Skype. A semistructured interview guide was used to elicit comments about leadership in general and in pharmacy, perceived leadership roles and barriers/enablers to leadership. Data were analyzed using Chan and Drasgow’s motivation-to-lead framework.

Results:

Key barriers to assuming leadership roles included lack of education/support, inadequate compensation, concerns about work-life balance, time constraints and a generalized discontent about leadership in society and in the profession.

Discussion:

While some of these barriers could be addressed through formal education (such as conflict management training) or through managerial influence (e.g., remuneration or scheduling to improve work-life balance), some (such as cynicism about leadership) will be more challenging to address. The need to address these barriers will grow as the need for new and emerging leaders in pharmacy continues to evolve.

Knowledge Into Practice.

• The pharmacy profession needs leaders, yet there is little formal research that examines what motivates pharmacists to want to become leaders.

• Chan and Drasgow’s motivation-to-lead framework highlights the different psychological processes that influence an individual’s desire to assume a leadership role.

• Pharmacists in this study highlighted 2 major categories of barriers: system/managerial barriers (e.g., compensation, work-life balance) and general attitudes towards leadership in society and in pharmacy.

• System/managerial barriers may be addressed through formal education/training or through changes in policies and practices; it will be more complicated to address generally negative attitudes towards leadership.

Mise En Pratique Des Connaissances.

• La profession pharmaceutique a besoin de leaders; pourtant, peu de recherches officielles ont été menées pour examiner ce qui motive les pharmaciens à devenir des leaders.

• Le cadre de travail « Motivation-to-Lead » (motivation à diriger) établi par Chan et Drasgow souligne les différents processus psychologiques qui influencent la volonté d’une personne à assumer un rôle de leadership.

• Les pharmaciens ayant participé à cette étude ont mis en lumière deux catégories principales d’obstacles : les obstacles liés au système ou à la direction (rémunération, équilibre vie personnelle et professionnelle, etc.) et les attitudes générales par rapport au leadership au sein de la société et du domaine pharmaceutique.

• Les obstacles liés au système ou à la direction peuvent être éliminés à l’aide de formations ou d’un enseignement officiel ou bien en modifiant les politiques et les pratiques; il sera plus difficile de changer les attitudes généralement négatives associées au leadership.

Background

The profession of pharmacy needs effective leadership to embrace an expanding scope of practice and support evolution from a product-based service to a patient-centred practice.¹ White and Enright² have described a “leadership crisis” in pharmacy as a significant impediment to practice change and evolution. In Canada, a lack of leadership in community practice has been cited as a cause for loss of influence of pharmacists within large corporate chains and a lack of unified vision/voice within the profession.^1,3,4

Leadership has been described in different ways. Byram⁵ has suggested that leadership is best defined by a skill set, rather than a job title. Vender⁶ has described leadership as a combination of position, responsibilities, attitude, skills and behaviours that allows someone to bring out the best in others and the best in their organization, in a sustainable manner. Summerfield⁷ has described the core function of leadership as simply “making things better.” Smith⁸ has differentiated leadership and management, noting that the former represents vision and change, while the latter represents procedures and systems.

While no universally accepted single definition of leadership exists, there has been research interest in the concept of motivation to lead (MTL). Motivation to lead is a framework for understanding the psychology of how individuals choose to become leaders and why individuals choose to make the sacrifices necessary to take on leadership roles within organizations. Chan and Drasgow⁹ have explained MTL based on 3 factors: 1) the affect identity (which suggests that people who choose to lead are natural extroverts who value competition, achievement and rewards and are confident in their own abilities to be leaders), 2) the noncalculative MTL (which suggests that individuals do not need rewards or prestige for leading but do so because of their agreeable disposition and desire for a specific goal or outcome), and 3) the social-normative MTL (which suggests that individuals elect to lead because they are motivated by a sense of duty and obligation to the group, i.e., they lead because it is simply expected of them). Chan and Drasgow’s work aligns with a central question in leadership research: are leaders born or they made? Boerma¹⁰ suggests that up to 30% of leadership traits can be explained by genetics, based on the “Big Five” psychological traits. Rosenthal et al.¹¹ have suggested that a key psychological trait—lack of confidence—may serve as a profession-wide barrier to practice change, supporting the affect-identity model of motivation to lead. Schoemaker et al.¹² suggest the core trait of effective leaders is their ability to navigate the unknown; they further dissect this trait into 6 skills (the ability to anticipate, challenge, interpret, decide, align and learn) and indicate that, as skills, these can all be taught and learned.

While leadership has been examined in other health care professions such as medicine¹³ and nursing,¹⁴ there is a paucity of literature examining leadership in community pharmacy. The objective of this study was to better understand practising community pharmacists’ attitudes, opinions and beliefs about leadership as a way of identifying opportunities to provide organizational support and profession development to nurture future leaders in the profession.

Methods

As there are little data and a paucity of literature examining leadership in community pharmacy, a qualitative exploratory research method was used to provide a mechanism for framing the research. Chan and Drasgow’s MTL model⁹ was used to guide this research; it was selected because of its influence within management education and its explicit focus on surfacing psychological barriers and facilitators to assuming leadership roles in diverse sectors. The method focused on mapping elements of the MTL model against the reported experiences, opinions, attitudes and beliefs of participants in this research. Inclusion criteria for this study were a minimum of 3 years’ experience in a community or outpatient pharmacy setting, a minimum of 20 hours worked per week in the past year, English speaking and licensed/registered as a pharmacist for at least 3 years.

A convenience and snowballing sampling method was used to recruit participants. A brief message requesting pharmacist volunteers that described inclusion criteria and the objectives of the study was posted on various pharmacy-related social media groups and forums (Facebook Pharmacy Communities). We specifically sought to amplify the diversity of respondents based on practice location (urban, suburban or rural), years of practice experience, positions held (owners, managers, staff pharmacists) and practice setting (independent, chain, grocery, etc.). Pharmacists who agreed to participate were invited to schedule a face-to-face or teleconference interview, based on their preference and geographical location. Teleconference interviews were conducted using either Google Hangouts, Skype or Facebook Video Calling. The first round of interviews conducted was part of a pilot phase in which the semistructured interview protocol used for this study was refined and adapted based on real-world experience. The final version of this protocol emerged after approximately the 10th interview (online Appendix 1). Each interview lasted approximately 30 to 50 minutes and was either audio-recorded or recorded using technology embedded in Google, Skype or Facebook.

A constant-comparative coding system was used in which preliminary coding and identification of themes from initial interviews were used to guide subsequent interviewing and analysis; interviewing was undertaken beyond saturation of themes to provide for a more nuanced understanding of participants’ comments. NVivo v11.0 was used to manage data and to support coding and identification and themes. Verbatim transcripts of all interviews were not produced for this research; verbatim transcript excerpts of relevant responses were produced for coding and used in conjunction with interviewer field notes. This study was approved by the University of Toronto Ethics Review Board.

Findings and Discussion

A total of 38 pharmacists were interviewed for this project, from a diverse array of geographic locations and practice settings (see Table 1 for demographic profile of participants). Several key themes emerged from the data:

Table 1.

Demographic profile of participants (n = 38)

Characteristic	Value
Male/female	10/28
Age, mean (range), y	33 (27-54)
Years in practice, mean ± SD	8.4 ± 5.5
Type of practice	Independent: 10 (26.3%) Chain/banner: 21 (55.3%) Grocery: 7 (18.4%)
Previous leadership role?	Yes: 20 (52.6%)—examples include designated manager, associate, owner, professional association, during school, within corporate office
Geographic location	Urban: 10 (26.3%) Suburban: 25 (65.8%) Rural: 3 (7.9%)

1. Where are the “real” leaders?

2. Costs vs rewards of leadership roles

3. Lack of interpersonal skills/readiness for leadership roles

4. Lack of structured incentives to support leadership in pharmacy

1. Where are the “real” leaders?

A central theme of this research related to general characteristics of leaders in society, politics and the profession. Many participants cited a widespread leadership deficit, noting that without appropriate aspirational role models (either in the profession or in society as a whole), it was challenging to actually think about becoming a leader oneself. Within the political world, most participants highlighted the current lack of suitable leadership exemplars as a primary reason why younger people were not interested in pursuing leadership. Several participants noted that, in the political world at least, leadership was increasingly equated with selfishness and self-interest (the affect MTL identity), and as a result, increasing mistrust of “leadership” and leaders’ motives was increasingly prevalent in society as a whole. Within the professional world, participants were able to identify and describe characteristics of individuals they saw as leaders: of interest, many of those identified as “leaders” (e.g., exemplary clinicians, researchers and professors, preceptors) did not necessarily have titles or other external indicators of leadership but instead were thought of as leaders simply in the course of doing their day-to-day job. In this context, several participants noted that having a leadership title might be seen by some as detrimental or counterproductive to the objective of actually being thought of by others as a leader. Many participants indicated they felt pharmacy, as a profession, was leaderless, particularly with respect to advocacy to government, representation to other professions (especially medicine) and presentation to the general public. Participants in this study were generally forthright in identifying deficits of named leaders, frequently suggesting they were self-interested, did not represent the profession as a whole or were less than inspirational in the way they presented to the public. The absence of leader role models in the profession was frequently identified as one of the most important reasons why individual pharmacists eschewed leadership.

Many participants noted an inherent potential tension in community pharmacy leadership: named leaders in pharmacy frequently work for or represent large corporations/corporate interests or their own small businesses. Separating commercial and corporate interests from those of the broader profession was identified as challenging by many participants, and in some cases, pharmacists stated that these may be incompatible roles from a trustworthiness perspective. As one participant noted, “I get that you have to ‘drink the Kool-Aid’ when you are in a [corporate position]. That’s your job, that’s your paycheck. But c’mon, you can’t really expect [pharmacists] then to believe you when you claim to be speaking for the whole profession. The [corporation’s interests] are really what you are speaking for, not pharmacy’s.” Importantly, participants in this study also noted that their own negative statements about those in pharmacy leadership roles were actually part of the problem: as noted by one participant, “Why would anyone even want to—I mean choose a leadership role in pharmacy when people like me and everyone like me is just going to criticize them anyway?”

2. Costs vs rewards of leadership

The personal costs vs rewards of leadership in pharmacy were highlighted as a barrier for many pharmacists assuming greater responsibilities in the profession. The majority of participants in this study emphasized the personal and financial toll associated with taking on a leadership role. This toll focused on factors such as 1) loss of personal time and in particular time to spend with family, friends or personal interests; 2) loss of flexibility in day-to-day scheduling and management of one’s work; 3) increased scrutiny of day-to-day work by others who may or may not understand the complexity of leadership roles; 4) the perception that leaders are “fair game” for blaming and criticism, even when matters were beyond their control; and 5) the belief that in pharmacy, the financial compensation for taking on a leadership role simply did not account for the losses/tolls associated with it. Participants in this study perceived the rewards of professional leadership to include 1) the potential of making a positive difference in the lives of others, 2) the possibility of helping the profession to evolve, 3) the ability to have greater control over some aspects of one’s work life, 4) the possibility of making “a name” for oneself, and 5) the intrinsic interest in seeing the profession at a higher system level and working with others at that higher system level. The framing of costs and rewards by participants in this study highlighted a central issue: rewards were generally framed as “possibilities,” while costs were framed as “certainties.” Pharmacists in this study demonstrated a type of probabilistic pessimistic reasoning in which the likelihood of cost trumped the distant promise of reward—and as a result, leadership itself became an unattractive proposition.

3. Lack of interpersonal skills/readiness for leadership

Participants in this study were asked about their own readiness for leadership, and most declared that they felt unprepared and undereducated for a leadership role. Many participants noted that management training in pharmacy school was minimal at best and did not really equip future pharmacists to deal with the interpersonal complexities of leadership. Specific areas of concern included conflict management training, understanding how to negotiate and have difficult conversations with others, public speaking with larger audiences, understanding of relevant human resources legislation and policies, basic principles of financial management, strategic planning and business plan development and learning how to motivate others. Most participants in this study felt that these deficits could and should be addressed through formal education, either during pharmacy school itself or through better continuing education and professional development opportunities. While no participants in this study articulated a belief that leaders are born and cannot be made (through education), many participants did note that the success of management education itself would be closely linked to the intrinsic motivation of the learner to assume leadership roles. However, most learners also noted that effective management education at the undergraduate level, coupled with greater exposure to positive pharmacy leader role models, would likely have the effect of inspiring younger practitioners to consider leadership in the future—with a new skill set to support this aspiration.

4. Lack of structured incentives to support leadership in the profession

Participants in this study highlighted the times in their own careers that they had been asked to assume leadership roles and how they decided to accept (or not) the invitation. Frequently, they noted the lack of a structured incentive system to support leadership development. Many participants noted that financial rewards for becoming leaders were insufficient, given the expected toll it would take on them personally. They also noted that there are few systems in the profession for pharmacists to gradually assume greater leadership roles, in an incremental way that would be less stressful, support greater mentorship and importantly allow pharmacists to “test drive” leadership before it became a more permanent role. Particularly in community pharmacy, the lack of a career trajectory or ladder to allow for individuals to take on some leadership roles led to the perception that leadership in the profession is an all-or-nothing state. This binary view led many participants to choose “nothing” rather than “all.” Importantly, in many cases, participants expressed both an interest and a desire to do more for their practices, their patients and their profession but felt that their options were severely limited because there were no gradual or incremental leadership opportunities afforded by the profession.

The 4 themes identified in the research highlight significant tensions within the profession related to leadership and the evolution of pharmacy. Perhaps unsurprisingly, given the current social and political climate, a perceived absence of respected named leaders in the profession poses a significant problem for those interested in nurturing the next generation of leaders. As participants themselves noted, it is always easy, too easy, to blame or dismiss leaders, even when these individuals are dedicated, self-sacrificing and earnest in their desire to seek improvement. The current social and political discourses around leadership in general are, frankly, corrosive; they also influence younger colleagues’ perceptions around whether leadership is “worth it.” As a profession, it is important to find a way of recognizing, celebrating and showcasing named leaders in a more positive and optimistic manner: importantly, there appear to be respected leaders in pharmacy, but many of those named do not actually have named leadership roles, leading one participant in the study to note, “It’s so weird, it’s like people are great pharmacists, do great things with patients, but then when they get a big title or promotion, they go berserk and lose respect.” While it is essential to reinforce the notion that everyone, not just named leaders, should be leaders in a profession, it is also important that our discourses and beliefs around named leaders in the profession (and society as a whole) assume a more respectful and inspirational tone.

Many participants felt that significant impediments to leadership in pharmacy could be addressed through 2 primary strategies: education and structured pathways/incentives. At the educational level, it is important to note that Canadian pharmacy schools have undertaken important steps to enhance the quality and quantity of management and administrative education within curricula. Innovative new programs (such as combined PharmD-MBA programs, inclusion of “Toastmasters” programming and pharmacy business plan competitions) within universities all help support young pharmacists in recognizing that management expertise is needed to truly unleash clinical expertise. There is, however, less support available for practitioners through continuing education (CE): greater emphasis on managerial skills development by CE providers may be an important tool for helping practising pharmacists overcome self-confidence and skills deficits related to leadership. Participants also highlighted the lack of a career trajectories and structured incentives (including appropriate financial compensation) for named leaders. Pharmacy employers may consider development of mentorship programs, project management opportunities, career ladders and other strategies to allow all pharmacists the opportunity to “test drive” leadership, acquire new skills, self-identify areas for professional/personal development and actually see the rewards (not just the costs) associated with accepting leadership roles.

Findings from this study align with Chan and Drasgow’s MTL theory⁹ and suggest that (for the pharmacists in this study) barriers to wanting to assume leadership are generally of an affective and noncalculative nature. Some of these barriers (e.g., lack of conflict management skill, lack of knowledge about human resources practices) can be addressed through formal education. Other barriers (e.g., insufficient financial remuneration for leadership roles) can be addressed through management decisions. However, some of the barriers (e.g., lack of self-confidence or cynicism towards the role and value of leadership [and the motivations of leaders] in general) will be more challenging to address through formal educational systems. One strength of this research was the use of the Chan and Drasgow⁹ framework to guide data collection and analysis: in using this framework to help surface internalized, psychological constructs of leadership within the pool of participants, an important theme emerged related to the notion that pharmacists lack confidence to self-identify as leaders and feel a lack of self-efficacy with respect to the core skills they believe real leaders should possess. This psychological barrier can be partially addressed through education and skills training but will require further exploration in future research.

The importance of leadership within a profession has been previously described, and as noted by Tsuyuki and Schindel,¹ the lugubrious pace of practice evolution in pharmacy may in fact be related to a dearth of leaders who focus specifically on the profession and on practice. While there are many individuals in leadership roles with managerial responsibilities, these individuals must frequently speak to local or corporate interests rather than profession-wide ones. As highlighted in this study, over 50% of the participants had held previous named leadership roles, yet virtually all of them did not self-identify as leaders in the profession, and most expressed discomfort with the idea of being called a leader in the profession. In part, this may be due to the lack of specificity as to what “leadership” really means or is within pharmacy. The term leader is used hierarchically (e.g., in describing an organizational chart of a business) or more metaphorically (e.g., in describing someone who is an inspiring role model). For this research, we did not put limits or constraints on the definition of “leader” as we were interested in exploring the nuances of the term within our participant group; it may be useful in future research in this area to narrow and specify the definition of leadership (vs management) to focus on one aspect or the other to gain a deeper understanding.

This research builds on previous work in this area. Rosenthal et al.¹¹ have noted that many community pharmacists may have low levels of self-confidence and demonstrate issues related to self-efficacy. Further work is required to determine whether there is a connection between these psychological propensities and the hesitancy of pharmacists to self-identify as leaders. A key finding of this work relates to the corporatization of the pharmacy profession and whether a tension exists between corporate and professional modes of leadership.¹⁵ As a field, pharmacy appears well suited for further sociologically oriented research examining this important distinction and whether, in fact, being a professional leader may be incompatible with being a corporate leader, as suggested by Bush et al.¹⁵

This research has illuminated important trends relevant to leadership in the profession of pharmacy. The qualitative method used, while appropriate for exploratory research such as this, may not be generalizable beyond the context of the research participants themselves. To enhance the quality of the research, we aligned our work with the COREQ (Consolidated Criteria for Reporting Qualitative Research) approach first described by Tong et al.¹⁶ This approach can be useful in enhancing the trustworthiness and indicativeness of qualitative studies, although challenges exist when undertaking exploratory research such as this. Not all elements of this approach were possible to achieve, mainly due to logistics constraints associated with sampling and participant recruitment. The sampling method used may have resulted in recruitment of participants who were similarly inclined, resulting in an echo-chamber effect that amplified negative attitudes and opinions towards leadership. The number of participants involved in this research, while large for an exploratory qualitative study, does not equate to a representative sample of the profession. Despite these limitations, the findings of this study do highlight opportunities for further research in this area, as well as opportunities for educators, regulators and employers to consider new ways of motivating pharmacists to engage more fully in their profession and its evolution.

Conclusion

A profession without leaders from within that profession is simply not sustainable. This research has attempted to elicit from Canadian pharmacists their views and perspectives on leadership in their profession as a way of understanding the dimensions of a perceived leadership crisis in pharmacy. While further research is required, findings of this study highlight opportunities to incrementally overcome societal bias against leadership in a productive manner, by focusing on skills development education and structural incentives to support pharmacists’ motivations to lead.