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Understanding customer expectations of community pharmacy services

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Title:
Understanding customer expectations of community pharmacy services
Creator:
Brice, Barbara F
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English
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ix, 110 leaves : ill. ; 29 cm.

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Subjects / Keywords:
Customers ( jstor )
Drug design ( jstor )
Drug interactions ( jstor )
Drug prescriptions ( jstor )
Grounded theory method ( jstor )
Marketing ( jstor )
Medications ( jstor )
Pharmacies ( jstor )
Pharmacists ( jstor )
Physicians ( jstor )
Community Pharmacy Services ( mesh )
Consumer Satisfaction ( mesh )
Department of Pharmacy Health Care Administration thesis Ph.D ( mesh )
Dissertations, Academic -- College of Pharmacy -- Department of Pharmacy Health Care Administration -- UF ( mesh )
Models, Theoretical ( mesh )
Quality Assurance, Health Care ( mesh )
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bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D.)--University of Florida, 2000.
Bibliography:
Bibliography: leaves 101-105.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Barbara F. Brice.

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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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UNDERSTANDING CUSTOMER EXPECTATIONS OF
COMMUNITY PHARMACY SERVICES











By

BARBARA F. BRICE


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2000

























Copyright 2000

by

Barbara F. Brice
























This project is dedicated to Lee, Kate, and Rob. Their love supports and guides

me always.













ACKNOWLEDGMENTS


This project could not have been completed without the support and guidance of

my committee chairperson, Dr. Earlene Lipowski, who allowed me the freedom to explore

and to choose a research method that best fit my and the project's needs. She fully

supported my research journey and has given me a wonderful example to follow. Thanks

also go to Dr. Sally Hutchinson, who applied her expertise and who kindly joined in and

supported my exploration of grounded theory. I thank my other committee members, Dr.

Carole Kimberlin and Dr. Richard Segal, for their time, help, and support. I thank Dr.

Doug Ried for his time and input. I am especially thankful for my family, Lee, Kate, and

Rob. Their love and support cannot be measured or described adequately enough. I

thank my parents, Bob and Vera Flynn, for creating in me a need to read. I am very

grateful for the support of my friends, Suzi Maue and Sabrina Scott. As fellow graduate

students they understood my needs. I also thank all of my fellow pharmacy administration

graduate students. I thank all of the folks at Mandarin Presbyterian Church. Their prayers

and encouragement made a difference. I thank Delayne for all of the transcription work,

and Debbie for being my phone buddy. I thank Bruce Allen for helping me draw the

model. I thank Drs. Jerome Hallan, Nick Wilson, and Larry Jean, faculty members in the

College of Health at the University of North Florida. It was their encouragement that led








me to apply to the University of Florida. I thank Mel and Dennis, for allowing me access

to their customers and their practices. I thank Leanne and Traci for allowing me to

observe. I thank Broni for sharing her pharmacist tools. A capital thank you goes to all

pharmacy customers. Clearly without them there would be no project. Finally, I am most

grateful to God who led and continues to lead me on my path through life.














TABLE OF CONTENTS




ACKNOW LEDGMENTS .............................................. iv

A B STR A C T ....................................................... viii

CHAPTERS

1 INTRODU CTION ............................................... 1

Problem Statem ent ......................................... 3
Theoretical Perspective ...................................... 4
Research Purpose .......................................... 7
Significance for Pharmacy .................................... 7

2 LITERATURE REVIEW ......................................... 8

Service Q uality ........................................... 11
Expectations ............................................. 23
Summary of Literature Review ............................... 39

3 M E TH O D S ................................................... 41


Research Design ...........
Sam ple ..................
Data Collection and Recording
Data Analysis .............
Scientific Rigor ............


4 FINDINGS: A MODEL OF PHARMACIST INTERCEDING .

Customer Needs: The Basic Social Problem ..........
Antecedent Conditions for Pharmacist Interceding .....
Sum m ary ....................................


...........
...........
...........








5 PHARMACIST INTERCEDING .................................. 69

A ssessing ............................................... 69
A cting ................................................. 70
Conditions Influencing Pharmacist Interceding ................... 75
Sum m ary ............................................... 81

6 THE CONSEQUENCES OF PHARMACIST INTERCEDING ............ 82

Professional Relationships .................................. 82
Personal Relationships ..................................... 83
C ases .. .. .. ........................ ... .... ............ 83

7 SUMMARY AND RECOMMENDATIONS .......................... 94

Sum m ary ............................................... 94
Model of Pharmacist Interceding ............................. 95
Relationship of the Model of Pharmacist
Interceding to Other Research .......................... 97
L im itations .............................................. 98
Recommendations for Pharmacy Practice ....................... 99
Recommendations for Future Research ......................... 99

REFEREN CE S ..................................................... 101

APPENDICES

A INITIAL INTERVIEW GUIDE ...................................... 106

B REVISED INTERVIEW GUIDE ..................................... 107

C DEMOGRAPHIC AND PHARMACY EXPERIENCE QUESTIONS ......... 109

BIOGRAPHICAL SKETCH ........................................ 110













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

UNDERSTANDING CUSTOMER EXPECTATIONS OF
COMMUNITY PHARMACY SERVICES

By

Barbara F. Brice

May 2000

Chairperson: Earlene Lipowski

Major Department: Pharmacy Health Care Administration

Customers of health care have often been ignored when assessing the quality of the

medical care that they receive. Historically, customers simply followed doctor's orders

and did not participate in assessing the quality of the care that they received. As the focus

of the health care system in general and pharmacy in particular evolves, both are making

strides toward including the customers' perspective when assessing quality. However,

current efforts to include the pharmacy customer in quality assessment seem to lack a

theoretical underpinning. Therefore the purpose of this grounded theory research was to

generate a substantive theory that explains customer expectations of community pharmacy

services, as those expectations may be a foundation on which to measure service quality.

A convenience sample of 27 community pharmacy customers was interviewed. In

addition, observations of the pharmacist-customer interaction took place in four








community pharmacies. Data were collected and analyzed using the grounded theory

method. Findings show that pharmacy customers participate in a medication use system

that they do not fully understand. This misunderstanding creates needs, the basic social

problem, for those customers. Included are needs for information, needs for a problem

solver, and needs for reassurance. This set of needs is addressed by the pharmacist acting

on the customer's behalf in the medication use system. The pharmacist's acting, called

interceding, is the basic social process that occurs in response to the customers' needs.

However, two conditions, need identification and pharmacist expertise, must precede

pharmacist interceding. Because interceding is a process, two phases occur: assessing and

acting. Also, several conditions influence interceding. They include pharmacy

environment, time, social structural variables, and personal characteristics. The

consequence of pharmacist interceding is the formation of a relationship between

pharmacist and customer. The proposed Model of Pharmacist Interceding illustrates the

connection between customer needs, pharmacist interceding, and the pharmacist-customer

relationship. Understanding the Model of Pharmacist Interceding provides pharmacists

with new insight into the needs created by the medication use system for their customers.

It shows pharmacists that customers expect their intercession in this system, and it

demonstrates that a relationship is the consequence of pharmacist interceding.













CHAPTER 1
INTRODUCTION



This is a study of customer expectations of community pharmacy services. It is a

study that seeks to create a theoretical understanding of customer expectations that is not

yet found in the academic literature. The following paragraphs outline the importance of

including the customer's perspective in assessing health care, and the current study of

customer expectations in an effort to support the importance of understanding those

expectations.

Customers of health care have often been ignored when assessing the quality of the

medical care that they receive (Davies and Ware, 1988). In fact, during the 1980s the

health care community focused on containing skyrocketing costs. Little attention was paid

to anyone's assessment of quality of care. However, the tide has turned and health care

customers, providers, and payers seem to have refocused their interests toward the quality

of the health care that they receive, provide, and pay for. This renewed interest in quality

leads us to an examination of the roles that customers, providers, and payers can and

should take in assessing and defining quality.

Historically, customers of health care played a passive role in assessing the quality

of their care. They simply followed the "doctor's orders." Patients did not participate in

assessing the quality of the care that they received. In fact, there was an argument against










customers evaluating their own health care. The validity of customer ratings of health

care was questioned on four points: (1) the data provided by customers reveals more

about the customer than the quality of care; (2) customers are able to tell how much was

done, but not how well it was done; (3) customers' and physicians' judgements regarding

quality are different; and (4) customers' ratings of quality just reflect whether their

provider was nice (Davies and Ware, 1988). However, in a review, Davies and Ware

(1988) consider the evidence both for and against customer participation in quality

assessments of care. The evidence collected in their review suggests that data from health

care customers can be useful in assessing the quality of medical care. For example, they

found that for common problems customers can distinguish between good and less than

good technical aspects of care. Also, customers' perceptions of quality affect their choice

of health care provider. Finally, they found that customers are the best source of data on

the interpersonal aspects of care (Davies and Ware, 1988).

Kaplan and Ware (1995) also discuss the patient's role in health care quality

assessment. They suggest that there are five reasons to include patients in the evaluation

of their care. First, they suggest that patients' evaluations are the most practical source of

information. Second, patient or customer satisfaction with services has been shown to

affect both the patient-physician relationship and the patient's health status. Dissatisfied

patients change physicians, change health plans, sue their providers, do not follow

treatment recommendations, and avoid medical care altogether. Third, they indicate that

research has shown a link between clinical measures of health and patient-reported

outcomes. Fourth, they suggest that there is evidence that patients want to expand their










role in their health care, and that they want to receive more information from their

providers. Finally, Kaplan and Ware suggest that if patients are not satisfied with their

care, they may turn to alternative therapies and/or therapists.

As the health care system and its focus on quality evolves, it is apparent that the

customers' role in assessing their quality of care has become increasingly important. For

example, the American Medical Association Council on Medical Service includes the

patient's informed cooperation and participation in decision making as an element of

quality medical care (Council on Medical Service, 1986). Also, Christensen and Penna

(1995) suggest that health care quality includes patients' expectations. In addition,

Holdford (1999) examined the relative importance of functional and technical quality on

patient perceptions of pharmaceutical service quality. Finally, Nau (2000) investigated

patients' perceptions of the benefits of participating in pharmaceutical care services.



Problem Statement



While health care in general and pharmacy in particular are making strides toward

including the customers perspective when assessing quality, the task is not complete.

Current research efforts aimed at defining service quality and/or customer satisfaction

have provided a complicated mix of results. However, one thread seems to weave

through the research and may be a foundation on which to build measures of service

quality and customer satisfaction. That thread is customer expectations. In other words,

the customer expectations construct is repeatedly found in studies concerning service










quality and customer satisfaction. Because of its seemingly foundational role, a clear

theoretical understanding of the expectations construct may lead to more useful definitions

of service quality and customer satisfaction.

Research centering on customers' expectations may be found in many disciplines,

including marketing and pharmacy. However, like service quality, no consensus has been

reached on a theoretical definition of the expectations construct. Because the expectations

construct has been a frequent topic of research, and because clarification of the construct

is needed, the grounded theory method provides an effective way of examining customer

expectations. Grounded theory will provide a better understanding of how customers

think about their interactions with their pharmacist(s), and what those customers expect

from the interactions.



Theoretical Perspective



Symbolic interactionism, the sociological roots for the grounded theory method,

finds its foundation in the work of Herbert Blumer. Blumer (1969) originally coined the

label, symbolic interactionism, as a way to describe a particular approach to the study of

human conduct and group life.

Blumer (1969) suggests that symbolic interactionism rests on three premises. The

first is that humans act toward things or objects based on the meanings that the things

have for them. These objects include everything that people find within their world,

ranging from physical objects such as a football to guiding ideals such as honesty. The








5

meanings of things to people are central in their own right and cannot be ignored when

studying human behavior. Blumer (1969) suggests that to disregard the meanings of

things in favor of factors declared to produce behavior is a serious neglect of the role of

meaning in the formation of behavior.

The second premise, according to Blumer (1969), is that the meaning of things

derives or arises from the social interaction of people. Therefore, meanings are social

products. They are created through the defining activities of people as they interact.

Finally, Blumer (1969) states that meanings are handled and modified by an

interpretive process that is used by individuals as they deal with the things that they

encounter. There are two steps in the interpretive process. First, through a process of

self-communication, an individual points out to himself the things that have meaning.

Second, through this process of self-communication, interpretation becomes a matter of

handling meanings. The individual acts to select, check, suspend, regroup, and transform

meaning based on the situation. Therefore, interpretation is a formative process in which

meaning is used and revised as necessary for guiding and forming action. Meanings

perform a part in action through the process of self-interaction.

Blumer (1969) suggests that as a human society, people are engaged in living

through symbolic interactionism. Living is a process of ongoing activity in which humans

develop lines of action for the many situations they encounter. People are involved in an

immense process of social interaction to which they must fit their developing actions.

Through the process of social interaction, individuals indicate to others what to do, and, in

turn, interpret the indications made by others. Humans live in a world of objects or things,








6

and they are guided in action and orientation by the meaning of those things. Meanings of

those things, including themselves, are formed, sustained, weakened, and transformed

through social interaction. Because people cluster in different groups, have different

occupations, and belong to a myriad of associations, they approach each other differently,

live in different worlds, and are guided by different sets of meanings.

Symbolic interactionism provides the foundation for the grounded theory method,

and as such guides the research questions, the interview questions, the data collection

strategies, and the data analysis techniques of the method. The grounded theorist searches

for the social processes present in human interaction. Grounded theory is useful in studies

where little is known about a particular subject or where much is known but clarification is

needed. Because grounded theory uses an inductive, from the ground up approach, a new

understanding of behavior may emerge, and the generated theory will be inherently

relevant to the world from which it emerges (Hutchinson, 1993).

In this study, the interaction between community pharmacy customers and their

pharmacist(s) was investigated using the grounded theory method. Grounded theory

research endeavors to understand the common issues facing the group of people under

study. A group's common experience leads to shared meaning and behaviors which in turn

leads to a specific social psychological problem. While this basic social problem is shared,

group members may not be able to articulate it. It is the job of the grounded theorist to

uncover the problem. Therefore, pharmacy customers were interviewed and observed in

order to identify and understand the basic social problem they face, and the basic social

process used to address that problem. The data collected from the interviews and










observations provides a better understanding of how pharmacy customers interact with

and assign meanings to their interactions with their pharmacist and the medication use

system.



Research Purpose



The purpose of this study was to build a substantive theory that explains customer

expectations of community pharmacy services.



Research Questions

1. What is the basic social problem faced by community pharmacy customers?

2. What basic social process is used to address this problem?



Significance for Pharmacy



Findings from this study will be useful on several fronts. First, the grounded

theory will provide pharmacy researchers with a common starting point for future

expectations research. Second, because the theory is specifically focused on the

expectations of community pharmacy customers, community pharmacists will be able to

use the theory as an aide in examining their own practices. Finally, understanding

customer expectations may enable pharmacy educators to develop better tools for telling

pharmacy customers about the services their pharmacist may provide.













CHAPTER 2
LITERATURE REVIEW


Like all professions, the practice of pharmacy continually evolves. As the

profession changes so do the interactions between pharmacist and customer, and a change

in the way that pharmacists and customers interact may affect customer expectations.

Four events seem to be shaping the current practice of community pharmacy, and

therefore customer expectations. Those events are: (1) the arrival of pharmaceutical care,

(2) the Omnibus Budget Reconciliation Act of 1990, (3) managed care, and (4) the shift

toward an emphasis on quality of care. Each is discussed in turn.

In their 1989 article, Hepler and Strand suggest that pharmacy adopt

pharmaceutical care as the philosophy of practice. They define pharmaceutical care as

"the responsible provision of drug therapy for the purpose of achieving definite outcomes

that improve a patient's quality of life" (p. 12). In order to accomplish this, the

pharmacist must perform certain activities for the patient. These activities include: curing

a disease, eliminating or reducing symptomatology, arresting or slowing the disease

process, and preventing the disease or symptomatology. Pharmacy and its professional

associations have embraced this concept as the philosophy of practice. In fact,

pharmaceutical care has become its own industry. Some companies (e.g., Caremark) have

been formed for the purpose of "teaching" pharmacists to perform pharmaceutical care.










Also, colleges of pharmacy have begun to revise their curricula so that newly graduated

pharmacists are better prepared for the new practice style.

The Omnibus Budget Reconciliation Act of 1990 (OBRA) specified that

pharmacists meet certain requirements each time a prescription is dispensed to a Medicaid

patient. Those requirements involve: record keeping, prospective drug use review, and

patient counseling. In turn, states have revised their pharmacy practice acts to mandate

those services for all pharmacy patients. Complying with OBRA requirements caused

some pharmacists to review and adjust their practice flow. For example, in order to better

provide patient counseling, some pharmacists have rearranged their practice flow so that

they are now the first and last contact for patients. In some pharmacies a separate

counseling area has been constructed.

The introduction of managed care into the pharmacy marketplace has also

impacted the profession and its relationships with its customers. Participation in managed

care contracts changes from year to year, leaving the pharmacy customer no choice but to

change pharmacies. Formularies, put in place by managed care organizations to contain

costs, may have an adverse effect on the pharmacist customer relationship. Pharmacists

must act as a kind of "enforcer" of the formulary. Physicians may begin to feel that the

pharmacist only calls to question their choice of therapy, not to act as a therapy

consultant.

Finally, health care, including pharmacy, has begun to examine the quality of care

provided. Several groups have an interest in pharmacy quality of care, each with their

own agenda. Regulatory agencies are charged with public safety. These agencies work to










set a minimum level of performance for practitioners. Pharmacists must meet their

requirements. Also, many organizations are developing report cards of pharmacist

performance. These report cards measure performance on items such as generic

substitution, significant drug interventions, and avoidance of therapeutic duplication

(Pisano, Tocco, and Vogenberg, 1997).

Examination of these four events shows a common thread running throughout.

That is, each affects the pharmacist-customer relationship in some way. Pharmaceutical

care works to increase the interaction between pharmacist and customer. Regulatory

agencies specifically direct some of the interaction between pharmacist and customer.

Managed care has perhaps interfered with the relationship by changing the pharmacist into

an insurance benefits policeman. Finally, the advent of the service quality paradigm

emphasizes the importance of the inclusion of the customer in care decisions. This

examination leaves us with the question, what does the customer think? If these factors

have affected the pharmacist-customer relationship, what is it that pharmacy customers

expect, and why are those expectations important?

The remainder of this chapter will explore those questions by presenting the

theoretical literature which explores some of those factors. Specifically, the service

quality and expectations literature will be presented as background supporting the need for

a study of customer expectations of community pharmacy services.










Service Ouality



Research in the area of service quality began in earnest in the mid 1980s when

Parasuraman, Zeithaml, and Berry (PZB) presented their conceptualization of the service

quality construct. Since that time the service quality literature has grown, with the

predominant focus on the foundation work of Parasuraman, Zeithaml, and Berry. In the

sections that follow, readers will find an overview of the work completed by service

quality researchers. This overview is presented so that the reader may gain an

understanding of the background work that supported the need for this study.



Parasuraman, Zeithaml, and Berry

The theoretical framework from which this study evolved was developed in 1985

by PZB, and is part of a stream of research that this group of authors has continued to

follow to date. PZB found that "quality is an elusive and indistinct construct" (p. 41)

which is not easily described by customers. Therefore, PZB planned a research agenda to

fill in the holes of service quality research. Their initial work included a review of the

studies investigating service quality, a report of the results of an exploratory investigation

of service quality in four businesses, development of a model of service quality, and

suggestions for future research.

PZB (1985) found that service quality had been the topic of few other research

agendas. However, they did note that there seemed to be three underlying themes in the

service quality literature: (1) customers may have a more difficult time evaluating service










rather than goods quality; (2) customer's perceptions about the quality of a service come

from a comparison of their expectations with actual service performance; and (3) both the

performance and outcome of the service encounter are part of the customer's quality

evaluation. These underlying themes and the lack of a conceptual foundation for service

quality led PZB to an exploratory qualitative study.

So that they might lay the groundwork for a conceptual framework of service

quality, PZB (1985) conducted an exploratory study of service quality. This study

consisted of in-depth interviews with executives and focus group interviews with

customers. Although the authors proposed a common set of service dimensions for all

service providers, the service categories investigated in this research included retail

banking, credit card, securities brokerage, and product repair and maintenance.

Participating executives were selected from the customer relations, marketing, operations,

and senior management departments of each firm. Three to four executives with titles

such as president, director, and senior manger participated from each firm. A total of

fourteen executives were interviewed about a broad range of service quality issues.

Customers were interviewed in a series of twelve focus groups. Focus group

participants were screened to ensure that they were users of the service in question. The

groups were designed to maintain homogeneity and assure maximum participation.

Questions for the focus groups covered such topics as descriptions of an ideal service,

factors important in evaluating a quality service, and the role of price in service quality.

The results of both the executive and the customer focus group interviews led PZB

to the development of the Service Quality Model (SQM). The model is formed by a series










of gaps between perceptions (both management and customer) of service quality and

actual delivery of the service. The gaps may be characterized as follows:



GAP 1: The marketing information gap is the difference between customer

expectations of service and management's understanding of those

expectations.

GAP 2: This gap, the standards gap, is the difference between

management's understanding of customer expectations of service

and the service standards which they specify. That is, this gap is a

function of management's knowledge and use of customer

expectations of service.

GAP 3: The third gap is the difference between service performance

specifications and the actual performance of service. This is

referred to as the service performance gap.

GAP 4: The communication gap is the difference between communications

to customers about the service and the actual performance of the

service.

GAP 5: The final gap is a function of the previous four gaps. This gap is

the difference between customer expectations of service and their

perceptions of actual service. The authors define perceived service

quality with this gap.










Examination of the five gaps shows that customer expectations are an integral

component of Gaps one, two, and five. It could also be argued, that while not explicitly

stated, customer expectations are a component of Gaps three and four. That is, according

to the model, service performance specifications from Gap three are built on customer

expectations. Also, the communications made to customers, found in Gap four, may

affect those customers' expectations.

The customer focus group interviews also provided a set often categories by

which service quality was evaluated. These categories were reliability, responsiveness,

competence, access, courtesy, communication, credibility, security, tangibles, and

understanding/knowing (PZB, 1985). The authors suggested, in this work, that

development of a measure of service quality that encompassed these ten categories or

dimensions was appropriate. Also, they concluded, work was needed in developing

measurements of the gaps and the importance of each gap in determining quality.

Research regarding the impact of past experience, word of mouth communication, and

personal needs on expected service was necessary. Finally, the authors suggested that it

might be useful to segment customers on the basis of their service quality expectations

(PZB, 1985).

Zeithaml, Berry, and Parasuraman (1988) continued the development of the

Service Quality Model by identifying a set of factors which might affect the magnitude and

direction of the first four gaps in the model. Once again the authors conducted an

exploratory study. This time the first stage of the study consisted of in-depth interviews

with three to four executives in each of four nationally recognized service firms. Interview










questions were open-ended, and covered a wide range of service quality issues. The

second stage of the research was a comprehensive case study of a bank. Employees at

every level were interviewed. The third stage of the research process was a systematic

group interview with eleven senior managers of six national service organizations. The

insights gained from the three stages of the exploratory study were combined to suggest

the main theoretical constructs and variables associated with each of the four gaps in the

SQM.

The marketing information gap was associated with marketing research

orientation, upward communication, and levels of management. The standards gap was

associated with management commitment to service quality, goal setting, task

standardization, and perception of feasibility. The service performance gap was associated

with teamwork, employee job fit, technology job fit, perceived control, supervisory

control systems, role conflict, and role ambiguity. Finally, the communications gap was

associated with horizontal communication, and propensity to overpromise.

The authors suggested that the model be tested with a technique such as LISREL.

Perceived service quality as measured by SERVQUAL (Gap 5) would be the unobservable

dependent variable, and the remaining four gaps would be the unobservable independent

variables. Other suggestions for future research included: (1) determining which of the

gap(s) is/are critical in explaining the variation in service quality; and (2) determining the

organizational factors that are responsible for the size of the four gaps.

SERVQUAL, a multiple item scale, was developed by PZB (1988) in order to

assess customer perceptions of service quality. The authors based the initial development








16

steps on their earlier work in service quality (PBZ, 1985). They began with a definition of

service quality as the discrepancy between customers' expectations of a firm's service and

customers' perceptions about the actual service. In their 1985 article PBZ identified ten

dimensions of service quality. Those ten dimensions served as a starting point for item

generation. A ninety-seven item instrument was developed and subjected to two stages of

data collection. As a result of the two stages of data collection a twenty-two item, five

dimension scale emerged. The dimensions included: tangibles, reliability, responsiveness,

assurance and empathy. Tangibles are defined as the "physical facilities, equipment and

appearance of personnel" (p. 22). Reliability is defined as the ability to execute the

promised service accurately and dependably. Responsiveness is the "willingness to help

customers and provide prompt service" (p. 22). Assurance requires knowledgeable and

courteous employees with an ability to inspire trust and confidence. Finally, empathy is

the "caring, individualized attention the firm provides its customers" (PBZ, 1988, p. 22).

Total reliability for the scale approached .90 in the cases of the four tapped service firms.

Convergent validity was assessed by comparing an overall measure of quality with

SERVQUAL scores using a one-way ANOVA. The scale was found to have convergent

validity.

An empirical examination of the Extended Service Quality Model (ESQM) may be

found in PBZ (1990). PBZ developed a list of propositions to be tested empirically. The

first four propositions hypothesized the relationship between the size of the gaps and their

related theoretical constructs (e.g., the size of the marketing information gap is negatively

related to marketing research orientation). The fifth proposition hypothesized a










relationship between customer expectations and perceptions and the size of the first four

gaps. The final proposition hypothesized that the SERVQUAL instrument is a valid

measure of customers' overall evaluations of service quality. Some of the propositions

were supported while others were not.

The results regarding the fifth proposition were mixed. The first four gaps were

found to be weakly associated with Gap 5 (service quality gap), and account for a

negligible amount of the variation in Gap 5. None of the regression coefficients were

statistically significant. These findings leave one to question whether service quality is not

measured by a difference between expectations and perceptions of performance, or

whether the constructs have not been adequately operationalized?

The results of the study done by PBZ (1990) led the authors to suggest the

following future research scenarios: (1) refine the scale for the contributing factors, (2)

conduct in-depth research on each gap, (3) investigate different levels of analysis, (4) look

at differences among companies, (5) identify other variables, and (6) develop alternative

measures of the difference score constructs.

PZB have themselves gone on to further research in the area of service quality.

They have continued work in the development of the SERVQUAL instrument (PZB,

1991, 1994a, 1994b) and have studied the role and use of expectations and their link to

behavioral intentions (Zeithaml, Berry, and Parasuraman, 1991,1996). That literature is

presented in a later section of this chapter.










Swartz and Brown

In their 1989 article Swartz and Brown explored the evaluation process for

professional services. Both providers and customers of a professional service (primary

health care) were covered in their analyses. Health care customers were surveyed by

means of a telephone interview. Health care providers (i.e., physicians) were surveyed by

means of a mail questionnaire. The focus of the survey instruments was the perceptions of

both customers and physicians toward health care and primary health care providers.

Participants were presented with a series of statements regarding physicians, health care,

and the public's view of each. They were asked to indicate their level of agreement or

disagreement using a five-point scale.

Results indicated that for both customers and physicians, the assessment of quality

is a function of both expectations and experiences. The authors used their results to

construct a conceptual model for evaluating professional service quality. This model

showed that a series of gaps were likely to occur when measuring service quality. Gap A

was the difference between customer expectations and their actual experience. Gap B was

the difference between customer expectations and physician perceptions of their patient's

expectations. Gap C was the difference between customer experiences and provider

perceptions of patient experience. Finally, Gap D was the difference between a physician's

personal thoughts about the patient and what they perceive the patients' views to be.










Bolton and Drew

Bolton and Drew (1991) conducted a study in which they investigated how

customers' evaluations of service quality were affected by changes in service offerings.

They performed a field experiment in which customers were repeatedly surveyed while a

significant service change was implemented. The study focused on temporal changes in

individual attitudes (i.e., evaluations of service quality). The authors outlined a general

model of attitude as follows. Attitude about a service depends on one's prior attitude.

This is modified by perceptions of current performance, prior expectations of

performance, and the difference between expectations and perceptions.

Results of the study, which involved telephone company customers, indicated that

perceived improvement in telephone service had a positive effect on customer attitude.

Also, customer perceptions of current performance seemed to have the biggest impact on

satisfaction and attitude. As hypothesized, current attitudes were influenced by prior

attitudes. Finally, the authors noted that individual ratings of the components of service

quality were sensitive to the effects of a service change, but average ratings of service

quality were stable and change slowly.



Cronin and Taylor

In their article, Cronin and Taylor (1992) suggested that the conceptualization and

operationalization of service quality by the SERVQUAL instrument was not adequate.

They contended that the marketing literature instead supports a simple performance based

measure of service quality, customer expectations should not be included. Therefore, they








20

developed and tested the SERVPERF instrument. In addition, the authors examined the

relationships between service quality, satisfaction, and purchase intentions.

Results of their research suggested that quality should be conceptualized and

measured as an attitude. In addition they contended that the SERVPERF scale explains

more of the variation in service quality than does SERVQUAL. They believed that this is

true because SERVQUAL is based on a satisfaction rather than attitude paradigm and the

SERVQUAL model is not confirmed for all industry types.

The seemingly contrariness (to PBZ) of this study points to need for additional

study of the service quality and customer satisfaction constructs. In addition, even though

the authors do not support the use of expectations in a measure of service quality, they do

support expectations as an element of customer satisfaction.



Bouldina

Boulding, Kalra, Staelin, and Zeithaml, (1993) developed a dynamic process of

service quality. They propose a model of service quality that follows customers' formation

and updating of perceptions of service quality. Also, the model delineates the effect of

those perceptions on individual behavioral intention variables. The authors made two

assumptions in the model: (1) a customer's current perceptions of service quality after

receiving the service are a blend of their prior expectations of what "will", and what

"should", happen and the actual delivered service; and (2) customers update their

expectations whenever they receive information about the service firm. This implies that

change and/or personally relevant experience may impact customer expectations. The










model was tested first in a laboratory study which involved multiple encounters within a

hotel setting. The analyses of the first study suggest that (1) "will" and "should"

expectations are different constructs; (2) "will" expectations positively affect and "should"

expectations negatively affect customers' perceptions of service quality; and (3) there is a

measurable effect of "will" and "should" expectations on behavioral intentions when the

service is fixed. The second study involved a field study conducted in an educational

institution. Results of the second study indicated once again a link between perceived

quality and behavioral intentions.



Spreng and Mackoy

Spreng and Mackoy (1996) discussed the conceptual arguments separating service

quality and customer satisfaction. Included in those arguments is the effect of customer

expectations on measurements of service quality and customer satisfaction. This was

accomplished by testing a model of service quality and satisfaction first developed by

Oliver (1993). In this model Oliver suggested that service quality is a function of the

comparison between ideals and perceptions of performance regarding quality dimensions.

However, satisfaction is a function of the disconfirmation of predictive expectations

surrounding both quality and non-quality dimensions. Also, perceived quality is an

antecedent of satisfaction. Spreng and Mackoy contend that there are several limitations

to the model. These include: (1) satisfaction is not related to disconfirmation of ideals,

and (2) expectations do not influence perceptions of performance.










To test the model Spreng and Mackoy examined student assessment of an

undergraduate advising office. Participants filled out a questionnaire prior to meeting with

an advisor. This questionnaire asked about student's desires and expectations regarding

ten attributes of advising. Students also completed a post-advising appointment

instrument. Again all ten attributes were measured. The authors completed confirmatory

factor analysis and structural equations modeling on the data collected by the surveys.

Results indicated that service quality and satisfaction are two distinct constructs.



Summary of the Service Quality Literature

It is clear from this review that a real interest in service quality research exists. It

is also clear that one thread appears in most of these models. That thread is customer

expectations (PBZ, 1990; PZB, 1985, 1988; Swartz and Brown, 1989; Bolton and Drew,

1991; Boulding et al., 1993; Spreng and Mackoy, 1996) In fact, in a review of the

literature pertaining to service quality, Iacobucci, Ostrom, Braig, and Bezjian-Avery

(1996) found that most models of service quality contain an expectations component.

Therefore, it appears that there is support for further study of the expectations construct.

The next section of this chapter provides a review of the literature as it directly relates to

the expectations construct.










Expectations



The expectations construct has a wide and varied past. It has been studied by

many disciplines, including economics, behavioral decision theory, and marketing (Oliver

and Winer, 1987). Because the theoretical framework that provoked the need for this

study evolved within the marketing discipline, the initial focus of this review will be on

expectations as studied within the marketing literature. This will be followed by a review

of expectations as studied in the pharmacy literature.



Expectations and Marketing

In marketing, the expectations construct is described primarily in the

satisfaction/dissatisfaction and service quality literature. This section will provide a

general review of the construct as presented in those areas.

One of the earliest definitions of expectation may be found in the work of

Georgescu-Roegen (1958), who defined expectations as "the state of mind of a given

individual with respect to an assertion, a coming event, or any other matter on which

absolute knowledge does not necessarily exist" (p. 12). He suggested that expectation and

motive are two distinct constructs.

An exploration of the expectations construct continued with the work of Olson

and Dover (1979). These authors criticized past work in disconfirmation of customer

expectations. They suggested that the expectations construct had not been clearly tested

or conceptualized. Therefore they presented a definition of expectations as pretrial beliefs








24

about a product. This allowed disconfirmation research to focus on: (1) the processes by

which belief expectations were created; (2) the effects that product trial experience have

on belief structures; and (3) the effects of pre and post trial beliefs on attitudes, intentions,

and behavior. Their study was designed to demonstrate the usefulness of conceptualizing

expectations as beliefs, and provide a stimulus for future research.

In their study Olson and Dover (1979) first exposed the subjects in the

experimental group to three ad-like communications from a coffee manufacturer. The

subjects were then asked to complete and return a written survey. In the fourth and final

exposure all subjects (control and experimental) participated in a taste test. The authors

were successful in creating a pretrial belief, in the experimental group, that the coffee was

not bitter. Results of the taste test showed that the experimental group was significantly

different than the control group in assessing the bitterness of the coffee. The control

group found the coffee to be more bitter than the experimental group both before and after

the experimental manipulation.

In his 1980 article, Oliver presented the case for the inclusion of the expectations

construct in the study of customer satisfaction. He argued that data from studies of that

time showed significant expectations effects when expectations were manipulated or

measured prior to product exposure. He also provided a study of the relationships among

expectations, disconfirmation, satisfaction, attitude, and purchase intention. In the study

expectations were measured as "the perceived belief probabilities attributed to eight

consequences of receiving the flu shot" (Oliver, 1980, p. 462). Results seemed to support

that post-usage ratings of satisfaction were a function of expectations and disconfirmation.








25

Woodruff, Cadotte, and Jenkins (1983) provided readers with an alternative model

to the confirmation/disconfirmation model of satisfaction. In their conceptual model

expectations are replaced with experience-based norms. These experience based norms

are the standard of comparison for a brand's performance. They base this "replacement"

on the argument that to date expectation based disconfirmation measures had modest

correlations with measurements of satisfaction. Also, they suggested that if one applied

social equity theory, the basis for comparisons of a brand's performance became the

degree of equity between the customer and their peers. Finally, they suggested that brand

comparison levels be based on the perceived capabilities of several brands in a brand

category. Therefore, satisfaction may be based on both standards and expectations.

In 1991, Zeithaml, Berry, and Parasuraman (ZBP) examined the nature and

determinants of customer expectations of service. The authors found that there is

agreement, in the literature, that expectations serve as standards for future experiences.

However, questions remain on other issues. For example, what is the specific nature of

the expectation standard? Also, how many standards are used? Finally, what are the

sources or antecedents of theses standards?

In order to answer the above questions, ZBP conducted focus group interviews

with customers. This exploratory research laid the groundwork for a conceptual model of

customer expectations of service. Sixteen focus group interviews were held. These group

interviews were divided into different segments as follows: (1) business customer and pure

service; (2) business customer and product related service; (3) end customer and pure

service; and (4) end customer and product related service. Four focus group interviews










were held with customers from each group. Two interviews were with experienced

customers and two with inexperienced customers. The interviews were held in five cities,

Atlanta, Chicago, Seattle, Rochester, and Dallas. Interviews were conducted by field

research companies in those cities. The interviews were unstructured in manner and

included broad open ended questions.

The analyses of the focus groups results involved a three step process. First, the

researchers conducting the groups met at the end of each interview to informally discuss

their impressions of the interview and to identify any emerging themes. Second, themes

identified by the first focus groups were also informally identified in later interviews.

Finally, a formal content and interpretive analysis of written transcripts was conducted

after all focus groups were completed. With these results the authors constructed a

generic model of customer expectations of service, which serves as an addition to the

Extended Service Quality Model. ZBP's generic model of customer expectations may be

divided into four sections, the expected service component, antecedents of desired service,

antecedents of both predicted and desired service, and antecedents of adequate service.

Each of these is described below.

The expected service component is comprised of three parts, expectations for

desired levels of service, expectations for adequate levels of service, and a zone of

tolerance between the two. Expectations for desired levels of service may be defined as

the level of service that the customer hopes to receive. This is a blend of what the

customer believes can and should be. Expectations for an adequate level of desired

service may defined as the level of service the customer will accept. ZBP (1991)










hypothesized that a customer's expectations for an adequate level of service would be

more variable than their expectations for desired levels of service. They based this

hypothesis on the assumption that desires come from an accumulation of experiences,

while adequate levels are a function of competition among other variables.

The zone of tolerance is the difference between a customer's expectations for a

desired level of service and their expectations for an adequate level of service. The

authors found (from the focus group interviews) that changes in the zone of tolerance are

more a function of expectations for adequate levels of service. Also, the zone of tolerance

may vary for the five dimensions of service quality: reliability, responsiveness, assurance,

empathy, and tangibles.

Expectations for desired levels of service are defined as the level of service that the

customer hopes to receive. Focus group interviews provided six antecedents for desired

levels of service. The first, enduring service intensifiers may be defined as "individual

stable factors that lead the customer to a heightened sensitivity to service" (ZBP, 1991, p.

15). One type of enduring service intensifier is derived service expectations. In this

instance a customer's expectations are driven by another party. Another enduring service

intensifier is a personal service philosophy. This is a customer's underlying attitude about

the meaning of service. The second antecedent is personal needs. Personal needs are "the

states or conditions essential to the physical or psychological well being of the customer"

(ZBP, 1991, p.15).

Four of the antecedents of desired service were found to impact predicted service.

Explicit service promises are statements which the service provider makes to its










customers. Implicit service promises are simply cues, which the service provider makes,

which lead to an inference about what the service encounter will be like. Word of mouth

communications were another antecedent of desired and predicted levels of service. Past

experience with the service is the final antecedent of desired and predicted levels of

service.

ZBP (1991) found that customer's expectations for adequate levels of service have

five antecedents. Those antecedents include transitory service intensifiers, perceived

service alternatives, customer self-perceived service roles, situational factors, and

predicted service. The first antecedent, transitory service intensifiers may be defined as

"temporary individual factors that lead the customer to a heightened sensitivity to service"

(p. 16). Perceived service alternatives are simply the customer's perceptions of the

availability of a comparable service. That is, what is the competition? The third

antecedent, customer self-perceived service role relates to the customer's involvement with

the service. It is the degree to which the customer perceives they influence the service.

At times a service provider cannot control the situation in which the service is provided.

The customer believes that these situational factors, the fourth antecedent, are not the

service provider's fault and they may accept a lower level of adequate service. Predicted

service is the level of service that customers believe they are likely to receive. It is

important to note that this definition of predicted service is synonymous with the definition

of expectations found in the satisfaction/dissatisfaction literature.

The development of these various levels of expectations for service led ZBP

(1991) to revise the gap model first presented in PZB (1985). The fifth gap was revised to








29

include two components: (1) the perceived service superiority gap; and (2) the perceived

service adequacy gap. The perceived service superiority gap is the difference between

desired and perceived levels of service. The perceived service adequacy gap is the

difference between adequate and perceived service.

PZB continued their research in the area of service quality with their 1994

Marketing Science Institute report. In this report the authors examined three issues: (1)

incorporation of adequate and desired expectations of service into the SERVQUAL

instrument; (2) assessment of alternative service quality measurement approaches; and (3)

examination of the relationship between customers' behavioral intentions toward service

providers and service quality. Of these three issues, the first two are relevant to this

literature review. The final issue is beyond the scope of the planned research study.

In order to test the incorporation of adequate and desired levels of service into the

SERVQUAL instrument, PZB developed and tested three versions of a questionnaire. In

the first, a three column format, separate ratings of desired, adequate, and predicted

service were obtained from three identical side by side scales. In the second, a two

column format, direct ratings of the service adequacy and service superiority gap were

obtained from two identical side by side scales. The third version was a one column

format. With the one column format direct measures of the service adequacy and service

superiority gap were also obtained. However in this version the measures followed one

another, similar to the original SERVQUAL instrument. The twenty-two attributes found

in PZB's 1991 version of the SERVQUAL instrument could be found in all three versions.

In addition to the section described above, each questionnaire contained two questions to










assess respondent ease and confidence in their answering the questions. Also, questions

were included that measured perceptions of overall service quality and value, relative

importance of the SERVQUAL dimensions, behavioral intentions, and demographics.

The surveys were mailed to customers of a computer manufacturer, a retail chain,

an auto insurer, and a life insurer. The sample for each company was randomly divided to

receive one of the three versions of the instrument. The overall response rate was 25%.

All three versions of the instrument exhibited high reliability, and showed evidence of

good predictive, convergent, and discriminant validity. The third version of the scale (i.e.,

one-column format) showed the most predictive power. This was followed by the two

then three column version of the instrument. Predictive validity was measured by the

percentage of variation accounted for in the single item overall measure of service quality.

Thus far this review has provide a description of the expectations construct as

explained in the marketing literature. The next section will review the construct as

presented in the pharmacy literature.



Expectations and Pharmacy

The study of expectations is not new to pharmacy research. However the study of

expectations has not traditionally been framed as in the marketing literature. That is, the

pharmacy research seems to be atheoretical in nature. Outlined below is an historical

overview of the construct as it relates to the practice of pharmacy.

Knapp, Knapp, and Edwards (1969) undertook a study to examine the

occupational role perceptions of the pharmacist. The authors suggested that if the










pharmacist was to take on a professional role in health care, current role expectations

would need to be modified. In their study the authors developed two scales to measure

the perceived occupational roles of pharmacists. Study participants included pharmacists,

physicians, and the general public.

The first scale contained statements describing possible characteristics of a

pharmacist. Study participants responded to this scale by first circling the one item which

they least wanted the ideal pharmacist to say or do. Next the participants were asked to

circle the item which corresponded to their ideal pharmacist. This continued until the

respondent circled no further items. Next, using the identical nineteen item scale,

participants were asked to circle the one statement most like the pharmacist of today and

the one statement least like the pharmacist of today. The procedure was modified for

pharmacist participants. This group was asked to predict how the other groups viewed

the pharmacist. The second scale was a semantic differential scale with nineteen pairs of

bipolar adjectives. All participants were asked to rate the occupational concepts of

physician, pharmacist, technician, and professional on each of the seven point bipolar

scales.

Results from the first scale showed that for all subjects there was agreement as to

the most preferred and least preferred pharmacist characteristics. Also, there were no

statistically significant differences among any of the groups for latitudes of acceptance and

non commitment in the description of the ideal pharmacist. However, physicians and the

general public of a lower socio-economic status (SES) were statistically different than the

remaining groups in their latitudes of rejection. That is, physicians and the general public










of the lower SES group had higher standards for pharmacists than did pharmacists

themselves. When perceptions of the ideal were compared to perceptions of the actual

pharmacist, pharmacists were found to not be doing those activities considered most

acceptable. Results from pharmacist participants showed that they rated the public as

being less particular than they actually were. The semantic differential scale showed that

physicians were rated most favorably. This was followed by professional, pharmacist and

then technician.

In a 1973 study conducted by the Dichter Institute for the American

Pharmaceutical Association (APhA), participants indicated that pharmacists were first a

business person with primarily commercial motivations. Also, in their study the Dichter

Institute found that the public was not aware of the services that pharmacists could

provide.

In their study, Norwood, Seibert, and Gagnon (1976) examined the attitudes of

rural customers and physicians toward expanded occupational roles for pharmacists. They

suggested that because drugstores were more evenly distributed (i.e., accessible) than

physicians, dentists, or hospitals, the pharmacist may be an ideal candidate for an

expanded role. In order to assess the acceptance of a broader role for pharmacists,

physicians in a nine county area of northeast Iowa as well as customers of a participating

pharmacist were asked to complete a questionnaire. The questionnaire contained "should"

statements describing roles that pharmacists might take. The physician group provided a

33% response rate while the customer group provided a 28% response rate.










In regards to statements about pharmacist consultations for drugs, poisons, and

sickroom supplies, both customers and physicians viewed all pharmacist roles favorably.

Both customers and physicians indicated that pharmacists should use a patient's records to

detect drug-drug interactions and should advise patients on prescription and non-

prescription medications. Of interest were the roles that customers indicated they would

pay for. Customers (27.6%) indicated that they would be willing to pay for the availability

of surgical and sick room supplies. Also, customers (14%) indicated that they would be

willing to pay for information regarding emergent treatment of poisonings.

Patients and physicians differed in their rankings of the pharmacist's role in

preliminary diagnosis, screening, and treatment. Customers viewed these roles more

favorably but were not strongly in favor of the pharmacist acting in these roles. Physicians

viewed any role of the pharmacist as a general health information source negatively.

Customers were neutral for this category. Finally, neither physician nor customers

positively viewed pharmacists in the role of drug selection, dosing, or administration.

DeSimone, Peterson, and Carlstedt (1977) gathered data regarding the interactions

between pharmacists and their patients. The authors believed that patient initiated

interactions with his or her pharmacist showed a level of need as well as an expectation

that the pharmacist could fulfill that need. Sixteen pharmacists participated in the study

which gathered the following information: (1) patient age, (2) patient gender, (3) whether

the patient came to or called the pharmacy, (4) whether the question concerned a

prescription or non-prescription drug, and (5) the question category.










Results showed that patients most often asked for a recommendation for a non-

prescription product. The second most often asked question regarded the indications of a

particular drug product. Third, patients asked questions about their prescription refills. In

terms of the demographic information gathered, results showed that women asked almost

twice as many questions as men. In terms of age, respondents in the twenty to twenty-

nine year old category had the most frequent contact with their pharmacist, while those in

the over sixty age category were next to last in terms of frequency. Most questions were

asked in person, and more questions were asked about prescription than nonprescription

medications.

In their study Ludy, Gagnon, and Caiola (1977) wished to determine if patient's

satisfaction with pharmacy services could be increased and drug misuse decreased if the

patient received more individualized care. Seventy-five patients were randomly assigned

to either a satellite or traditional pharmacy. These patients completed two questionnaires.

The first consisted of attitudinal questions about the patient's satisfaction with services in

general and the interaction with the pharmacist. In addition, the patient was asked to

indicate which of a list of nineteen activities they expected the pharmacist to do and

whether the pharmacist performed the activity with each prescription. At a later date

sixty-eight of the original patients completed a second questionnaire in their home or at

the hospital. This questionnaire contained three attitudinal questions regarding the

patient's satisfaction with the drug therapy. Also included were open-ended questions

regarding the patient's recall about information provided about the drug therapy.








35

A chi-square analysis of the results showed that there was a statistically significant

difference in expectations regarding most activities between those assigned to the satellite

and those assigned to the traditional pharmacy. Also, patients were significantly more

satisfied with the satellite pharmacy. Finally, waiting time, satisfaction with hospital

service in general, time spent with the pharmacist, and the total number of activities

performed by the pharmacist during an interaction were all significantly correlated with

satisfaction.

In order to better understand demand for comprehensive pharmaceutical services,

Banahan, Sharpe, and Smith (1980) studied customer expectations and use of those

services in a rural area. Trained personnel interviewed a responsible adult in 603

households in a three county area of Mississippi. The interview questions covered a wide

range of health care topics, including: demographic characteristics; use of and attitude

toward pharmacy services; current health status and behavior; and general satisfaction

with current medical services, among others.

Results showed that patients most often expected services related to medications

and medication use (e.g., 65.9% expected counseling on side effects). While most of the

results were reported as frequencies, the authors did note some differences among groups.

For example, respondents that either strongly or somewhat strongly agreed that

pharmacists should counsel on side effects were more likely (p
pharmacist did explain side effects. Also, respondents who expected their pharmacist to

provide health information (other than on drugs) were more likely (p
asking those questions.










Mackowiak and Manasse (1984) completed a study comparing the expectations

for ambulatory services in both office based and traditional pharmacies. The study site

was a small Midwestern town in which both pharmacy types existed. The study used a

posttest only and measured differences in expectations and satisfaction between the two

practice types. The study questionnaire was designed to measure patient expectations of,

and satisfaction with, sixteen pharmacy services. To measure expectations the items were

labeled: "I expect the pharmacist", and the satisfaction items were labeled "Level of

satisfaction with the way your pharmacist provides this service is". Researchers attained a

62% response rate. The mean expectation score for all respondents and all services was

3.98, and the average satisfaction score was 3.74. Of the sixteen activities, office practice

customers reported significantly higher expectations scores for ten of the activities.

Satisfaction scores were also significantly higher in nine of the sixteen activities. In

addition to practice type differences, the authors found that frequency of pharmacist

contact was significantly related to higher expectation and satisfaction scores.

In their study, Sirdeshmukh, Pathak, Kucukarslan, Segal, Kier, and Aversa (1991)

presented the results of an exploratory analysis of patient satisfaction/dissatisfaction and

post exchange actions in the high blood pressure prescription market. The study examined

the relationship of patient satisfaction with providers of treatment (e.g., pharmacists) and

the drug product to the following variables: expectations and performance, perceptions of

equity, overall perceived satisfaction, and responses to dissatisfaction.

Four focus groups with an average often customers each were conducted in

Florida and Ohio. Participants were elderly high blood pressure patients. The interview










was originally conducted using a matrix approach with a horizontal investigation of all

variables with respect to each exchange partner. That is, participants were first asked

questions about the physician followed by the pharmacist, manufacturer, and then the drug

product. However, the format was changed when researchers found that participants

tended to speak about their experiences and feelings based on the variable rather than the

exchange partner. Therefore, the last three focus groups followed a vertical investigation

of each variable across exchange partners. Written transcripts of each focus group were

content analyzed to identify the key themes associated with each variable. With regard to

the first variable, expectations and performance, the analysis showed that patients judged

their providers in terms of performance without an explicit use of expectations. The

authors suggested that this was a result of the patients' high involvement state. However,

patients did rely on expectations in the judgement of the drug product's side effects.

Therefore the authors concluded that patients have two sets of standards, one for persons

(e.g., pharmacists) and the other for tangibles (e.g., drug product).

In order to gain a better understanding of customer expectations toward

pharmacist provided drug information (PPDI), Wiederholt and Rosowski (1996) examined

pharmacy customers in three community pharmacies. The study was based on the

following questions: (1) do customers have expectations of PPDI as a service? (2) what

antecedents are associated with the formation of those expectations? and (3) are patient's

age, gender, and/or delivery site related to the expectations of service? The authors based

their work on the model created by ZBP (1991). However, because the authors chose the

customer satisfaction/dissatisfaction paradigm as an underlying theme, they chose










predictive expectations as defined in the model to be their dependent variable. The

independent variables included past experience with PPDI, implicit services associated

with PPDI, word of mouth communications associated with PPDI, and explicit service

promises associated with PPDI. Each of these are suggested antecedents found in ZBP

(1991).

A multi-attribute measure of expectations toward PPDI was developed by

examining existing literature, and the recommendations for patient counseling made by the

National Association of Boards of Pharmacy, the Wisconsin Board of Pharmacy, the

American Society of Health System Pharmacists, and OBRA 1990. This resulted in a list

of thirteen attributes that were measured with a five point scale labeled definitely do not

expect to definitely expect.

A factor analysis of the multi attribute expectation scale revealed that all items

loaded onto one factor which explained 56.4% of the variance. Cronbach's alpha for the

scale was 0.97. Also, the four antecedents of customer expectations became six factors,

intra personal sources, extra personal sources, past experience 1 (recency, frequency,

times), past experience 2 (duration, completeness), implicit service promises, and explicit

service promises. When examining the effects of the antecedent variables on customer

expectations, the authors found that explicit service promises and word of mouth

communication were the only two variables with a significant association. Association

between the other variables (age, gender, and site) and expectations varied from pharmacy

to pharmacy.








39

Ranelli and Coward (1997) examined the relationship between place of residence

of elderly patients and their expectations about communication with pharmacists.

Interviews were completed with 200 respondents from each of two (urban and rural)

residence groups. Interviews were completed using a forty-six item scale. The scale was

comprised of mostly closed end and forced choice items.

The authors hypothesized that three clusters of independent variables (personal

characteristics, self-reported health measure, and experience with prescription drugs)

would affect the expectations of the respondents. The dependent variable was older adult

expectations about communication with a pharmacist.

Results showed that the rural sample, in general, held higher expectations for

pharmacists. Of the nine items in the expectation scale, there were significant differences

on six of the items. Also, the rural elders had higher means on all nine items. However,

there was no significant difference between rural and urban adults in the relative rankings

of the nine items. The multivariate analysis of the independent variables showed that place

of residence was a significant predictor of expectations in three of the four models

specified. Only in the fourth fully specified model did place of residence become

insignificant.



Summary of Literature Review



Marketing literature is replete with research involving the expectations construct.

However, most of the early research involved the customer satisfaction/dissatisfaction










domain (Olson and Dover, 1979; Oliver, 1980; Woodruff, Cadotte, and Jenkins, 1983).

PZB (1985, 1988) and PBZ (1990) were the first marketing researchers to begin a

thorough examination of the expectations construct in terms of the service quality domain.

While they have continued to work in this area, they have not continued to develop the

expectations construct. That is, they have made propositions about the construct (ZBP,

1991; PZB, 1994b) but have not continued to examine the construct.

Pharmacy literature also shows an interest in the expectations construct.

Expectations of pharmacist roles were examined by Knapp, Knapp and Edwards (1969) as

well as Norwood, Seibert, and Gagnon (1976). DeSimone, Peterson, and Carlstedt

(1977) studied patient initiated contact with their pharmacists. Patient initiated contact

was considered an expectation that the pharmacist could respond to the contact. The

relationship of expectations with customer satisfaction/dissatisfaction is also a focus of

study (Ludy, Gagnon, and Caiola, 1977; Sirdeshmukh, et al., 1991; Wiederholt and

Rosowski, 1996). However, none of these studies defined expectations in terms of a

service quality framework. In fact, few of the pharmacy studies provide any conceptual

definition of, or theoretical framework for, the construct and often show conflicting

results. Therefore, this study is proposed to fill that gap. That is, the purpose of this

study is to develop a substantive theory of customer expectations of community pharmacy

services.

Using the grounded theory approach pharmacy customers were interviewed and

observed in an effort to understand their expectations for community pharmacy service.

That approach is described in the following chapter.













CHAPTER 3
METHODS


The purpose of this research was to build a substantive theory of customer

expectations of community pharmacy services. In order to accomplish this goal, the

grounded theory method was used. That method and the specifics relating to this research

are described below.



Research Design



The grounded theory method was developed by sociologists Barney Glaser and

Anselm Strauss in 1967, as a way of systematically generating theory from data.

Grounded theory enables the researcher to understand just how individuals interact with,

and subsequently view, their world. This method is useful in studies where little is known

about a particular subject or where much is known but clarification is needed (Hutchinson,

1993).

In grounded theory, data are collected (e.g., through interviews), coded (i.e., taken

apart), and analyzed (i.e., put back together) in a continuous process. As data are

compared, concepts emerge and categories are formed. Continued study reveals

relationships among the categories along with higher conceptual levels of categories.








42

Hypotheses about the data are generated and a core variable of a theory emerges (Glaser

and Strauss, 1967). A grounded theory is complete when the properties, conditions,

strategies, and consequences of that variable are explicated and integrated.

As was indicated in the previous chapter of this work, the expectations construct

has been studied from many viewpoints, however, researchers have not yet reached a

common understanding of the construct. Therefore, grounded theory provides a method

for examining the expectations construct directly from the data. The result of this study, a

substantive theory of customer expectations of community pharmacy services, provides a

clear common starting point for future expectations research.







Choosing a sample for qualitative interviews does not always follow the same rules

(e.g., random sampling) as choosing a sample of participants to complete a quantitative

survey. In qualitative research sampling is often purposeful. That is, the sample of events,

settings, or persons is chosen to provide information that is not readily available from

other choices (Maxwell, 1996). Using a random sampling technique to draw a small

sample may introduce chance variation.

Purposeful sampling has four possible goals. The first is to achieve

representativeness in the chosen sample. That is, the sample will be systematically chosen

for typicality and relative homogeneity. This may provide confidence that any conclusions

actually represent the members of the population from which the sample was drawn. A








43

second goal of purposeful sampling is to specifically examine cases that are critical for the

theoretical framework underpinning the study. A third goal is to pick a sample that will

enable the researcher to make comparisons of the reasons for differences between those

sampled. A fourth goal of purposeful sampling is to sufficiently capture the population's

heterogeneity, with the aim of representing the range of variation within that population

(Maxwell, 1996). The initial sample for this study was purposively chosen from

community pharmacy customers with a range of pharmacy experiences.

In order to assess the range of pharmacy customers to be sampled, the pharmacy

expectations literature was examined. Past studies of pharmacy customer expectations

examined customer's gender (DeSimone, Peterson, and Carlstedt, 1977; Kucukarslan,

1998), race (Kucukarslan, 1998), and age (DeSimone, Peterson, and Carlstedt, 1977;

Mackowiak and Manasse, 1988; Norwood, Seibert, and Gagnon, 1976). Kucukarslan

(1998) included an assessment of education level in her study of expectations.

Kucukarslan (1998) and Ranelli and Coward (1997) examined whether customers had

acute or chronic illnesses, and the average number of prescriptions purchased. Also

included in past studies of customer expectations were type of pharmacy patronized

(Ludy, Gagnon, and Caiola, 1977; Mackowiak and Manasse, 1984; Kucukarslan, 1998)

and frequency of pharmacy contact (DeSimone, Peterson, and Carlstedt, 1977;

Mackowiak and Manasse, 1984). Each person interviewed was asked about these

characteristics and an effort was made to represent the range in variation of the

characteristics.










Sample Recruitment

The first seven participants in this study were recruited by contacting individuals

suggested by friends and asking for their participation. Only current or past customers of

community pharmacies were asked to participate. All seven persons contacted agreed to

participate.

Recruiting later in the research process began in two independently owned

community pharmacies in Jacksonville, Florida. I visited the two pharmacies on separate

occasions and spoke with various customers about the research project while they were

waiting for their prescriptions. The pharmacists and staff at both stores had been briefed

about the project and at times they introduced a possible volunteer to this researcher.

However, none of the pharmacy customers that were approached volunteered. Therefore,

I devised another recruiting technique.

The revised technique involved two changes. The first was to add a fifteen dollar

gift certificate to a local restaurant as a token of regard and appreciation for the

participant's time. In addition, a small bag clipper was developed. This bag clipper listed

the researcher's name and phone number, a brief description of the participant's

involvement, three ways to volunteer for the interviews, and a mention of the gift

certificate. Staff at both pharmacies were asked to attach one pink bag clipper to each

pharmacy bag. The bag clippers were put into use for a two week period, resulting in a

total of twenty-three volunteers. Fifteen of those volunteers completed interviews, and

the remaining eight are available for future interviews.








45

In addition to the bag clippers, friends and interviewees were tapped for possible

volunteers. Eight additional individuals volunteered for interviews. Five have completed

interviews, and the remaining three are available for future interviews.



Sample Description

Twenty-seven individuals participated in interviews during the course of this

research. Twenty-one (78%) of the participants were female, and six (22%) were male.

In regard to age, eight (30%) were under the age of forty. Nine (33%) of the interviewees

were between the ages of forty and fifty-nine, and ten (37%) were age sixty and above.

Ages ranged from twenty-eight to eighty-seven years. The majority, twenty-four of

twenty-seven (89%) of the participants were white. Two (7%) were African American

and one (4%) was Hispanic. The sample group included two (7%) individuals who had a

high school diploma, and seventeen (63%) individuals who had some college experience.

Eight (30%) of the participants had at least a four year college degree.

There was an attempt to interview pharmacy customers who would have a range

of pharmacy related experience. To that end, three (11%) of the interviewees paid for

their medications themselves. Twenty (74%) of the interviewees shared payment with

another source (e.g., insurance), and three (11%) of the interviewees depended on an

outside source to completely cover the cost of their medication. One (4%) individual

shared payment responsibility on some medications, and on others another source (i.e., the

military) paid the bill. With regard to the type of pharmacy patronized, five (19%) strictly

shopped at chain pharmacies. Sixteen (59%) of the participants shopped at independent










pharmacies, and one (4%) patronized a clinic pharmacy. Four (15%) of the participants

patronized both chain and independent stores, while one (4%) patronized both a chain and

military pharmacy. Of those asked (n= 18), twelve (67%) participants visited their

pharmacy at least every two weeks. Two (11%) visited monthly, three (17%) quarterly,

and one (6%) visited yearly. Participants estimated that their average medication use

ranged from one-half to twenty-five prescriptions per month. Most (twenty-three or 85%)

indicated that they had some sort of chronic medical condition. Finally, of those asked

(n=18), six (33%) rated their health status as fair, six (33%) as good, and four (22%) as

excellent. One (9%) participant rated her health as poor to fair, and one (9%) as fair to

good.



Theoretical Sampling

Theoretical sampling is defined as "the process of data collection for generating

theory whereby the analyst jointly collects, codes, and analyzes his data and decides what

data to collect next and where to find them, in order to develop his theory as it emerges"

(Glaser and Strauss, 1967, p. 45). Theoretical sampling allows the researcher to sample

not with a preconceived notion, but with real, specific guidance from what is occurring in

the research setting (Glaser, 1978). In this study, theoretical sampling was employed after

the interview participants were chosen. Theoretical sampling of the interview transcripts

and field notes allowed me to pursue and expand the codes emerging from the data. This

in turn led to the discovery of the basic social problem and process which form the core

for the developing theory.










Data Collection and Recording



Data for this research were collected through a series of semi-structured interviews

and observations. Interviews were conducted at a time and place designated by the

interviewee, and lasted from forty-five minutes to an hour and a half. Each interview was

tape recorded and subsequently transcribed into the Word Perfect computer software.

Customer pharmacist interactions were observed on five separate occasions, with

observation times ranging from two and one-fourth hours to six hours. I sat or stood in an

inconspicuous place in each of the four pharmacies. Twenty-three pages of field notes

describing the pharmacy environment as well the customer pharmacist interactions were

recorded. Observations took place in two independent pharmacies, one chain pharmacy,

and one grocery store pharmacy.

In addition to the customer interviews described above, four community

pharmacists were asked to record their thoughts regarding the process that they used in

problem assessment. One pharmacist provided his notes to me. Another pharmacist was

interviewed via the telephone and I reduced the conversation to writing.



Interview Guide

An initial interview guide for this study was developed using a four step process.

First, a review of the literature was undertaken. Next, with the aide of the research

objective, the literature, and suggestions from Patton (1980), I developed nine, multi-part

expectations interview questions. Then, faculty members in the College of Pharmacy








48

reviewed and suggested improvements in the questions. Finally, a practice interview was

completed with the aid of a University of Florida Anthropology graduate student. A

discussion of possible interview improvements followed the close of the practice

interview. Revisions were made, resulting in the final interview guide. The final form of

the interview guide includes introductory remarks, nine, multi-part, open-ended questions

and four biographical questions. Throughout the interviews, probes were used as

necessary to clarify points and/or to further tap any emerging ideas. The final form of the

initial interview guide may be found in Appendix A.

After seven interviews were conducted the interview guide was revised in an effort

to expand the range of responses from the interview participants. Transcripts from the

first seven interviews and continued exploration of the grounded theory methods literature

served as a guide to the expansion of the questions. A group of sixteen questions formed

the basis for the revised interview guide. After development, two faculty members from

the College of Pharmacy reviewed the questions as an additional check. No revisions

were made after faculty review. The final form of the revised interview guide may be

found in Appendix B.

In addition to the questions specifically relating to the area of interest, interviewees

were asked a series of questions (Appendix C) focusing on both demographic and

pharmacy experience variables. The responses to these questions were used to describe

and to assess the breadth of the sample.










Data Analysis



In grounded theory, data are analyzed in a detailed systematic manner. All

interviews were tape recorded, transcribed, and entered into the computer software

program WordPerfect. In addition, the complete transcripts of the first seven interviews

were then entered into the software program Atlas.ti for Windows 95 version 4.1. This

software program aids in the organization, and coding of qualitative data. After data

entry, each sentence of the interview transcripts was examined and coded. Comparisons

were made among the codes, sentences, and interviews. Categories emerged and a theory

was developed. Throughout the process the focus was on organizing the ideas that

emerged from the data, not the data itself (Glaser, 1978). Doing grounded theory requires

the researcher to multitask as there are several steps in the research process that take place

simultaneously. While those steps are described separately below, they were used as

required by the method to uncover the basic social process described in the data.



Constant Comparison

Constant comparison is a foundation on which grounded theory rests. Data are

not analyzed in a linear fashion, but are instead revisited throughout the research process.

In other words, the grounded theorist is on constant watch for patterns in the data by

comparing incident with incident, incident with category, and finally category with

category (Hutchinson, 1993). In this study, comparisons began with specific responses

found within the transcribed interviews (i.e., incidents). Those comparisons lead to the










development of codes and categories that were subsequently compared to each other as

well as other incidents. Constantly comparing the data in this fashion revealed the

conditions, causes, and consequences of the revealed basic social process. That is,

constantly comparing the incidents and categories enabled the researcher to see the

conceptual connections and test their fit as an integrated substantive theory.



Coding

According to Glaser, "the essential relationship between data and theory is a

conceptual code" (1978, p. 55). A theory is generated when the hypothetical relationships

between codes are developed. Coding allows the researcher to fracture the data and then

conceptually piece it back together to form the theory. Two types of coding occur during

analysis. Substantive coding allows the analyst to conceptualize the empirical content of

the research. Theoretical coding conceptualizes the fit of the substantive codes into the

integrated theory (Glaser, 1978). While both types of coding occur throughout the

research process, substantive coding occurs most frequently in the initial stages and

theoretical coding in later stages.

Initial substantive coding in this study was accomplished by reading each line of

the transcripts of the first seven interviews and attaching codes to important words,

phrases, and/or paragraphs. During this phase of coding I purposely coded without a

preconceived list of ideas, an open coding procedure, resulting in a list of 162 codes.

Subsequent to this, the complete list of codes was examined to determine whether some

codes might be grouped together to form higher conceptual groups or categories.








51

Substantive coding continued with the next set of twenty interviews. However, at

this point the coding focused on the use of the forty-four higher level codes developed

from the first seven interviews. In addition to the use of the higher level codes, coding

began to focus on the questions that Glaser (1978) suggests one ask: "What is this data a

study of, what category does this incident indicate, and what is actually happening in the

data" (p.57). It was at this point in the process that the basic social process emerged.

Once the basic social process emerged theoretical coding began. Data were

examined to determine the conditions, causes, and consequences of the basic social

process. This level of coding allowed the theory to become fully formed and integrated.



Memoing and Sorting

"Memos are the theorizing write-up of ideas about codes and their relationships as

they strike the analyst while coding" (Glaser, 1978, p.83). Writing memos is at the core of

doing grounded theory. Memoing allows the researcher to "to theoretically develop ideas

with complete freedom into a memo fund that is highly sortable" (Glaser, 1978, p. 83).

Through memoing the analyst is able to raise data to a conceptual level, develop the

properties of each category, develop hypotheses about relationships between categories

and their properties, begin the integration of ideas, and place the emerging theory among

other theories of more or less relevance (Glaser, 1978). In this study, memoing began

with notes describing the settings of the initial interviews, and the demeanor of the

participants during the interviews. Also, memos were written as ideas emerged about new

codes, the basic social process, and connections between categories.










Sorting begins when codes and memos are plentiful, and the basic social process

has been identified. Through sorting the analyst is able to discern the relationship of the

different levels of codes to the basic social process. From this sort an outline of the theory

emerges and write-up begins (Hutchinson, 1993).



Core Category

The result of the steps described above and central to grounded theory is the

discovery of a core category or the basic social process within the data. The goal is to

generate a theory, centered on this category, which will account for a pattern of behavior

which is both relevant and problematic for the group under study. In other words, the

basic social problem of the group under study is addressed by the basic social process.

The basic social process should account for most of the variation in the pattern of

behavior found within the data. Also, most of the other categories and their properties

will relate to the core category. Because of these relationships, the core category serves

as the integrating point for the theory (Glaser, 1978). The basic social process discovered

in this study, Pharmacist Interceding, is discussed in complete detail later in this work.



Scientific Rigor



Internal validity, external validity, reliability, and objectivity, are the criteria by

which the rigor of a quantitative study is judged. Lincoln and Guba (1985) suggest,

however, that because the nature of qualitative inquiry is different, a separate set of










criteria be used to judge the rigor of naturalistic (i.e., qualitative) inquiry. Their criteria

includes assessments of credibility, transferability, dependability, and confirmability.

Credibility, the qualitative researcher's equivalent to internal validity, is

demonstrated when the researcher has shown that the findings and interpretation of those

findings has "truth value" (Lincoln and Guba, 1985, p. 296) to those being studied. In this

study, credibility was enhanced by the use of theoretical sampling, and concurrent data

collection and analysis. Also, discussing the findings with colleagues and study

participants provided a check on the truthfulness of the results.

Lincoln and Guba (1985) suggest that the qualitative researcher cannot comment

on the external validity of a study. Instead, the naturalist provides a thick description that

will enable other interested researchers to make judgements about the transferability of the

findings from one context to another. In this study, descriptions were written to provide

the widest possible range of information. For example, the case studies presented in

Chapter Six describe both the process of interceding as it occurs for the customer and the

customer's relevant demographic and pharmacy experience information. This information

will enable other researchers to judge how similar the current research context is to their

proposed research context.

Dependability and confirmability address the issues of reliability and objectivity. A

determination of dependability and confirmability may be made through an audit process in

which another investigator examines both the process and product of the inquiry (Lincoln

and Guba, 1985). In this study, every effort was made to provide clear, understandable,

and confirmable explanations of each step in the research process.










While the above criteria relate to qualitative inquiry as a whole, Glaser (1978)

provides some specific guidelines for the evaluation of grounded theory studies.

According to Glaser, "grounded theories have grab and they are interesting" (1978, p. 4).

The theory must fit the area under study. Data are neither forced to fit pre-conceived

categories, nor are they discarded just to keep a theory in place. The constant

comparative method requires that data be compared and contrasted constantly, allowing

an ongoing check on validity. A quality theory will explain the major behavioral and

interactional variations in the area under study. The grounded theory must be relevant to

the core variable that explains the social processes in the substantive area. That is, the

individuals who are the actors in a particular setting should recognize the theory as being

an accurate picture of the action. A good grounded theory is dense. There are a few

theoretical constructs that are supported by a network of properties and categories, that

are integrated to form a tight theoretical framework (Hutchinson, 1993). Finally, a

grounded theory must be modifiable. While the basic social process remains stable, its

variation and relevance may change quickly in the social world. Through coding and the

constant comparative method, the grounded theory can be refined to account for new data

found in further research (Glaser, 1978).













CHAPTER 4
FINDINGS: A MODEL OF PHARMACIST INTERCEDING


Customers of community pharmacy participate in a medication use system that is

often confusing and hard to negotiate. They walk into the door of their community

pharmacy with a piece of paper (i.e., prescription) in their hands, having been given a

range of details about the drug(s) they are about to take. The prescription is dispensed,

there is some interaction with the pharmacist or other pharmacy personnel, and the

customer is on his or her way home. But what about the customer's expectations for this

pharmacy visit?

This research shows that the complexity of the medication use system creates

needs (the basic social problem) for community pharmacy customers. For community

pharmacy customers, the needs created by the medication use system are addressed by the

pharmacist acting on their behalf within the system. The pharmacist's acting, called

interceding, is the basic social process which occurs in response to the customers' needs.

Pharmacist interceding, which has phases of assessing and acting, is explained by the

Model of Pharmacist Interceding.










Customer Needs: The Basic Social Problem



Thousands of customers enter community pharmacies every day. Some are

picking up routine refill prescriptions, some are picking up a one time medication for an

acute illness, and some are picking up new prescriptions for a chronic illness. For some

customers the ideal pharmacy provides accurate and efficient service. For others, the

addition of a personal touch is important. Regardless of these circumstances, all

community pharmacy customers participate in the same complex medication use system,

and at some point this participation creates a need(s) for the customer. Data from this

study suggest that customer needs may be classified into three areas: the need for

information, the need for a problem solver, and the need for reassurance. Because these

needs may occur during any visit to a pharmacy, and because they will affect the

customer-pharmacist interaction, it is important that they be examined. The remainder of

this section is devoted to an analysis of the basic social problem of customer needs.



Need for Information

Customers enter the pharmacy with a variety of needs for information, ranging

from a simple drug information printout to a detailed explanation of the best method for

taking a medication.

Information Printouts, Many of the interviewees indicated that the drug

information print-out that most pharmacies provide is useful.










Each medication came with a sheet that explained in greater detail and that was
great.

In fact one customer indicated that the printouts are even more important for maintenance

medications.

I like to get the detailed printout sheets, especially on maintenance, because... I
still like getting them because there might be things that you've forgotten about.

Some customers are interested in even more detailed information about their medication

(e.g., maximum dosage, name of manufacturer, how many different types of dosage).

I want to know a lot, I want to know a lot. Because this is my body and if I'm not
informed, then I inadvertently could do something that I wouldn't want to do.

However one pharmacy customer did indicate that "you can go overboard and waste a lot

of paper on things". In other words, this customer saw no need for the printout every

time a prescription is refilled.

Side Effects, Pharmacy customers seem to be particularly interested in receiving

information about a medication's side effects. Learning about possible side effects

prepares the customers for what lies ahead.

It would help a lot. Not to have it come down on you suddenly, and you not know
what drug's doing what.

Parents, in particular, need advance warning about a possible side effect from their

children's medication. "Is there anything I should notice about their behavior?"

Additional Information. Pharmacy customers expressed a need for their

pharmacist to inform them about any changes in the color, shape, or size of their

medication. In addition, they want the pharmacist to inform them about any new

information regarding their medication. Tips on administering medication are also








58

welcome. Finally, one customer suggested that pharmacies provide "an area of education

while you're waiting." In other words, the pharmacy should provide a specific area in the

store stocked with reading material about medications.



Need for Reassurance

To reassure may be defined as dispelling a fear or concern (The New Shorter

Oxford English Dictionary, 1993). One of the problems that pharmacy customers face is

the need to dispel any fears or concerns about their participation in the medication use

system. Customers' needs for reassurance stem from three areas. They include emotional,

dependability, and professional issues.

Emotional Issues. Emotional issues may envelop a pharmacy customer as they

enter the store.

There is another thing too that I think that pharmacists and physicians should
understand, is the emotional thing that you are going through from your illness.

These issues range from wanting to talk to a need to feel safe. Customers understand that

the pharmacist's job impacts their health, and because that is an important issue they need

a pharmacist to care about them.

Well it's concerning my health and my well being and the fact that someone is
dispensing medication that could affect that health and well being, knows me and
cares about what he is doing.

Pharmacy customers need their pharmacist to understand their family problems, listen to

their gripes, and teach them how to give their baby medication the very first time. When

they are feeling bad they want a "little sympathy." They need their pharmacist to be aware










of their emotional state.

I think a pharmacist [who] works with that pharmacy ought to be aware that there
are times when you go into a pharmacy and you're distraught. I think they ought
to show concern.

Finally, pharmacy customers expect to find "someone you could trust" behind the

pharmacy counter.

Dependability. In addition to the emotional issues encompassing the pharmacy

interaction, customers need to be reassured that they can depend on their care giver. The

consistency of the pharmacist plays an important role in a customer's assessment of

dependability.

Not too many rotating pharmacists. I don't like that, that's why I go where I go
because I like to know who I'm talking to.

There was always a different pharmacist so there was no consistent person that
knew me, and that knew the drugs that my daughter was on ... and I did not like
that.

Customers want a pharmacist "that they can count on." They want to "know it's going to

be the same people every time." Also, simple things like posting an emergency telephone

number builds the customer's confidence in the dependability of the pharmacist.

I like to know that if I got in trouble I could call he has an emergency number to
call his home.

Professional Issues, Finally, customers need to be reassured that their pharmacist

is a medication professional. They "want to know how up to date he is." They need for

their pharmacist to be able to help them work through the costs versus benefits of taking a

medication.










But when I talked to my doctor and talked to my pharmacist I realized that the
benefits would outweigh, you know, what I was feeling at the time.

Also, they need for their pharmacist to know their medication history and to act on it.

I feel confidant that, that number one my pharmacist will question if he thinks that
there is something that I might not be able to take.., because he knows my
history.

In addition, customers want the pharmacist to respect their privacy and to provide follow-

up care when needed.



Need for a Problem Solver

As stated previously, pharmacy customers face a complicated medication use

system, and as with any complicated system problems develop. A variety of customer's

problems were suggested, ranging from a perceived simple special order to complicated

insurance issues.

Special Orders. In one instance, an interviewee recounted the story of needing

calibration solutions for her child's blood glucose machine. The customer visited one

pharmacy prepared with the serial number of the machine and the number for the

company, hoping that if the items were not in stock that they could be ordered. However,

the customer indicated that the individual that she spoke with "didn't have a clue," and he

"never really offered to order them." Fortunately the customer did not give up and she

found a pharmacy that did not have the calibration solutions, but worked through the

system and replaced the whole machine. Now the customer did not expect that the whole

machine would be replaced, but she did need the first pharmacy to attempt to help.








61

If they had said we don't have it and we don't carry that, but we would certainly be
happy to order it for you. Or to talk with our drug rep or whatever and get that
for you.

Vacation Supplies. Several problems stem from customers and their vacations.

For example, one customer indicated that he had a difficult time in obtaining needed

medication prior to leaving on vacation. His frustration was increased because he knew

that the pharmacist could provide the needed help.

I'm going away for three weeks, oh I'm sorry I can't fill it, you're not due for
another two and a half weeks. A pharmacist who cares about the person he's
dealing with or she's dealing with will find a way to do that. I've had it done for
me. I know it can be done. Not all of them will do it.

In another instance an interviewee spoke of a visiting friend and their frustration that the

local pharmacist, an employee of the same pharmacy organization that she patronized at

home, made no effort to contact her physician in order to verify and fill a CoumadinTM

prescription. In a similar incident a customer recounted the story of being on vacation

with her father. While on vacation in another state the father discovered that he had

forgotten his blood pressure medication. They contacted his home pharmacy and

requested that they send the medication to their location. "So he called down to the...

and said I need you and they wouldn't send it." Not one to give up when she needed help,

the daughter contacted her pharmacist, and explained the problem. She had a medication

related problem and looked to her pharmacist as the problem solver.

Physician Back-up, Customers often look to their pharmacist to solve or prevent

problems caused by physician error. For example, one customer told of a time when she

received the wrong strength blood pressure medication. It seems that the physician had










mistakenly changed the strength, but she expected her pharmacist to catch and fix that

problem. While her pharmacist did not catch the problem, the customer still believed that

the pharmacist was in the position to do so. In another instance a customer, with many

medication allergies, relied upon her pharmacist to keep records that would prevent her

from receiving a medication she was allergic to.

Financial Issues. Many times throughout the interviews customers told of times

when, for one reason or another, they felt they had wasted money when completely filling

a prescription. One customer's mother seemed to have many allergic responses to

medication.

The pharmacist, suggested that he would give me a few pills when I got a
prescription for her, give me only a few of the pills and see if she could tolerate
them... Boy was that a lifesaver. Because I threw out so much medicine.

In another case, the pharmacist discovered that the customer seemed to be allergic to the

fillers found in many medications. The pharmacist suggested that this customer get a trial

of two doses each time she had a new prescription, saving her money.

Insurance Problems. Customers look to their pharmacist to solve all manner of

insurance problems. One customer looks to the pharmacist to complete Medicare

paperwork, "which is a boon to older patients." Another looks to her pharmacist to

handle her Medicaid paperwork.

See I'm on Medicaid and I don't take care of my paperwork. They absolutely do
everything for me.... if I didn't have [name of Pharmacist] I would just be
floundering.

For another customer the issue was whether his insurance company would pay for the

brand name medication that he needed. This customer has a seizure disorder that is








63

regulated on a brand name medication. Generic drugs have not worked for him. So when

his insurance denied payment for the brand name he looked to his pharmacist to solve the

problem.

I must have the brand name and that's the only one that works.... one of the
biggest things that a pharmacist can do for you, is to perhaps, throw himself in the
center and take care of details that you may or may not have the wherewithal or
the knowledge to take care of properly.

Customers also approach their pharmacist to solve problems regarding hard to get

medications, and product malfunctions. One mother turned to her pharmacist when her

infant son had a difficult time keeping his medicine down. Finally, customers often come

into the pharmacy when they are truly hurting. These customers look to the pharmacist to

fill their prescriptions on a priority basis, allowing them to return home to heal that much

faster.

Customers are faced with many unknowns each time they enter the pharmacy.

Participation in a medication use system full of unknowns creates needs for those

customers. Included are needs for information, needs for a problem solver, and needs for

reassurance. Those needs are addressed by a process of pharmacist interceding.

However, before the pharmacist can intercede or address the customer's problem(s), two

conditions must exist. First the problem(s) must be recognized, and second the pharmacist

must have the expertise to address the problem. Those conditions are discussed below.










Antecedent Conditions for Pharmacist Interceding



The preceding sections describe a variety of customer needs, needs that the

customer expects the pharmacist to act on. However, before the pharmacist may act or

intercede for the customer two conditions must be in place. First, the need must be

identified and second, the pharmacist must have the expertise to intercede. The sections

below describe those antecedent conditions.



IdentiWng A Need

In order for the pharmacist to intercede on the customer's behalf, a need must be

identified. Identifying the need occurs through the giving and receiving of a cue. A cue,

according to Oxford's English Dictionary (1993) is a word or phrase which serves as a

signal to another actor to enter the play. A cue, in the context of pharmacist interceding,

operates in the same way. That is, a signal is given by an actor (e.g., a customer) to

another actor (e.g., the pharmacist) to enter the play (e.g., the medication use system).

Cues are the signal to start the process of pharmacist interceding and may come from any

of three actors: (1) the pharmacy customer, (2) other pharmacy personnel, or (3) the

pharmacist.

The Pharmacy Customer, Cues to begin the process most often come from

pharmacy customers themselves. All pharmacy personnel are possible targets for those

cues. Straightforward cues may come in the form of questions. For example, one

customer directly asked the pharmacist how to use his injectable medication. Another








65

asked the pharmacist about the best way to apply an eye ointment. Cues from customers

may come from a statement made during a conversation with their pharmacist, and may be

harder to detect. One customer indicated, during the regular course of conversation, that

she was hoping not to take any pain medication. Still another described the allergy

symptoms that she was having.

Pharmacy Personnel. Other pharmacy personnel (e.g., technicians, cashiers) also

participate in identifying needs. In a busy pharmacy they are often the first and last

pharmacy contact for the customer. Customers may present questions to technicians or

cashiers in hopes that they will be passed along to the pharmacist. While all the actors in

the system receive cues, judging the seriousness of cues they receive may be more difficult

for technicians and cashiers. For example, in one case a customer entered the pharmacy to

pick up some medication. Fortunately, the technician noticed that the customer looked

very ill (a cue), called for the pharmacist's assistance, and the customer was immediately

sent to the hospital. However, if the relatively untrained technician had missed the cue, a

bad result might have occurred.
The Pharmacist. Cues may also originate within the pharmacist. Pharmacists may

hear conversations between their technicians and customers that generate concern. They

may notice a drug-drug interaction because they have access to customers' medication

profiles. Finally, simply knowing the purposes and side effects of the medications

themselves may generate a cue to act.

Miscues. Cues without notice lead nowhere. That is, customers may ask

questions, or come into the pharmacy looking extremely ill, but if pharmacy personnel do










not notice these cues (i.e., attend to them) then the pharmacist cannot intercede. For

example, one customer mentioned a fear of taking pain medications during her

conversation with the pharmacist. The pharmacist, however, missed the cue and missed

an opportunity to address this customer's need for reassurance. In another instance, a

customer explained that she was having breathing difficulties (the cue). The pharmacist

heard the cue and went on to explain why her medications may be causing the difficulties.



Pharmacist Expertise

Examination of the interview transcripts shows that pharmacist expertise is a

condition that must be present in order for the process of interceding to be successful.

Pharmacist expertise is defined as the set of special skills and knowledge that pharmacists

have obtained because of their training and educational backgrounds.

Medication Experts. Pharmacist expertise includes the ability to understand drug-

drug and drug-disease contraindications for both prescription and over-the-counter

medications. One customer explained, "He said something about me picking up [over-the-

counter remedy] one day and he goes, now did you read that pamphlet, that [over-the-

counter remedy] sometimes has a reaction to [prescription medication]." Another

customer explained.

I'm sure he has to be heads up to any interaction type things that may be going on
so that somebody hasn't actually written something that doesn't go with another
thing. That you would run up a flag on the thing and say look this needs to be
looked into before dispensing.










Expertise includes a knowledge of"how it [medication] affects you." In other words,

pharmacists must be an expert in medication side effects. Pharmacists must have the

expertise that allows them to confirm and extend any medication related information that

customers receive from their physicians.

It's also nice that if I go in and I have met with the neurologist and Il say you
know what she said about a drug, what do you think.

But I've usually already asked the doctor and I'm looking for [the pharmacist] to
confirm or relay any other things he has seen.

In one instance a pharmacist declined to dispense a prescription that a patient had seen on

a television advertisement and requested from her physician. The pharmacist recognized

that the drug could cause harm and stopped the dispensing process.

Customer Experts, Pharmacists must also be customer experts. Because they may

be the one consistent health care professional that a customer visits, pharmacists must

have the ability to understand and act on the medication history of the customer. For

example, one customer suggested that "number one, my pharmacist will question if he

thinks that there is something that I might not be able to take, that I shouldn't take or

anything, because he knows my history."

System Experts, Pharmacists must also be experts in the medication use system.

Pharmacists must understand the relationships between themselves and other health care

providers. They must have a clear understanding of the rules under which they practice.

Finally, pharmacists must understand the payment system for prescription medication.

Evidence of the need for this type of expertise may be found in the interview transcripts.

For example, one customer needed a specific brand name medication. His pharmacist had








68

to be an expert in the insurance payment system in order for that customer to receive his

medication. In another instance a customer reported that her pharmacist would not leave

her without medication for a day. This required the pharmacist to understand the working

relationship between himself and the physician, and the rules under which he practiced.





Summary



Participation in a complicated medication use system creates needs for community

pharmacy customers, and they expect those needs to be addressed by another participant

in the system, their pharmacist. Included are the customers' need for information, for

reassurance, and for problem solving. Pharmacists address those needs through a process

of interceding, but two conditions, identification of the need and pharmacist expertise,

must be present prior to the act of interceding. The process of pharmacist interceding is

discussed in the following chapter.













CHAPTER 5
PHARMACIST INTERCEDING


Interceding may be defined as acting on behalf of another. Specifically, in this

study, interceding refers to the pharmacist acting on behalf of a customer in our

medication use system. Because interceding is a process, not a static event, a series of

phases occur. Data from this study showed that the process of interceding has two

phases: (1) assessing, and (2) acting. Each is discussed below.



Assessin



Once a problem has been identified the process of pharmacist interceding may

begin. The first phase in this process is assessing. During the assessing phase of

interceding the pharmacist works to understand the real issue underlying the identified

problem. That is, the pharmacist evaluates the identified problem.

The process begins, says one pharmacist, with an effort to let the customer know

that they have the full attention of the pharmacist. The pharmacist focuses on the

customer and attempts to relay the feeling that she is receptive and willing to talk. This

pharmacist finds that customers are more willing to talk, and "give you the whole story"

when they feel comfortable. Once the customer is talking, assessing may begin in earnest.










During conversations with customers, pharmacists said that they listen to the

questions posed by their customers. They assess the customer's level of comprehension

through responses to their questions, the language used, their past history with the

customer, and the apparent educational level of the customer. Pharmacists echo back the

customer's responses in an effort to make sure that they really understand the customer.

While echoing back the customer's statements, the pharmacist gets clues from body

language and facial expressions. These clues allow the pharmacist to judge the customer's

receptivity and understanding of what they are discussing.

Once the pharmacist is sure of the issue at hand, an internal assessment begins.

That is, the pharmacist asks, do I have enough information, do I have enough knowledge,

should I look something up, or should I make a referral? The pharmacist is concerned that

the right response is provided. When the pharmacist fully understands the issue at hand

and feels capable of handling the issue, interceding moves to the acting phase.



ctinag



Acting on an identified customer need is the core of pharmacist interceding.

Without action there is no process, no interceding. Because of the wide range of needs

expressed by customers, pharmacists act in a variety of ways. Their actions may be

categorized as follows: (1) problem solving, (2) educating, and (3) reassuring.










Problem Solving

The need for problem solving generated the most diversity in pharmacist action.

Examples found in the data include completing Medicare paperwork, providing a delivery

service, and opening charge accounts for customers in need. While pharmacy customers

report a wide variety of problems, two categories of problems seem to emerge. They are

(1) problems stemming from the bureaucracy of the medication use system, and (2)

problems stemming directly from the use of the products found in a pharmacy.

The Bureaucracy. The medication use system is no different than any other large

system. It has layers of bureaucracy that create problems for those involved in the system.

Pharmacists are constantly called upon to work through the layers and solve their

customer's problems. For example, pharmacists often work to solve insurance problems.

These problems may include making sure the customer has a vacation supply of

medication, getting the customer a needed brand name medication, and assisting the

customer with a new plan. One customer needed a new blood glucose machine for her

child. The pharmacist provided and participated in the step by step procedures required

by the insurance company.

Well we don't carry those any more, but if you will go over to the pediatrician and
get another prescription for it we'll give you a new kit and it was free... She gave
me a solution.

Pharmacists often act to make sure that their customers do not go without

medication. This may occur because a physician has not answered a request for a refill or

because a customer simply forgot to call the refill order in on time. For one customer

solving the problem meant having access to experimental seizure medications for her








72

daughter. The pharmacist was able to help. "I can remember being on experimental drugs

and [the pharmacist] was able to get them." In another case a customer's car was stolen.

The pharmacist was able to replace the medication stolen along with the car.

One customer recounts a story of being in great discomfort from a medical

procedure. At home, she noticed that she had mistakenly asked the pharmacist to fill the

wrong prescription. She returned to the pharmacy, explained her problem to the

pharmacist, and he promptly filled the needed prescription.

I guess that he saw that I was in so much pain and remembered that I was there
... what he did was, on his own, went on and filled mine, okay while there were
other people there so I could leave.

In each of these cases the pharmacist understood and worked through the rules of the

particular bureaucracy to solve the customer's problem.

Product Use. A variety of products may be found in any community pharmacy,

and the use of those products creates a variety of problems. Several customers reported

having numerous allergies to medications. These allergies created possible health and

financial problems for the customer. The pharmacist was able to alleviate these problems

by: (1) dispensing only a few pills at the first dispensing of a new prescription, and (2)

keeping and using computer records which allowed him to keep a watch for any possible

problems. Pharmacists may also act to solve problems of medication compliance. For

example, a shorter duration antibiotic was suggested to a Mom whose child fought taking

medicine. Some customers may have a problem choosing an appropriate over the counter

therapy. The pharmacist is able to assist the customer in a choice of over the counter

medication.










I told him what was going on and he knows I have to take blood pressure
medication, so he watched that and you know, he went out on the floor there and
he looked at different possibilities.

Finally, one pharmacist reworked a durable medical equipment item so that it would fit his

customer's thumb.

If I've got a particular problem ... not to long ago I had tendinitis in my thumb,
and I was just at a loss. I kept trying to find,., a splint for my thumb.., and the
pharmacist said, I think I've got something that will work. And he fooled around
with it until he got it to work.



Educating

Pharmacists act to educate their customers in several ways. An assessed need for

information may be met by providing the customer with a drug information sheet.

I have noticed that every time that I have gotten a new medication I also at the
same time get a computer printout with it that has all kinds of interactions,
notifications, and warnings of any kind, side effects and things of that nature. And
yeah, sure that's a great thing to have in there.

In some instances the pharmacist educates through conversation. One customer said "he's

gone into his big book and read things to me." In other instances, the pharmacist educates

by demonstrating. For example, pharmacists are frequently called upon to teach people

how to properly administer medication. One pharmacist was observed showing a

customer the correct technique for using an injectable medication. In another instance the

pharmacist taught a Mom how to give an infant medication.










Reassuring

Pharmacists reassure their customers in a variety of ways. One customer, who

indicated that she always checks her health care providers credentials, was reassured

because "his credentials are on the wall." In another case a customer was reassured by the

reaction of the pharmacist to a mistake made in his pharmacy.

It's a terrible thing that happened ... I mean I can't dismiss the severity, but they
were responsive right away.., come in and get what you do need, you know, it's
not oh, we're sorry. You know they helped me all the way through it.

The customer felt that because of the pharmacist's reaction to the mistake, pharmacy

personnel would be more careful in the future. Pharmacists reassure their customers when

they make themselves available for questions. They reassure their customers when they

come from behind the counter and sit down to explain and show a mother how to

administer drugs to a fussy infant.

I was just so upset and frazzled over the whole thing. He made me comfortable
about giving him that medicine and stuff... By talking to me and he came out and
actually went into his [the baby's] pumpkin seat and said let me show you how you
could give it to him and he did an eyedropper with a little bit of water and he said
if you put it into the side, he said almost like a kitten and blow on his nose a little
bit, he'll swallow.

Customers are reassured when their pharmacist pre-warns them about changes in their

medication. For example, one customer spoke of a change in the manufacturer of her

child's medication. She was glad that her pharmacist informed her of the change before

she left the store, alleviating the anxiety that she might have felt later without the warning.

Customers are reassured when their pharmacist acts to show concern. For one customer

this meant that the pharmacist called to make sure that she was taking her medicine










correctly. For another customer it meant the pharmacist taking her for medical care.

After that event the customer was surely reassured that the pharmacist would look out for

her well-being. Finally, one customer indicated that she was reassured that the pharmacist

respected her privacy, because he had never asked any invasive questions.

Pharmacist interceding is a complex process that goes on in an ever changing

medication use system. Because pharmacist interceding takes place in a system of care, a

variety of conditions may influence it. They are discussed below.



Conditions Influencing Pharmacist Interceding



The process of pharmacist interceding takes place in a complex medication use

system. Therefore, there are several surrounding conditions which influence interceding.

Influencing conditions discovered within the data include the pharmacy environment, time,

social structural variables, and the personalities of both the pharmacist and customer.

Each is discussed below.



Pharmacy Environment

Community pharmacies may be found as stand alone units, as departments within a

grocery store, in clinics, and as departments within a general merchandise store. Because

pharmacies are located in many different types of establishments a variety of environments

surround the pharmacy. This variety of environments and the specifics of the pharmacy

set-up may influence the process of interceding. Included as factors in the pharmacy










environment are the physical set-up of the pharmacy, the focus of the establishment that

includes the pharmacy, and the number and types of personnel working within the

pharmacy. Each is discussed below.

Physical Set-Up. While pharmacies have some common physical features, not all

are set-up in the same way. For example, the dispensing area of the pharmacy is most

often found behind a counter of some sort. However, in some pharmacies the dispensing

area is also on a raised platform, or behind glass windows, or beyond a window, or two

counters back. Because the pharmacist operates in the dispensing area, this physical

location becomes an important issue for interceding. Observations of pharmacists at work

confirmed this point. For example, in one pharmacy the pharmacist was generally found

working at a dispensing counter on floor level, with no other barriers. This pharmacist

was constantly involved in the interactions with customers. With this easy access

dispensing area, customers were able to easily cue the pharmacist when a need arose. In

addition, the closeness of the pharmacist to the customer enabled her to initiate interceding

as she judged necessary. Contrast this with the pharmacy in which the dispensing area is

located two counters back. That is, in one of the observed pharmacies, the pharmacist

primarily worked at a dispensing counter which was located behind the main pharmacy

counter. While this physical set-up may create an efficient dispensing process, it places

two physical barriers between the customer and pharmacist. Observations in this

pharmacy showed that it was difficult for customers to directly cue the pharmacist. In

fact, at one point, thirty-five minutes elapsed before an interaction between a pharmacist

and customer was observed after the pharmacist dispensed the customer's medication.










Physical barriers may not always interfere with the process of interceding. In one

pharmacy, where the dispensing area was located on a raised platform, one customer was

not deterred. He simply placed his prescription on the top of the counter and spoke with

the pharmacist. In this same pharmacy, the pharmacist consistently greeted customers

from the platform, almost as if it were an observation post from which he could keep an

eye on the pharmacy. Rather than deterring interaction, the platform seemed to facilitate

interaction.

Pharmacy Focus, The focus of the store in which the pharmacy is located may also

influence the process of interceding. Some pharmacies are departments within stores that

sell a wide variety of merchandise, and some are within stores that focus on medicine and

other health related items. One customer indicated that "you go into some of them...

and it's just a little department shoved in the back somewhere. And that doesn't feel

important enough to me." For this customer, the focus on medicine signals that it is okay

to express a need for pharmacist interceding. Customers who patronize a pharmacy that

focuses on health care more often described their pharmacies as warm, homey, or

comfortable. Perhaps this environmental factor enables the customer to feel comfortable

expressing a need.

Pharmacy Personnel, Another environmental factor which may influence

pharmacist interceding is the number and types of personnel working in the dispensing

area. Pharmacies tend to employee three types of personnel to work within the dispensing

area: pharmacists, pharmacy technicians, and cashiers. Clearly the addition of layers of

personnel between the pharmacist and customer may influence the process of interceding.








78

In one store that employed all three levels of personnel, customers had infrequent chances

to cue the pharmacist about a need. The levels of employees acted as a barrier to the

pharmacist. That is, customers generally interacted with cashiers or technicians before they

were able to interact with a pharmacist. However, in another three level store, the

pharmacist had frequent interactions with customers. This may indicate that the number

of employees between the pharmacist and customer becomes a barrier only when other

factors come into play. Those factors might include store policy and pharmacist time.



Time

The process of pharmacist interceding may be affected in several ways by time.

That is, time is a multi-faceted issue that affects both customers and pharmacists.

Customer's Time. Effective use of time is important to customers. One customer

indicated just how important her time is.

The other one [insurance plan] would cost me less money out of my paycheck each
year and I chose to pay, more money to stay at [name of pharmacy]. That's how
valuable my time is.

This customer had previously related instances in which she felt her time had been wasted

at other pharmacies. She chose a pharmacy where she perceived the wait time was low.

Other customers also indicated that they are interested in fast service. This desire for fast

service may adversely affect the pharmacist's ability to appropriately intercede on the

customer's behalf.

Pharmacist's Time. Pharmacist's interceding is also affected by the amount of time

available for the process. The amount of time available may be affected by the










prescription volume of store as well as the assignment of personnel to the various

dispensing tasks. For example, in one high volume store the pharmacists had little time

available for interactions with customers. Most of the pharmacists' time was spent filling

prescriptions and answering phone calls. Cashiers and technicians were assigned the tasks

involving direct customer contact, not the pharmacist. However, in another high volume

store the dispensing tasks were set up so that the pharmacist did have time to intercede.



Social Structural Variables

The medication use system is replete with social structural variables that influence

pharmacist interceding. Those variables seem to fall into two categories, government

regulations and insurance regulations.

Government Regulations. Government regulations, both state and federal, provide

the pharmacist with a practice template. That is, those agencies decide and subsequently

describe how a pharmacist is to practice pharmacy. One regulation that may affect

pharmacist interceding is the requirement that all pharmacy customers be offered

counselling (i.e., the chance to talk to a pharmacist). In some pharmacies the cashier or

technician makes a verbal offer to the customer. Imagine the observed difference between

an offer of, "you don't have any questions for the pharmacist do you," and "what questions

do you have for the pharmacist today?" The first question places an obstacle in the way of

interceding, the second opens a direct path for the pharmacist to intercede.

Insurance Regulations. Insurance rules and regulations also affect the process of

pharmacist interceding. In today's medication use system, most customers' prescription










insurance claims are adjudicated online. That is, the insurance claim is electronically

transmitted to the insurance company as the prescription is being filled. The pharmacy

knows immediately whether the prescription is covered or not by the customer's insurance,

and in some instances the pharmacist is provided with additional information. This online

adjudication provides an opportunity for the pharmacist to intercede in several ways. For

example, when one drug is not covered the pharmacist knows immediately and he may

suggest another medication. In another instance the customer may be patronizing several

pharmacies, online adjudication may reject a prescription because of an interaction with a

drug dispensed at another pharmacy. The pharmacist may then act to suggest a different,

more compatible medication. Insurance regulations may also act to hamper a pharmacist's

ability to intercede. For example, insurance companies dictate the quantity of medication

that a pharmacist may dispense. They may also provide a formulary of covered

medications.



Personal Characteristics

A final factor that may affect the process of interceding is personality type of both

the pharmacist and customer. Time and time again customers stated that they want their

pharmacist to be friendly, to be polite, and to take a personal interest.

But he is a very personable person and he seems to take an interest in all people.
He calls most people by name, that I like.

A seemingly open and friendly pharmacist may open the way for a customer to express a

need. However, the personality of the customer may be just as important to the process.








81

For example, one customer indicated that her pharmacist "appears to be very stiff, but he's

very nice to me. Very nice to me." Perhaps this customer's personality, open and friendly,

allows the pharmacist to be open to the possibilities of interceding.



Summary



Because of the complicated medication use system in which they participate,

pharmacy customers develop needs. Those needs include a need for information, a need

for reassurance, and a need for a problem solver. Together they comprise the basic social

problem that pharmacy customers face. The basic social process which addresses those

needs is pharmacist interceding. Pharmacist interceding may be defined as the pharmacist

acting on behalf of a customer in the medication use system. Pharmacist interceding as a

process includes the phases of assessing and acting. The process is preceded by two

conditions, problem identification and pharmacist expertise, and it is influenced by a group

of factors including, pharmacy environment, time, social structural variables, and personal

characteristics. But what happens after the pharmacist intercedes? What are the

consequences of pharmacist interceding? That final piece of the model is discussed in the

following chapter.













CHAPTER 6
THE CONSEQUENCES OF PHARMACIST INTERCEDING


Pharmacy customers present their pharmacists with a variety of needs, and

pharmacists respond to these needs by interceding or acting on behalf of their customers in

our medication use system. But what are the consequences of that interceding? Data

from this study indicate that a relationship is formed between customer and pharmacist.

That is, a connection or association is formed between the two. While some

commonalities among the data were found, not all customer- pharmacist relationships are

alike. Findings from this study show that relationships may be classified into one of two

types: professional and personal. In the following sections, a description of the two

relationship types is presented. This is followed by six cases or in depth descriptions of

the processes described by the Model of Pharmacist Interceding.



Professional Relationships



The formation of a professional relationship between customer and pharmacist

seems to be common to all pharmacy customers. In other words, the minimum

consequence of pharmacist interceding is the formation of a professional relationship

between the customer and pharmacist. For this study, a professional relationship may be










defined as an association between pharmacist and customer which focuses on the

customer's medication use. This relationship is role based, and is formal in nature. In a

professional relationship, there is recognition of the partners and a purposive exchange.

Pharmacists and their customers recognize each other, have some affinity for each other,

but focus their interactions on getting the prescription dispensed: accurately, efficiently,

and safely.



Personal Relationships



Personal relationships may also be a consequence of pharmacist interceding. While

personal relationships included some of the same elements as a professional relationship

(i.e., recognition and accurate, efficient, safe prescription dispensing), they also include an

increased level of personal involvement. Pharmacy customers who formed a personal

relationship related instances in which their interactions with their pharmacists included

discussions of family and work matters, and they more often referred to their pharmacist

as a friend. Also, at this level, customers reported that their pharmacist acts to provide an

extra degree of service.







So that the reader may have a better understanding of the consequences of

pharmacist interceding as well as the Model of Pharmacist Interceding as a whole, the










remaining section of this chapter includes six case descriptions. The cases were chosen

because they illustrate a range of customer needs, pharmacist action, and type of

relationship formed. Cases one, two, and three describe instances in which a professional

relationship is formed. Cases four, five, and six illustrate the process as it ends in a

personal relationship.



Case One

At the time of the interview Bonnie* was a sixty-three year old semi-retired

certified nursing assistant (CNA). She visited her pharmacy, a chain store, every week on

average, due in part to her job as a CNA. While she does have two chronic illnesses, she

characterized her health status as good. Bonnie bears the entire obligation of paying for

her medication. Her story provides us with an example of the progression from customer

needs through pharmacist interceding to building a professional relationship.

Throughout her interview, Bonnie expressed needs for information. For example

she suggested that the pharmacist should make you aware "you can have reactions by

taking this medicine." Also, she indicated that the pharmacist was the one to ask about

medications that she wanted to try. She found "that the pharmacist has a lot of update on

the medicines that doctors don't have," and with this statement revealed one of the

conditions for interceding, that is pharmacist expertise.

Bonnie's expression of her need for information, a question for her pharmacist, is

an example of customer need identification. Bonnie cued her pharmacist that she needed


* all names are pseudonyms










some interceding, but in this case the process ended.

I've went to the drugstore before and asked a pharmacist, well what do you think
about a certain drug. And the pharmacist would say well it's up to the individual.
Well I didn't want that answer. I wanted an answer like well have you ever taken
this or that and how did it react? Well this is the one I think, why don't you try this
one? I think he should be more knowledgeable and more information, give you
more information.

This pharmacist did not attend to Bonnie's cue, resulting in no interceding. Bonnie tells of

another time when she visited her pharmacy.

I got a prescription one day and I didn't understand it and he didn't have time to
tell me about it. So I thought oh well, he'll give me a slip and I'll know a little bit
more about it, but he didn't. So I started going to a drugstore that was farther
away, but they talked to me when I went in.

This time Bonnie had a need for information that was not met. The pharmacist did not

intercede so Bonnie went looking for a pharmacist who would meet her needs. Bonnie

goes on to say that "the next time I had to have a prescription filled I tried them (again). I

liked the way they explained things to me." This new pharmacist was able to identify,

assess, and act (i.e., intercede) on Bonnie's needs. As a result of the interceding, a

professional relationship has formed between Bonnie and her pharmacist.

I would want to go where I liked the pharmacist. Because the pharmacist I was
going to just got a new job so I may switch.

Bonnie is willing to change pharmacies so that she has the opportunity to work with the

same pharmacist.










Case Two

At the time of her interview, Joan was a thirty-nine year old human resources

generalist. She visited her independent pharmacy four to six times each month. Joan

characterized her health status as good even though she has a chronic illness. She shares

prescription payment obligations with her insurer. Her story provides us with an example

of pharmacist interceding that leads to a professional relationship.

Joan classifies herself as a "very informed medical patient. Because I have a lot of

things wrong with me." This classification drives her need for information. Because they

know her, Joan's pharmacist will provide her with specific information tailored to her

medication profile.

They will mention, don't forget, you need to take this with food, because of your
bad stomach. Okay, or you've never had this before, this may make you drowsy.

Joan also relies on the information sheets provided with each prescription. She reads

those sheets from beginning to end every time she has a prescription dispensed, and she

calls her pharmacist if she has any questions.

Oh, I would never call the doctor.... Because, you know what, the pharmacy
knows more about drugs, I think, than the doctor does. Especially the interactions
to be perfectly honest with you.

Joan also indicated that from time to time she has the need for a problem solver.

She tells of one instance when she had injured her back. Two prescriptions were phoned

to a pharmacy and even though she was in pain she was told that the wait for the

prescriptions would be an hour and a half Joan had a problem, pain. In this case, the

pharmacist did not identify or cue into the pain. Therefore there was no interceding and










no relationship. In fact, Joan called the pharmacy supervisor for this pharmacy to relay

her displeasure. She indicated that she will not return to that pharmacy. However, Joan

does tell of a pharmacist that will help her solve this same problem.

And when you bring in a prescription for pain medicine or something he knows
where you need it right away. He'll bump your prescription up, so that's nice.

Joan knows the name of her former pharmacist and "he remembers my name" even though

she moved and he has not been her pharmacist for six years.

Time is a very important issue in Joan's life. In fact, one of the reasons that she

patronizes her current pharmacy is the efficiency with which they dispense her

prescriptions. They have recognized that wasting time is a big problem for Joan and they

have acted to solve the problem.

They are fast and let me tell you, what has kept me there. Something in addition
to that. That this year we have more than one type of HMO [health maintenance
organization] that I like. It's a point of service HMO and we have two this year to
choose from. The other one would cost me less money out of my paycheck each
year and I choose to pay more money to stay at [name of pharmacy]. That's how
valuable my time is.

Joan has formed a professional relationship with the pharmacist who values her

time, provides her specific drug information, and respects her privacy.



Case Thr

George was a forty-three year old project director at the time of his interview.

Like Bonnie, George patronizes a chain pharmacy, but very infrequently. He says his

health status as "somewhere between fair and good." His insurer covers the complete cost

of his medication. George's story illustrates the formation of a professional relationship.










While George is an infrequent patron in his pharmacy, he did express a need for

information during his interview.

Tell me about the medication. What are the side effects, how do you take it, if
there, if you should take it with dinner, with water, what not to take it with, so
that, you know there's obvious stuff like don't take it with alcohol, but if there's
other things that you can take it with that could possibly make you sick of
something, or queasy or uncomfortable.... And if they are aware of other
medications that are out now that will address the same or similar issues.

George expects his pharmacist to be able intercede and provide this information. He tells

of a time when he had a need for information and the pharmacist did not help.

I started asking questions and they couldn't answer it, they didn't know and as a
consequence I thought they didn't know and that was the reason for their being
curt with me. I'm trying to find out what I need to know and they were well your
doctor gave it to you isn't that sufficient.

In this case, the pharmacist did not identify and act on George's need for information.

When asked how the pharmacist could have made things better, George replied as follows.

Answer my questions. And not tell me, if you don't know, it's perfectly okay to
say you don't know.... Just say well Mr. X I'm really not sure. It would probably
be best if you could talk with your doctor about this in more detail. And that's
fine. Then I can choose to come back or not come back to that pharmacy.

George currently patronizes a pharmacy where he likes "this place because the guy

explains everything." The pharmacist is "friendly and open." Also, he remembers a

pharmacy in another city "where the guy would explain what you had, but it wasn't like I

was talking to my best friend or anything, but he did his job." This last sentence seems to

summarize George's professional relationship with his pharmacist. That is, he has a need

for information, and the pharmacist acts to meet that need in the context of the

professional relationship between customer and pharmacist.










Case Four

At the time of her interview, Moira was a fifty-two year old disabled medical

technician. Moira suffers from an illness that does not allow her to work. She patronizes

her independent pharmacy at least monthly, and her prescriptions are completely paid for

by a third party.

While Moira expressed needs for information, the clearest depiction of relationship

building stems from her need for reassurance.

I checked and [name of pharmacist] was there and I was glad.... He knows all of
my medicines and he knows what to tell me about them or if there are any
problems about them.

Having one pharmacist available reassures Moira that "they know her and they pay

attention to what you're doing."

Not too many rotating pharmacists. I don't like that, that's why I go where I go
because I like to know who I'm talking to.

Moira has clear evidence that her pharmacist pays attention to what she is doing.

I mean one day, I'll just tell you, I was very sick in the pharmacy and [name
of pharmacist] saw that I was because he knows me, he just took me to the
hospital.... But the point is that he saw it, he recognized it and he knew that I
needed to go and he helped me.

In this instance, the pharmacist identified the customer's physical state, assessed the need
for immediate medical attention, and interceded by getting the customer the needed
medical care. Moira feels certain that her pharmacist would act to help her, no matter
what.
If [name of pharmacist] couldn't have done it, he would have found someone who
could have done it.










Because of the interceding Moira has formed a personal relationship with her

current pharmacist.

I go down to Shands and [pharmacist] familiar with that. He knows what's going
on. He knows that partly because I've told him and he's listened and remembered.



Case Five

Betty was a sixty-one year old homemaker at the time of her interview. She

patronizes an independent pharmacy, and visits about every two weeks. She does have

some chronic illnesses, but says she is in good health. Betty shares the responsibility of

payment for her medication with her insurance company.

Betty expressed all three needs throughout her interview. She looks to her

pharmacist to solve problems with insurance coverage, out of stock items, and vacation

supplies of medication. She needs her pharmacist to provide her with extensive drug

information, to advise her of interactions with her current medications, and to suggest

over the counter medications. Betty needs reassurance that her pharmacist "is up to date

on his, with the knowledge of medicines that are coming up." This reassurance comes in

the form of credentials in plain sight. Betty wants her pharmacist to show concern when

she comes in distraught. She also revealed the condition of pharmacist expertise during

our conversation when she said that her pharmacist should "be an expert in what type of

medicine he's giving me."

Throughout our conversation Betty shared several instances that provided a

pharmacist the opportunity to intercede.










I went to a particular pharmacy, presented my prescription and my medical card,
my medical insurance card and I was promptly told we don't take this medical
insurance. Do you know where I can go to get this filled? I was under the
impression that you did take it, well we don't. End of subject, end of conversation
and their back was turned to take care of someone else.

Betty needed someone to help her solve her problem, but instead she found a pharmacist

who missed a cue. Betty ultimately solved her own problem by going to another

pharmacy, but the first pharmacy missed an opportunity to build a relationship with Betty,

and has now lost her as a customer. As Betty said "now I would not go in there, I just

wouldn't, I just would not do it."

Betty relates another instance in which a pharmacist had the chance to solve a

problem by using his expertise and interceding.

I called, I had a hard time breathing, I had post nasal drip there in the back. And I
get really stuffed. Well I don't need to go to the doctor to find out about that, but
I can call my pharmacist and say look I feel this. My head is hurting, I know you
can't prescribe... but I would say, what is there over the counter that you can tell
me that I can take and he'll ask me well what are the symptoms, I tell him, he tells
me what I can buy over the counter .... That saves me a trip, an unnecessary trip
to the doctor.... it makes me feel like I have somebody I can go to, over the
phone, that is going to help me.

Clearly in this instance the pharmacist acted on the cue given by Betty, and in this case a

relationship has been developed. Betty patronizes the pharmacy where this pharmacist

works. Like others who formed a personal relationship, Betty described the pharmacy as

having a "homey atmosphere" and being treated as if "we're old friends."




Full Text
APPENDIX A
INITIAL INTERVIEW GUIDE
1. Please think about your last visit to a pharmacy to pick up a prescription. You
arrived at the pharmacy and opened the door. What happened next? What did the
pharmacy look like? Where were the people? Who were the people? What were
you doing? What were they doing? What was said? When was it said? What was
the most important thing that happened during your visit?
2. When you need a prescription, what are your minimum expectations of a
pharmacy? What about the facilities? Services? Personnel?
3. Now imagine the ideal pharmacy visit in your eyes. Please describe an ideal visit
to that pharmacy. How is it different than the minimum you described a minute
ago? Facilities? Services? Personnel?
4. Please think about a pharmacy visit when your expectations were not met. What
happened? What was different? Who was involved? Facilities? Services?
Personnel?
5. Are there any times when your expectations might be different?
6. Have you ever had a change in your health plan that necessitated a change in
pharmacies? How did you choose the new pharmacy? What were your
expectations for service in that new store? Facilities? Services? Personnel?
7. Suppose you move to a new town. How do you choose a new pharmacy? Why?
8. Suppose someone asked you for a recommendation. Describe the pharmacy that
you would recommend. Facilities? Services? Personnel?
9. Do you currently patronize one pharmacy? More? Why?
106


34
Results showed that patients most often asked for a recommendation for a non
prescription product. The second most often asked question regarded the indications of a
particular drug product. Third, patients asked questions about their prescription refills. In
terms of the demographic information gathered, results showed that women asked almost
twice as many questions as men. In terms of age, respondents in the twenty to twenty-
nine year old category had the most frequent contact with their pharmacist, while those in
the over sixty age category were next to last in terms of frequency. Most questions were
asked in person, and more questions were asked about prescription than nonprescription
medications.
In their study Ludy, Gagnon, and Caiola (1977) wished to determine if patient's
satisfaction with pharmacy services could be increased and drug misuse decreased if the
patient received more individualized care. Seventy-five patients were randomly assigned
to either a satellite or traditional pharmacy. These patients completed two questionnaires.
The first consisted of attitudinal questions about the patient's satisfaction with services in
general and the interaction with the pharmacist. In addition, the patient was asked to
indicate which of a list of nineteen activities they expected the pharmacist to do and
whether the pharmacist performed the activity with each prescription. At a later date
sixty-eight of the original patients completed a second questionnaire in their home or at
the hospital. This questionnaire contained three attitudinal questions regarding the
patient's satisfaction with the drug therapy. Also included were open-ended questions
regarding the patient's recall about information provided about the drug therapy.


CHAPTER 5
PHARMACIST INTERCEDING
Interceding may be defined as acting on behalf of another. Specifically, in this
study, interceding refers to the pharmacist acting on behalf of a customer in our
medication use system. Because interceding is a process, not a static event, a series of
phases occur. Data from this study showed that the process of interceding has two
phases: (1) assessing, and (2) acting. Each is discussed below.
Assessing
Once a problem has been identified the process of pharmacist interceding may
begin. The first phase in this process is assessing. During the assessing phase of
interceding the pharmacist works to understand the real issue underlying the identified
problem. That is, the pharmacist evaluates the identified problem.
The process begins, says one pharmacist, with an effort to let the customer know
that they have the full attention of the pharmacist. The pharmacist focuses on the
customer and attempts to relay the feeling that she is receptive and willing to talk. This
pharmacist finds that customers are more willing to talk, and "give you the whole story"
when they feel comfortable. Once the customer is talking, assessing may begin in earnest.
69


50
development of codes and categories that were subsequently compared to each other as
well as other incidents. Constantly comparing the data in this fashion revealed the
conditions, causes, and consequences of the revealed basic social process. That is,
constantly comparing the incidents and categories enabled the researcher to see the
conceptual connections and test their fit as an integrated substantive theory.
Coding
According to Glaser, "the essential relationship between data and theory is a
conceptual code" (1978, p. 55). A theory is generated when the hypothetical relationships
between codes are developed. Coding allows the researcher to fracture the data and then
conceptually piece it back together to form the theory. Two types of coding occur during
analysis. Substantive coding allows the analyst to conceptualize the empirical content of
the research. Theoretical coding conceptualizes the fit of the substantive codes into the
integrated theory (Glaser, 1978). While both types of coding occur throughout the
research process, substantive coding occurs most frequently in the initial stages and
theoretical coding in later stages.
Initial substantive coding in this study was accomplished by reading each line of
the transcripts of the first seven interviews and attaching codes to important words,
phrases, and/or paragraphs. During this phase of coding I purposely coded without a
preconceived list of ideas, an open coding procedure, resulting in a list of 162 codes.
Subsequent to this, the complete list of codes was examined to determine whether some
codes might be grouped together to form higher conceptual groups or categories.


67
Expertise includes a knowledge of "how it [medication] affects you." In other words,
pharmacists must be an expert in medication side effects. Pharmacists must have the
expertise that allows them to confirm and extend any medication related information that
customers receive from their physicians.
It's also nice that if I go in and I have met with the neurologist and I'll say you
know what she said about a drug, what do you think.
But I've usually already asked the doctor and I'm looking for [the pharmacist] to
confirm or relay any other things he has seen.
In one instance a pharmacist declined to dispense a prescription that a patient had seen on
a television advertisement and requested from her physician. The pharmacist recognized
that the drug could cause harm and stopped the dispensing process.
Customer Experts. Pharmacists must also be customer experts. Because they may
be the one consistent health care professional that a customer visits, pharmacists must
have the ability to understand and act on the medication history of the customer. For
example, one customer suggested that "number one, my pharmacist will question if he
thinks that there is something that I might not be able to take, that I shouldn't take or
anything, because he knows my history."
System Experts. Pharmacists must also be experts in the medication use system.
Pharmacists must understand the relationships between themselves and other health care
providers. They must have a clear understanding of the rules under which they practice.
Finally, pharmacists must understand the payment system for prescription medication.
Evidence of the need for this type of expertise may be found in the interview transcripts.
For example, one customer needed a specific brand name medication. His pharmacist had


89
Case Four
At the time of her interview, Moira was a fifty-two year old disabled medical
technician. Moira suffers from an illness that does not allow her to work. She patronizes
her independent pharmacy at least monthly, and her prescriptions are completely paid for
by a third party.
While Moira expressed needs for information, the clearest depiction of relationship
building stems from her need for reassurance.
I checked and [name of pharmacist] was there and I was glad. ... He knows all of
my medicines and he knows what to tell me about them or if there are any
problems about them.
Having one pharmacist available reassures Moira that "they know her and they pay
attention to what you're doing."
Not too many rotating pharmacists. I don't like that, that's why I go where I go
because I like to know who I'm talking to.
Moira has clear evidence that her pharmacist pays attention to what she is doing.
I mean one day, I'll just tell you, I was very sick in the pharmacy and [name
of pharmacist] saw that I was because he knows me, he just took me to the
hospital. . But the point is that he saw it, he recognized it and he knew that I
needed to go and he helped me.
In this instance, the pharmacist identified the customer's physical state, assessed the need
for immediate medical attention, and interceded by getting the customer the needed
medical care. Moira feels certain that her pharmacist would act to help her, no matter
what.
If [name of pharmacist] couldn't have done it, he would have found someone who
could have done it.


97
Relationship of the Model of Pharmacist Interceding to Other Research
The expectations construct has been studied over a period of many years, with
varying results. The Model of Pharmacist Interceding is not meant to replace previous
work. Instead this Model will act as an adjunct to improve the outcomes of expectations
research. Previous work in expectations has a primarily deductive origin. That is, the
research process was designed to test hypotheses based on a specific theoretical
perspective. The development of this model followed the grounded theory method.
Grounded theory uses an inductive approach in order to provide an explanation for
behavior. In other words, the developed theory is grounded in the study data. This new
approach to expectations research provides several advantages. For example, the actors in
the process provide the data from which the theory or model is built. This allows for a
theory that describes the problems and processes that are important to the participants.
Also, the grounded theorist is not tied to another researcher's ideas. In grounded theory
the data tell the story, an idea (theory) is not imposed upon the data.
Comparison of the Model of Pharmacist Interceding with other pharmacy
expectations research shows some agreement. For example, DeSimone, Peterson, and
Carlstedt (1977) began their study with an idea that customers had some needs and an
expectation that their pharmacist might meet those needs. However, their research
focused on the number and types of questions posed by pharmacy customers, using
pharmacists as the data recorders. Their focus on customers asking questions limited their
findings and did not allow them to completely tap the customers' perceptions. In this


49
Data Analysis
In grounded theory, data are analyzed in a detailed systematic manner. All
interviews were tape recorded, transcribed, and entered into the computer software
program WordPerfect. In addition, the complete transcripts of the first seven interviews
were then entered into the software program Atlas.ti for Windows 95 version 4.1. This
software program aids in the organization, and coding of qualitative data. After data
entry, each sentence of the interview transcripts was examined and coded. Comparisons
were made among the codes, sentences, and interviews. Categories emerged and a theory
was developed. Throughout the process the focus was on organizing the ideas that
emerged from the data, not the data itself (Glaser, 1978). Doing grounded theory requires
the researcher to multitask as there are several steps in the research process that take place
simultaneously. While those steps are described separately below, they were used as
required by the method to uncover the basic social process described in the data.
Constant Comparison
Constant comparison is a foundation on which grounded theory rests. Data are
not analyzed in a linear fashion, but are instead revisited throughout the research process.
In other words, the grounded theorist is on constant watch for patterns in the data by
comparing incident with incident, incident with category, and finally category with
category (Hutchinson, 1993). In this study, comparisons began with specific responses
found within the transcribed interviews (i.e., incidents). Those comparisons lead to the


52
Sorting begins when codes and memos are plentiful, and the basic social process
has been identified. Through sorting the analyst is able to discern the relationship of the
different levels of codes to the basic social process. From this sort an outline of the theory
emerges and write-up begins (Hutchinson, 1993).
Core Category
The result of the steps described above and central to grounded theory is the
discovery of a core category or the basic social process within the data. The goal is to
generate a theory, centered on this category, which will account for a pattern of behavior
which is both relevant and problematic for the group under study. In other words, the
basic social problem of the group under study is addressed by the basic social process.
The basic social process should account for most of the variation in the pattern of
behavior found within the data. Also, most of the other categories and their properties
will relate to the core category. Because of these relationships, the core category serves
as the integrating point for the theory (Glaser, 1978). The basic social process discovered
in this study, Pharmacist Interceding, is discussed in complete detail later in this work.
Scientific Rigor
Internal validity, external validity, reliability, and objectivity, are the criteria by
which the rigor of a quantitative study is judged. Lincoln and Guba (1985) suggest,
however, that because the nature of qualitative inquiry is different, a separate set of


CHAPTER 1
INTRODUCTION
This is a study of customer expectations of community pharmacy services. It is a
study that seeks to create a theoretical understanding of customer expectations that is not
yet found in the academic literature. The following paragraphs outline the importance of
including the customer's perspective in assessing health care, and the current study of
customer expectations in an effort to support the importance of understanding those
expectations.
Customers of health care have often been ignored when assessing the quality of the
medical care that they receive (Davies and Ware, 1988). In fact, during the 1980s the
health care community focused on containing skyrocketing costs. Little attention was paid
to anyone's assessment of quality of care. However, the tide has turned and health care
customers, providers, and payers seem to have refocused their interests toward the quality
of the health care that they receive, provide, and pay for. This renewed interest in quality
leads us to an examination of the roles that customers, providers, and payers can and
should take in assessing and defining quality.
Historically, customers of health care played a passive role in assessing the quality
of their care. They simply followed the "doctor's orders." Patients did not participate in
assessing the quality of the care that they received. In fact, there was an argument against
1


103
Kucukarslan, S. (1998). Identifying Patient Needs in the Context of the
Medication Use Situation. Journal of the American Pharmaceutical Association, 38, 440-
445.
Lincoln, Y.S., & Guba, E G., (1985). Naturalistic Inquiry, Beverly Hills, CA:
Sage.
Ludy, J.A., Gagnon, J.P., & Caiola, S.M. (1977). The Patient-Pharmacist
Interaction in Two Ambulatory Settings. Drug Intelligence and Clinical Pharmacy. 11, 81-
89.
Mackowiak, J.L., & Manasse, H R. (1984). Expectations for Ambulatory Services
in Traditional and Office-Practice Pharmacies. American Journal of Hospital Pharmacy,
41, 1140-1146.
Mackowiak, J.L., & Manasse, H R. (1988). Expectation vs. Demand for Pharmacy
Service. Journal of Pharmaceutical Marketing & Management. 2. 57-72.
Maxwell, J.A. (1996). Qualitative Research Design An Interactive Approach
Thousand Oaks: Sage Publications.
au, DP., Ried, L.D., Lipowski, E.E., Kimberlin, C., Pendergast, J., & Spivey-
Miller, S. (2000). Patients' Perceptions of the Benefits of Pharmaceutical Care. Journal of
the American Pharmaceutical Association. 40. 36-40.
Norwood, G.J., Seibert, J.J., & Gagnon, J.P. (1976). Attitudes of Rural
Consumers and Physicians Toward Expanded Roles for Pharmacists. Journal of the
American Pharmaceutical Association. 16. 551-554.
Oliver, R.L. (1980). A Cognitive Model of the Antecedents and Consequences of
Satisfaction Dimensions. Journal of Marketing Research. 17. 460-469.
Oliver, R.L. (1993). A Conceptual Model of Service Quality and Service
Satisfaction: Compatible Goals, Different Concepts. Advances in Services Marketing and
Management. 2. 65-85.
Oliver, R.L., & Winer, R.S. (1987). A Framework for the Formation and Structure
of Consumer Expectations: Review and Propositions. Journal of Economic Psychology. 8.
469-499.
Olson, J.C., & Dover, P A. (1979). Disconfirmation of Consumer Expectations
Through Product Trial. Journal of Applied Psychology. 64. 179-189


75
correctly. For another customer it meant the pharmacist taking her for medical care.
After that event the customer was surely reassured that the pharmacist would look out for
her well-being. Finally, one customer indicated that she was reassured that the pharmacist
respected her privacy, because he had never asked any invasive questions.
Pharmacist interceding is a complex process that goes on in an ever changing
medication use system. Because pharmacist interceding takes place in a system of care, a
variety of conditions may influence it. They are discussed below.
Conditions Influencing Pharmacist Interceding
The process of pharmacist interceding takes place in a complex medication use
system. Therefore, there are several surrounding conditions which influence interceding.
Influencing conditions discovered within the data include the pharmacy environment, time,
social structural variables, and the personalities of both the pharmacist and customer.
Each is discussed below.
Pharmacy Environment
Community pharmacies may be found as stand alone units, as departments within a
grocery store, in clinics, and as departments within a general merchandise store. Because
pharmacies are located in many different types of establishments a variety of environments
surround the pharmacy. This variety of environments and the specifics of the pharmacy
set-up may influence the process of interceding. Included as factors in the pharmacy


TABLE OF CONTENTS
page
ACKNOWLEDGMENTS iv
ABSTRACT viii
CHAPTERS
1 INTRODUCTION 1
Problem Statement 3
Theoretical Perspective 4
Research Purpose 7
Significance for Pharmacy 7
2 LITERATURE REVIEW 8
Service Quality 11
Expectations 23
Summary of Literature Review 39
3 METHODS 41
Research Design 41
Sample 42
Data Collection and Recording 47
Data Analysis 49
Scientific Rigor 52
4 FINDINGS: A MODEL OF PHARMACIST INTERCEDING 55
Customer Needs: The Basic Social Problem 56
Antecedent Conditions for Pharmacist Interceding 64
Summary 68
vi


37
was originally conducted using a matrix approach with a horizontal investigation of all
variables with respect to each exchange partner. That is, participants were first asked
questions about the physician followed by the pharmacist, manufacturer, and then the drug
product. However, the format was changed when researchers found that participants
tended to speak about their experiences and feelings based on the variable rather than the
exchange partner. Therefore, the last three focus groups followed a vertical investigation
of each variable across exchange partners. Written transcripts of each focus group were
content analyzed to identify the key themes associated with each variable. With regard to
the first variable, expectations and performance, the analysis showed that patients judged
their providers in terms of performance without an explicit use of expectations. The
authors suggested that this was a result of the patients' high involvement state. However,
patients did rely on expectations in the judgement of the drug product's side effects.
Therefore the authors concluded that patients have two sets of standards, one for persons
(e g., pharmacists) and the other for tangibles (e g., drug product).
In order to gain a better understanding of customer expectations toward
pharmacist provided drug information (PPDI), Wiederholt and Rosowski (1996) examined
pharmacy customers in three community pharmacies. The study was based on the
following questions: (1) do customers have expectations of PPDI as a service? (2) what
antecedents are associated with the formation of those expectations? and (3) are patient's
age, gender, and/or delivery site related to the expectations of service? The authors based
their work on the model created by ZBP (1991). However, because the authors chose the
customer satisfaction/dissatisfaction paradigm as an underlying theme, they chose


79
prescription volume of store as well as the assignment of personnel to the various
dispensing tasks. For example, in one high volume store the pharmacists had little time
available for interactions with customers. Most of the pharmacists' time was spent filling
prescriptions and answering phone calls. Cashiers and technicians were assigned the tasks
involving direct customer contact, not the pharmacist. However, in another high volume
store the dispensing tasks were set up so that the pharmacist did have time to intercede.
Social Structural Variables
The medication use system is replete with social structural variables that influence
pharmacist interceding. Those variables seem to fall into two categories, government
regulations and insurance regulations.
Government Regulations. Government regulations, both state and federal, provide
the pharmacist with a practice template. That is, those agencies decide and subsequently
describe how a pharmacist is to practice pharmacy. One regulation that may affect
pharmacist interceding is the requirement that all pharmacy customers be offered
counselling (i.e., the chance to talk to a pharmacist). In some pharmacies the cashier or
technician makes a verbal offer to the customer. Imagine the observed difference between
an offer of, "you don't have any questions for the pharmacist do you," and "what questions
do you have for the pharmacist today?" The first question places an obstacle in the way of
interceding, the second opens a direct path for the pharmacist to intercede.
Insurance Regulations. Insurance rules and regulations also affect the process of
pharmacist interceding. In today's medication use system, most customers' prescription


84
remaining section of this chapter includes six case descriptions. The cases were chosen
because they illustrate a range of customer needs, pharmacist action, and type of
relationship formed. Cases one, two, and three describe instances in which a professional
relationship is formed. Cases four, five, and six illustrate the process as it ends in a
personal relationship.
Case One
At the time of the interview Bonnie* was a sixty-three year old semi-retired
certified nursing assistant (CNA). She visited her pharmacy, a chain store, every week on
average, due in part to her job as a CNA. While she does have two chronic illnesses, she
characterized her health status as good. Bonnie bears the entire obligation of paying for
her medication. Her story provides us with an example of the progression from customer
needs through pharmacist interceding to building a professional relationship.
Throughout her interview, Bonnie expressed needs for information. For example
she suggested that the pharmacist should make you aware "you can have reactions by
taking this medicine." Also, she indicated that the pharmacist was the one to ask about
medications that she wanted to try. She found "that the pharmacist has a lot of update on
the medicines that doctors don't have," and with this statement revealed one of the
conditions for interceding, that is pharmacist expertise.
Bonnie's expression of her need for information, a question for her pharmacist, is
an example of customer need identification. Bonnie cued her pharmacist that she needed
* all names are pseudonyms


40
domain (Olson and Dover, 1979; Oliver, 1980; Woodruff, Cadotte, and Jenkins, 1983).
PZB (1985, 1988) and PBZ (1990) were the first marketing researchers to begin a
thorough examination of the expectations construct in terms of the service quality domain.
While they have continued to work in this area, they have not continued to develop the
expectations construct. That is, they have made propositions about the construct (ZBP,
1991; PZB, 1994b) but have not continued to examine the construct.
Pharmacy literature also shows an interest in the expectations construct.
Expectations of pharmacist roles were examined by Knapp, Knapp and Edwards (1969) as
well as Norwood, Seibert, and Gagnon (1976). DeSimone, Peterson, and Carlstedt
(1977) studied patient initiated contact with their pharmacists. Patient initiated contact
was considered an expectation that the pharmacist could respond to the contact. The
relationship of expectations with customer satisfaction/dissatisfaction is also a focus of
study (Ludy, Gagnon, and Caiola, 1977; Sirdeshmukh, et al., 1991; Wiederholt and
Rosowski, 1996). However, none of these studies defined expectations in terms of a
service quality framework. In fact, few of the pharmacy studies provide any conceptual
definition of, or theoretical framework for, the construct and often show conflicting
results. Therefore, this study is proposed to fill that gap. That is, the purpose of this
study is to develop a substantive theory of customer expectations of community pharmacy
services.
Using the grounded theory approach pharmacy customers were interviewed and
observed in an effort to understand their expectations for community pharmacy service.
That approach is described in the following chapter.


87
no relationship. In fact, Joan called the pharmacy supervisor for this pharmacy to relay
her displeasure. She indicated that she will not return to that pharmacy. However, Joan
does tell of a pharmacist that will help her solve this same problem.
And when you bring in a prescription for pain medicine or something he knows
where you need it right away. He'll bump your prescription up, so that's nice.
Joan knows the name of her former pharmacist and "he remembers my name" even though
she moved and he has not been her pharmacist for six years.
Time is a very important issue in Joan's life. In fact, one of the reasons that she
patronizes her current pharmacy is the efficiency with which they dispense her
prescriptions. They have recognized that wasting time is a big problem for Joan and they
have acted to solve the problem.
They are fast and let me tell you, what has kept me there. Something in addition
to that. That this year we have more than one type of HMO [health maintenance
organization] that I like. It's a point of service HMO and we have two this year to
choose from. The other one would cost me less money out of my paycheck each
year and I choose to pay more money to stay at [name of pharmacy]. That's how
valuable my time is.
Joan has formed a professional relationship with the pharmacist who values her
time, provides her specific drug information, and respects her privacy.
Case Three
George was a forty-three year old project director at the time of his interview.
Like Bonnie, George patronizes a chain pharmacy, but very infrequently. He says his
health status as "somewhere between fair and good." His insurer covers the complete cost
of his medication. George's story illustrates the formation of a professional relationship.


61
If they had said we don't have it and we don't carry that, but we would certainly be
happy to order it for you. Or to talk with our drug rep or whatever and get that
for you.
Vacation Supplies. Several problems stem from customers and their vacations.
For example, one customer indicated that he had a difficult time in obtaining needed
medication prior to leaving on vacation. His frustration was increased because he knew
that the pharmacist could provide the needed help.
I'm going away for three weeks, oh I'm sorry I can't fill it, you're not due for
another two and a half weeks. A pharmacist who cares about the person he's
dealing with or she's dealing with will find a way to do that. I've had it done for
me. I know it can be done. Not all of them will do it.
In another instance an interviewee spoke of a visiting friend and their frustration that the
local pharmacist, an employee of the same pharmacy organization that she patronized at
home, made no effort to contact her physician in order to verify and fill a Coumadin
prescription. In a similar incident a customer recounted the story of being on vacation
with her father. While on vacation in another state the father discovered that he had
forgotten his blood pressure medication. They contacted his home pharmacy and
requested that they send the medication to their location. "So he called down to the . .
and said I need you and they wouldn't send it." Not one to give up when she needed help,
the daughter contacted her pharmacist, and explained the problem. She had a medication
related problem and looked to her pharmacist as the problem solver.
Physician Back-up. Customers often look to their pharmacist to solve or prevent
problems caused by physician error. For example, one customer told of a time when she
received the wrong strength blood pressure medication. It seems that the physician had


30
assess respondent ease and confidence in their answering the questions. Also, questions
were included that measured perceptions of overall service quality and value, relative
importance of the SERVQUAL dimensions, behavioral intentions, and demographics.
The surveys were mailed to customers of a computer manufacturer, a retail chain,
an auto insurer, and a life insurer. The sample for each company was randomly divided to
receive one of the three versions of the instrument. The overall response rate was 25%.
All three versions of the instrument exhibited high reliability, and showed evidence of
good predictive, convergent, and discriminant validity. The third version of the scale (i.e.,
one-column format) showed the most predictive power. This was followed by the two
then three column version of the instrument. Predictive validity was measured by the
percentage of variation accounted for in the single item overall measure of service quality.
Thus far this review has provide a description of the expectations construct as
explained in the marketing literature. The next section will review the construct as
presented in the pharmacy literature.
Expectations and Pharmacy
The study of expectations is not new to pharmacy research. However the study of
expectations has not traditionally been framed as in the marketing literature. That is, the
pharmacy research seems to be atheoretical in nature. Outlined below is an historical
overview of the construct as it relates to the practice of pharmacy.
Knapp, Knapp, and Edwards (1969) undertook a study to examine the
occupational role perceptions of the pharmacist. The authors suggested that if the


11
Service Quality
Research in the area of service quality began in earnest in the mid 1980s when
Parasuraman, Zeithaml, and Berry (PZB) presented their conceptualization of the service
quality construct. Since that time the service quality literature has grown, with the
predominant focus on the foundation work of Parasuraman, Zeithaml, and Berry. In the
sections that follow, readers will find an overview of the work completed by service
quality researchers. This overview is presented so that the reader may gain an
understanding of the background work that supported the need for this study.
Parasuraman. Zeithaml. and Berry
The theoretical framework from which this study evolved was developed in 1985
by PZB, and is part of a stream of research that this group of authors has continued to
follow to date. PZB found that "quality is an elusive and indistinct construct" (p. 41)
which is not easily described by customers. Therefore, PZB planned a research agenda to
fill in the holes of service quality research. Their initial work included a review of the
studies investigating service quality, a report of the results of an exploratory investigation
of service quality in four businesses, development of a model of service quality, and
suggestions for future research.
PZB (1985) found that service quality had been the topic of few other research
agendas. However, they did note that there seemed to be three underlying themes in the
service quality literature: (1) customers may have a more difficult time evaluating service


19
Bolton and Drew
Bolton and Drew (1991) conducted a study in which they investigated how
customers' evaluations of service quality were affected by changes in service offerings.
They performed a field experiment in which customers were repeatedly surveyed while a
significant service change was implemented. The study focused on temporal changes in
individual attitudes (i.e., evaluations of service quality). The authors outlined a general
model of attitude as follows. Attitude about a service depends on one's prior attitude.
This is modified by perceptions of current performance, prior expectations of
performance, and the difference between expectations and perceptions.
Results of the study, which involved telephone company customers, indicated that
perceived improvement in telephone service had a positive effect on customer attitude.
Also, customer perceptions of current performance seemed to have the biggest impact on
satisfaction and attitude. As hypothesized, current attitudes were influenced by prior
attitudes. Finally, the authors noted that individual ratings of the components of service
quality were sensitive to the effects of a service change, but average ratings of service
quality were stable and change slowly.
Cronin and Taylor
In their article, Cronin and Taylor (1992) suggested that the conceptualization and
operationalization of service quality by the SERVQUAL instrument was not adequate.
They contended that the marketing literature instead supports a simple performance based
measure of service quality, customer expectations should not be included. Therefore, they


15
questions were open-ended, and covered a wide range of service quality issues. The
second stage of the research was a comprehensive case study of a bank. Employees at
every level were interviewed. The third stage of the research process was a systematic
group interview with eleven senior managers of six national service organizations. The
insights gained from the three stages of the exploratory study were combined to suggest
the main theoretical constructs and variables associated with each of the four gaps in the
SQM.
The marketing information gap was associated with marketing research
orientation, upward communication, and levels of management. The standards gap was
associated with management commitment to service quality, goal setting, task
standardization, and perception of feasibility. The service performance gap was associated
with teamwork, employee job fit, technology job fit, perceived control, supervisory
control systems, role conflict, and role ambiguity. Finally, the communications gap was
associated with horizontal communication, and propensity to overpromise.
The authors suggested that the model be tested with a technique such as LISREL.
Perceived service quality as measured by SERVQUAL (Gap 5) would be the unobservable
dependent variable, and the remaining four gaps would be the unobservable independent
variables. Other suggestions for future research included: (1) determining which of the
gap(s) is/are critical in explaining the variation in service quality; and (2) determining the
organizational factors that are responsible for the size of the four gaps.
SERVQUAL, a multiple item scale, was developed by PZB (1988) in order to
assess customer perceptions of service quality. The authors based the initial development


58
welcome. Finally, one customer suggested that pharmacies provide "an area of education
while you're waiting." In other words, the pharmacy should provide a specific area in the
store stocked with reading material about medications.
Need for Reassurance
To reassure may be defined as dispelling a fear or concern (The New Shorter
Oxford English Dictionary, 1993). One of the problems that pharmacy customers face is
the need to dispel any fears or concerns about their participation in the medication use
system. Customers' needs for reassurance stem from three areas. They include emotional,
dependability, and professional issues.
Emotional Issues. Emotional issues may envelop a pharmacy customer as they
enter the store.
There is another thing too that I think that pharmacists and physicians should
understand, is the emotional thing that you are going through from your illness.
These issues range from wanting to talk to a need to feel safe. Customers understand that
the pharmacist's job impacts their health, and because that is an important issue they need
a pharmacist to care about them.
Well it's concerning my health and my well being and the fact that someone is
dispensing medication that could affect that health and well being, knows me and
cares about what he is doing.
Pharmacy customers need their pharmacist to understand their family problems, listen to
their gripes, and teach them how to give their baby medication the very first time. When
they are feeling bad they want a "little sympathy." They need their pharmacist to be aware


BIOGRAPHICAL SKETCH
Born in Camp Lejeune, North Carolina, Barbara Brice lived in the South and on
the island of Okinawa before her parents settled in Florida in 1972. She received a
Bachelor of Arts degree in marketing from the University of South Florida in 1981, and a
Master of Health Administration degree from the University of North Florida in 1993.
Since 1984 Barbara has co-owned and managed the Medicine Shoppe Pharmacy in
Jacksonville, Florida, with her husband Lee, a Gator Pharmacist. Together they are
raising two children, Kate and Rob. Barbara will earn her Doctor of Philosophy degree
from the University of Florida in May 2000, and plans to pursue a career in research and
teaching.
110


80
insurance claims are adjudicated online. That is, the insurance claim is electronically
transmitted to the insurance company as the prescription is being filled. The pharmacy
knows immediately whether the prescription is covered or not by the customer's insurance,
and in some instances the pharmacist is provided with additional information. This online
adjudication provides an opportunity for the pharmacist to intercede in several ways. For
example, when one drug is not covered the pharmacist knows immediately and he may
suggest another medication. In another instance the customer may be patronizing several
pharmacies, online adjudication may reject a prescription because of an interaction with a
drug dispensed at another pharmacy. The pharmacist may then act to suggest a different,
more compatible medication. Insurance regulations may also act to hamper a pharmacist's
ability to intercede. For example, insurance companies dictate the quantity of medication
that a pharmacist may dispense. They may also provide a formulary of covered
medications.
Personal Characteristics
A final factor that may affect the process of interceding is personality type of both
the pharmacist and customer. Time and time again customers stated that they want their
pharmacist to be friendly, to be polite, and to take a personal interest.
But he is a very personable person and he seems to take an interest in all people.
He calls most people by name, that I like.
A seemingly open and friendly pharmacist may open the way for a customer to express a
need. However, the personality of the customer may be just as important to the process.


23
Expectations
The expectations construct has a wide and varied past. It has been studied by
many disciplines, including economics, behavioral decision theory, and marketing (Oliver
and Winer, 1987). Because the theoretical framework that provoked the need for this
study evolved within the marketing discipline, the initial focus of this review will be on
expectations as studied within the marketing literature. This will be followed by a review
of expectations as studied in the pharmacy literature.
Expectations and Marketing
In marketing, the expectations construct is described primarily in the
satisfaction/dissatisfaction and service quality literature. This section will provide a
general review of the construct as presented in those areas.
One of the earliest definitions of expectation may be found in the work of
Georgescu-Roegen (1958), who defined expectations as "the state of mind of a given
individual with respect to an assertion, a coming event, or any other matter on which
absolute knowledge does not necessarily exist" (p. 12). He suggested that expectation and
motive are two distinct constructs.
An exploration of the expectations construct continued with the work of Olson
and Dover (1979). These authors criticized past work in disconfirmation of customer
expectations. They suggested that the expectations construct had not been clearly tested
or conceptualized. Therefore they presented a definition of expectations as pretrial beliefs


5 PHARMACIST INTERCEDING 69
Assessing 69
Acting 70
Conditions Influencing Pharmacist Interceding 75
Summary 81
6 THE CONSEQUENCES OF PHARMACIST INTERCEDING 82
Professional Relationships 82
Personal Relationships 83
Cases 83
7 SUMMARY AND RECOMMENDATIONS 94
Summary 94
Model of Pharmacist Interceding 95
Relationship of the Model of Pharmacist
Interceding to Other Research 97
Limitations 98
Recommendations for Pharmacy Practice 99
Recommendations for Future Research 99
REFERENCES 101
APPENDICES
A INITIAL INTERVIEW GUIDE 106
B REVISED INTERVIEW GUIDE 107
C DEMOGRAPHIC AND PHARMACY EXPERIENCE QUESTIONS 109
BIOGRAPHICAL SKETCH 110
vii


73
I told him what was going on and he knows I have to take blood pressure
medication, so he watched that and you know, he went out on the floor there and
he looked at different possibilities.
Finally, one pharmacist reworked a durable medical equipment item so that it would fit his
customer's thumb.
If I've got a particular problem ... not to long ago I had tendinitis in my thumb,
and I was just at a loss. I kept trying to find ... a splint for my thumb . and the
pharmacist said, I think I've got something that will work. And he fooled around
with it until he got it to work.
Educating
Pharmacists act to educate their customers in several ways. An assessed need for
information may be met by providing the customer with a drug information sheet.
I have noticed that every time that I have gotten a new medication I also at the
same time get a computer printout with it that has all kinds of interactions,
notifications, and warnings of any kind, side effects and things of that nature. And
yeah, sure that's a great thing to have in there.
In some instances the pharmacist educates through conversation. One customer said "he's
gone into his big book and read things to me." In other instances, the pharmacist educates
by demonstrating. For example, pharmacists are frequently called upon to teach people
how to properly administer medication. One pharmacist was observed showing a
customer the correct technique for using an injectable medication. In another instance the
pharmacist taught a Mom how to give an infant medication.


70
During conversations with customers, pharmacists said that they listen to the
questions posed by their customers. They assess the customer's level of comprehension
through responses to their questions, the language used, their past history with the
customer, and the apparent educational level of the customer. Pharmacists echo back the
customer's responses in an effort to make sure that they really understand the customer.
While echoing back the customer's statements, the pharmacist gets clues from body
language and facial expressions. These clues allow the pharmacist to judge the customer's
receptivity and understanding of what they are discussing.
Once the pharmacist is sure of the issue at hand, an internal assessment begins.
That is, the pharmacist asks, do I have enough information, do I have enough knowledge,
should I look something up, or should I make a referral? The pharmacist is concerned that
the right response is provided. When the pharmacist fully understands the issue at hand
and feels capable of handling the issue, interceding moves to the acting phase.
Acting
Acting on an identified customer need is the core of pharmacist interceding.
Without action there is no process, no interceding. Because of the wide range of needs
expressed by customers, pharmacists act in a variety of ways. Their actions may be
categorized as follows: (1) problem solving, (2) educating, and (3) reassuring.


21
model was tested first in a laboratory study which involved multiple encounters within a
hotel setting. The analyses of the first study suggest that (1) "will" and "should"
expectations are different constructs; (2) "will" expectations positively affect and "should"
expectations negatively affect customers' perceptions of service quality; and (3) there is a
measurable effect of "will" and "should" expectations on behavioral intentions when the
service is fixed. The second study involved a field study conducted in an educational
institution. Results of the second study indicated once again a link between perceived
quality and behavioral intentions.
Spreng and Mackov
Spreng and Mackoy (1996) discussed the conceptual arguments separating service
quality and customer satisfaction. Included in those arguments is the effect of customer
expectations on measurements of service quality and customer satisfaction. This was
accomplished by testing a model of service quality and satisfaction first developed by
Oliver (1993). In this model Oliver suggested that service quality is a function of the
comparison between ideals and perceptions of performance regarding quality dimensions.
However, satisfaction is a function of the disconfirmation of predictive expectations
surrounding both quality and non-quality dimensions. Also, perceived quality is an
antecedent of satisfaction. Spreng and Mackoy contend that there are several limitations
to the model. These include: (1) satisfaction is not related to disconfirmation of ideals,
and (2) expectations do not influence perceptions of performance.


32
of the lower SES group had higher standards for pharmacists than did pharmacists
themselves. When perceptions of the ideal were compared to perceptions of the actual
pharmacist, pharmacists were found to not be doing those activities considered most
acceptable. Results from pharmacist participants showed that they rated the public as
being less particular than they actually were. The semantic differential scale showed that
physicians were rated most favorably. This was followed by professional, pharmacist and
then technician.
In a 1973 study conducted by the Dichter Institute for the American
Pharmaceutical Association (APhA), participants indicated that pharmacists were first a
business person with primarily commercial motivations. Also, in their study the Dichter
Institute found that the public was not aware of the services that pharmacists could
provide.
In their study, Norwood, Seibert, and Gagnon (1976) examined the attitudes of
rural customers and physicians toward expanded occupational roles for pharmacists. They
suggested that because drugstores were more evenly distributed (i.e., accessible) than
physicians, dentists, or hospitals, the pharmacist may be an ideal candidate for an
expanded role. In order to assess the acceptance of a broader role for pharmacists,
physicians in a nine county area of northeast Iowa as well as customers of a participating
pharmacist were asked to complete a questionnaire. The questionnaire contained "should"
statements describing roles that pharmacists might take. The physician group provided a
33% response rate while the customer group provided a 28% response rate.


CHAPTER 7
SUMMARY AND RECOMMENDATIONS
Summary
The purpose of this research was to generate a substantive theory that explains
customer expectations of community pharmacy services. Using the grounded theory
approach, pharmacy customers were interviewed and observed in order to identify and
understand the basic social problem they face as well as the basic social process used in
addressing the problem.
Pharmacy customers participate in a medication use system that is complex and
confusing. The complexity of the system creates a set of needs for pharmacy customers.
Findings from this project show that the basic social problem of needs is addressed by the
basic social process of pharmacist interceding. In response to customers' needs the
pharmacist engages in a process of interceding that results in a relationship between the
customer and pharmacist. Pharmacist interceding, which is explained by the Model of
Pharmacist Interceding (Figure 1) includes the phases of assessing and acting. The
formation of a relationship between the pharmacist and customer is the outcome of the
process of interceding.
94


53
criteria be used to judge the rigor of naturalistic (i.e., qualitative) inquiry. Their criteria
includes assessments of credibility, transferability, dependability, and confirmability.
Credibility, the qualitative researcher's equivalent to internal validity, is
demonstrated when the researcher has shown that the findings and interpretation of those
findings has "truth value" (Lincoln and Guba, 1985, p. 296) to those being studied. In this
study, credibility was enhanced by the use of theoretical sampling, and concurrent data
collection and analysis. Also, discussing the findings with colleagues and study
participants provided a check on the truthfulness of the results.
Lincoln and Guba (1985) suggest that the qualitative researcher cannot comment
on the external validity of a study. Instead, the naturalist provides a thick description that
will enable other interested researchers to make judgements about the transferability of the
findings from one context to another. In this study, descriptions were written to provide
the widest possible range of information. For example, the case studies presented in
Chapter Six describe both the process of interceding as it occurs for the customer and the
customer's relevant demographic and pharmacy experience information. This information
will enable other researchers to judge how similar the current research context is to their
proposed research context.
Dependability and confirmability address the issues of reliability and objectivity. A
determination of dependability and confirmability may be made through an audit process in
which another investigator examines both the process and product of the inquiry (Lincoln
and Guba, 1985). In this study, every effort was made to provide clear, understandable,
and confirmable explanations of each step in the research process.


102
Dichter Institute for Motivational Research, Inc. (1973) Communicating the Value
of Comprehensive Pharmaceutical Services to the Consumer. Washington, DC: American
Pharmaceutical Association.
Georgescu-Roegen, N. (1958). The Nature of Expectation and Uncertainty. In
M.J. Bowman (Ed ), Expectations. Uncertainty, and Business Behavior (pp. 11-29). New
York: Social Science Research Council.
Glaser, B.G. (1978). Theoretical Sensitivity. Mill Valley, CA: The Sociology
Press.
Glaser, B.G., & Strauss, A.L. (1967). The Discovery of Grounded Theory:
Strategies for Qualitative Research. New York: Aldine De Gruyter.
Hepler, C D, & Strand, L.M. (1989). Opportunities and Responsibilities in
Pharmaceutical Care. American Journal of Pharmacy Education. 53. 7S-15S.
Holdford, D., & Schulz, R. (1999). Effect of Technical and Functional Quality on
Patient Perceptions of Pharmaceutical Service Quality. Pharmaceutical Research. 16.
1344-1351.
Hutchinson, S.A. (1988). Education and Grounded Theory. In R.R. Sherman &
R.B. Webb (Eds ), Qualitative Research in Education: Focus and Methods (pp. 123-140).
New York: The Falmer Press.
Hutchinson, S.A. (1993). Grounded Theory: The Method. In P.L. Munhall & C O.
Boyd (Eds.), Nursing Research: A Qualitative Perspective (pp. 180-212). New York:
National League for Nursing Press.
Iacobucci, D., Ostrom, A.L., Braig, B.M., & Bezjian-Avery, A. (1996). A
Canonical Model of Consumer Evaluations and Theoretical Bases of Expectations.
Advances in Services Marketing and Management. 5. 1-44.
Kaplan, S.H., & Ware, J.E. (1995). The Patient's Role in Health Care and Quality
Assessment. In N. Golfield & D.B. Nash (Eds ), Providing Quality Care (pp. 25-52). Ann
Arbor, MI: Health Administration Press.
Knapp, D.E., Knapp, D.A., & Edwards, J.D. (1969). The Pharmacist as Perceived
by Physicians, Patrons, and Other Pharmacists. Journal of the American Pharmaceutical
Association NS9. 80-84.


13
of gaps between perceptions (both management and customer) of service quality and
actual delivery of the service. The gaps may be characterized as follows:
GAP 1:
The marketing information gap is the difference between customer
GAP 2:
expectations of service and management's understanding of those
expectations.
This gap, the standards gap, is the difference between
management's understanding of customer expectations of service
and the service standards which they specify. That is, this gap is a
function of management's knowledge and use of customer
expectations of service.
GAP 3:
The third gap is the difference between service performance
specifications and the actual performance of service. This is
referred to as the service performance gap.
GAP 4: The communication gap is the difference between communications
GAP 5:
to customers about the service and the actual performance of the
service.
The final gap is a function of the previous four gaps. This gap is
the difference between customer expectations of service and their
perceptions of actual service. The authors define perceived service
quality with this gap.


39
Ranelli and Coward (1997) examined the relationship between place of residence
of elderly patients and their expectations about communication with pharmacists.
Interviews were completed with 200 respondents from each of two (urban and rural)
residence groups. Interviews were completed using a forty-six item scale. The scale was
comprised of mostly closed end and forced choice items.
The authors hypothesized that three clusters of independent variables (personal
characteristics, self-reported health measure, and experience with prescription drugs)
would affect the expectations of the respondents. The dependent variable was older adult
expectations about communication with a pharmacist.
Results showed that the rural sample, in general, held higher expectations for
pharmacists. Of the nine items in the expectation scale, there were significant differences
on six of the items. Also, the rural elders had higher means on all nine items. However,
there was no significant difference between rural and urban adults in the relative rankings
of the nine items. The multivariate analysis of the independent variables showed that place
of residence was a significant predictor of expectations in three of the four models
specified. Only in the fourth fully specified model did place of residence become
insignificant.
Summary of Literature Review
Marketing literature is replete with research involving the expectations construct.
However, most of the early research involved the customer satisfaction/dissatisfaction


16
steps on their earlier work in service quality (PBZ, 1985). They began with a definition of
service quality as the discrepancy between customers' expectations of a firm's service and
customers' perceptions about the actual service. In their 1985 article PBZ identified ten
dimensions of service quality. Those ten dimensions served as a starting point for item
generation. A ninety-seven item instrument was developed and subjected to two stages of
data collection. As a result of the two stages of data collection a twenty-two item, five
dimension scale emerged. The dimensions included: tangibles, reliability, responsiveness,
assurance and empathy. Tangibles are defined as the "physical facilities, equipment and
appearance of personnel" (p. 22). Reliability is defined as the ability to execute the
promised service accurately and dependably. Responsiveness is the "willingness to help
customers and provide prompt service" (p. 22). Assurance requires knowledgeable and
courteous employees with an ability to inspire trust and confidence. Finally, empathy is
the "caring, individualized attention the firm provides its customers" (PBZ, 1988, p. 22).
Total reliability for the scale approached .90 in the cases of the four tapped service firms.
Convergent validity was assessed by comparing an overall measure of quality with
SERVQUAL scores using a one-way ANOVA. The scale was found to have convergent
validity.
An empirical examination of the Extended Service Quality Model (ESQM) may be
found in PBZ (1990). PBZ developed a list of propositions to be tested empirically. The
first four propositions hypothesized the relationship between the size of the gaps and their
related theoretical constructs (e g., the size of the marketing information gap is negatively
related to marketing research orientation). The fifth proposition hypothesized a


14
Examination of the five gaps shows that customer expectations are an integral
component of Gaps one, two, and five. It could also be argued, that while not explicitly
stated, customer expectations are a component of Gaps three and four. That is, according
to the model, service performance specifications from Gap three are built on customer
expectations. Also, the communications made to customers, found in Gap four, may
affect those customers' expectations.
The customer focus group interviews also provided a set of ten categories by
which service quality was evaluated. These categories were reliability, responsiveness,
competence, access, courtesy, communication, credibility, security, tangibles, and
understanding/knowing (PZB, 1985). The authors suggested, in this work, that
development of a measure of service quality that encompassed these ten categories or
dimensions was appropriate. Also, they concluded, work was needed in developing
measurements of the gaps and the importance of each gap in determining quality.
Research regarding the impact of past experience, word of mouth communication, and
personal needs on expected service was necessary. Finally, the authors suggested that it
might be useful to segment customers on the basis of their service quality expectations
(PZB, 1985).
Zeithaml, Berry, and Parasuraman (1988) continued the development of the
Service Quality Model by identifying a set of factors which might affect the magnitude and
direction of the first four gaps in the model. Once again the authors conducted an
exploratory study. This time the first stage of the study consisted of in-depth interviews
with three to four executives in each of four nationally recognized service firms. Interview


68
to be an expert in the insurance payment system in order for that customer to receive his
medication. In another instance a customer reported that her pharmacist would not leave
her without medication for a day. This required the pharmacist to understand the working
relationship between himself and the physician, and the rules under which he practiced.
Summary
Participation in a complicated medication use system creates needs for community
pharmacy customers, and they expect those needs to be addressed by another participant
in the system, their pharmacist. Included are the customers' need for information, for
reassurance, and for problem solving. Pharmacists address those needs through a process
of interceding, but two conditions, identification of the need and pharmacist expertise,
must be present prior to the act of interceding. The process of pharmacist interceding is
discussed in the following chapter.


17
relationship between customer expectations and perceptions and the size of the first four
gaps. The final proposition hypothesized that the SERVQUAL instrument is a valid
measure of customers' overall evaluations of service quality. Some of the propositions
were supported while others were not.
The results regarding the fifth proposition were mixed. The first four gaps were
found to be weakly associated with Gap 5 (service quality gap), and account for a
negligible amount of the variation in Gap 5. None of the regression coefficients were
statistically significant. These findings leave one to question whether service quality is not
measured by a difference between expectations and perceptions of performance, or
whether the constructs have not been adequately operationalized9
The results of the study done by PBZ (1990) led the authors to suggest the
following future research scenarios: (1) refine the scale for the contributing factors, (2)
conduct in-depth research on each gap, (3) investigate different levels of analysis, (4) look
at differences among companies, (5) identify other variables, and (6) develop alternative
measures of the difference score constructs.
PZB have themselves gone on to further research in the area of service quality.
They have continued work in the development of the SERVQUAL instrument (PZB,
1991, 1994a, 1994b) and have studied the role and use of expectations and their link to
behavioral intentions (Zeithaml, Berry, and Parasuraman, 1991,1996). That literature is
presented in a later section of this chapter.


71
Problem Solving
The need for problem solving generated the most diversity in pharmacist action.
Examples found in the data include completing Medicare paperwork, providing a delivery
service, and opening charge accounts for customers in need. While pharmacy customers
report a wide variety of problems, two categories of problems seem to emerge. They are
(1) problems stemming from the bureaucracy of the medication use system, and (2)
problems stemming directly from the use of the products found in a pharmacy .
The Bureaucracy. The medication use system is no different than any other large
system. It has layers of bureaucracy that create problems for those involved in the system.
Pharmacists are constantly called upon to work through the layers and solve their
customer's problems. For example, pharmacists often work to solve insurance problems.
These problems may include making sure the customer has a vacation supply of
medication, getting the customer a needed brand name medication, and assisting the
customer with a new plan. One customer needed a new blood glucose machine for her
child. The pharmacist provided and participated in the step by step procedures required
by the insurance company.
Well we don't carry those any more, but if you will go over to the pediatrician and
get another prescription for it we'll give you a new kit and it was free . She gave
me a solution.
Pharmacists often act to make sure that their customers do not go without
medication. This may occur because a physician has not answered a request for a refill or
because a customer simply forgot to call the refill order in on time. For one customer
solving the problem meant having access to experimental seizure medications for her


24
about a product. This allowed disconfirmation research to focus on: (1) the processes by
which belief expectations were created; (2) the effects that product trial experience have
on belief structures; and (3) the effects of pre and post trial beliefs on attitudes, intentions,
and behavior. Their study was designed to demonstrate the usefulness of conceptualizing
expectations as beliefs, and provide a stimulus for future research.
In their study Olson and Dover (1979) first exposed the subjects in the
experimental group to three ad-like communications from a coffee manufacturer. The
subjects were then asked to complete and return a written survey. In the fourth and final
exposure all subjects (control and experimental) participated in a taste test. The authors
were successful in creating a pretrial belief, in the experimental group, that the coffee was
not bitter. Results of the taste test showed that the experimental group was significantly
different than the control group in assessing the bitterness of the coffee. The control
group found the coffee to be more bitter than the experimental group both before and after
the experimental manipulation.
In his 1980 article, Oliver presented the case for the inclusion of the expectations
construct in the study of customer satisfaction. He argued that data from studies of that
time showed significant expectations effects when expectations were manipulated or
measured prior to product exposure. He also provided a study of the relationships among
expectations, disconfirmation, satisfaction, attitude, and purchase intention. In the study
expectations were measured as "the perceived belief probabilities attributed to eight
consequences of receiving the flu shot" (Oliver, 1980, p. 462). Results seemed to support
that post-usage ratings of satisfaction were a function of expectations and disconfirmation.


56
Customer Needs: The Basic Social Problem
Thousands of customers enter community pharmacies every day. Some are
picking up routine refill prescriptions, some are picking up a one time medication for an
acute illness, and some are picking up new prescriptions for a chronic illness. For some
customers the ideal pharmacy provides accurate and efficient service. For others, the
addition of a personal touch is important. Regardless of these circumstances, all
community pharmacy customers participate in the same complex medication use system,
and at some point this participation creates a need(s) for the customer. Data from this
study suggest that customer needs may be classified into three areas: the need for
information, the need for a problem solver, and the need for reassurance. Because these
needs may occur during any visit to a pharmacy, and because they will affect the
customer-pharmacist interaction, it is important that they be examined. The remainder of
this section is devoted to an analysis of the basic social problem of customer needs.
Need for Information
Customers enter the pharmacy with a variety of needs for information, ranging
from a simple drug information printout to a detailed explanation of the best method for
taking a medication.
Information Printouts. Many of the interviewees indicated that the drug
information print-out that most pharmacies provide is useful.


29
include two components: (1) the perceived service superiority gap; and (2) the perceived
service adequacy gap. The perceived service superiority gap is the difference between
desired and perceived levels of service. The perceived service adequacy gap is the
difference between adequate and perceived service.
PZB continued their research in the area of service quality with their 1994
Marketing Science Institute report. In this report the authors examined three issues: (1)
incorporation of adequate and desired expectations of service into the SERVQUAL
instrument; (2) assessment of alternative service quality measurement approaches; and (3)
examination of the relationship between customers' behavioral intentions toward service
providers and service quality. Of these three issues, the first two are relevant to this
literature review. The final issue is beyond the scope of the planned research study.
In order to test the incorporation of adequate and desired levels of service into the
SERVQUAL instrument, PZB developed and tested three versions of a questionnaire. In
the first, a three column format, separate ratings of desired, adequate, and predicted
service were obtained from three identical side by side scales. In the second, a two
column format, direct ratings of the service adequacy and service superiority gap were
obtained from two identical side by side scales. The third version was a one column
format. With the one column format direct measures of the service adequacy and service
superiority gap were also obtained. However in this version the measures followed one
another, similar to the original SERVQUAL instrument. The twenty-two attributes found
in PZB's 1991 version of the SERVQUAL instrument could be found in all three versions.
In addition to the section described above, each questionnaire contained two questions to


105
Swartz, T.A., & Brown, S. W. (1989). Consumer and Provider Expectations and
Experiences in Evaluating Professional Service Quality. Journal of the Academy of
Marketing Science. 17. 189-195.
Wiederholt, J.B., & Rosowski, P. (1996, February). Antecedents of Expectations
for Pharmacist Information Services. Paper presented at the American Marketing
Association Winter Educators Conference, Hilton Head, S.C.
Woodruff, R.B., Cadotte, E.R., & Jenkins, R.L. (1983). Modeling Consumer
Satisfaction Processes Using Experience-Based Norms. Journal of Marketing Research.
20, 296-304.
Zeithaml, V.A., Berry, L.L., & Parasuraman, A. (1988). Communication and
Control Processes in the Delivery of Service Quality. Journal of Marketing. 52. 35-48.
Zeithaml, V.A., Berry, L.L., & Parasuraman, A. (1991). The Nature and
Determinants of Customer Expectations of Service (Report No. 91-113). Cambridge, MA:
Marketing Science Institute.
Zeithaml, V.A., Berry, L.L., & Parasuraman, A. (1996). The Behavioral
Consequences of Service Quality. Journal of Marketing. 60. 31-46.


CHAPTER 3
METHODS
The purpose of this research was to build a substantive theory of customer
expectations of community pharmacy services. In order to accomplish this goal, the
grounded theory method was used. That method and the specifics relating to this research
are described below.
Research Design
The grounded theory method was developed by sociologists Barney Glaser and
Anselm Strauss in 1967, as a way of systematically generating theory from data.
Grounded theory enables the researcher to understand just how individuals interact with,
and subsequently view, their world. This method is useful in studies where little is known
about a particular subject or where much is known but clarification is needed (Hutchinson,
1993).
In grounded theory, data are collected (e g., through interviews), coded (i.e., taken
apart), and analyzed (i.e., put back together) in a continuous process. As data are
compared, concepts emerge and categories are formed. Continued study reveals
relationships among the categories along with higher conceptual levels of categories.
41


91
I went to a particular pharmacy, presented my prescription and my medical card,
my medical insurance card and I was promptly told we don't take this medical
insurance. Do you know where I can go to get this filled? I was under the
impression that you did take it, well we don't. End of subject, end of conversation
and their back was turned to take care of someone else.
Betty needed someone to help her solve her problem, but instead she found a pharmacist
who missed a cue. Betty ultimately solved her own problem by going to another
pharmacy, but the first pharmacy missed an opportunity to build a relationship with Betty,
and has now lost her as a customer. As Betty said "now I would not go in there, I just
wouldn't, I just would not do it."
Betty relates another instance in which a pharmacist had the chance to solve a
problem by using his expertise and interceding.
I called, I had a hard time breathing, I had post nasal drip there in the back. And I
get really stuffed. Well I don't need to go to the doctor to find out about that, but
I can call my pharmacist and say look I feel this. My head is hurting, I know you
can't prescribe ... but I would say, what is there over the counter that you can tell
me that I can take and he'll ask me well what are the symptoms, I tell him, he tells
me what I can buy over the counter. . That saves me a trip, an unnecessary trip
to the doctor. ... it makes me feel like I have somebody I can go to, over the
phone, that is going to help me.
Clearly in this instance the pharmacist acted on the cue given by Betty, and in this case a
relationship has been developed. Betty patronizes the pharmacy where this pharmacist
works. Like others who formed a personal relationship, Betty described the pharmacy as
having a "homey atmosphere" and being treated as if "we're old friends."


38
predictive expectations as defined in the model to be their dependent variable. The
independent variables included past experience with PPDI, implicit services associated
with PPDI, word of mouth communications associated with PPDI, and explicit service
promises associated with PPDI. Each of these are suggested antecedents found in ZBP
(1991).
A multi-attribute measure of expectations toward PPDI was developed by
examining existing literature, and the recommendations for patient counseling made by the
National Association of Boards of Pharmacy, the Wisconsin Board of Pharmacy, the
American Society of Health System Pharmacists, and OBRA 1990. This resulted in a list
of thirteen attributes that were measured with a five point scale labeled definitely do not
expect to definitely expect.
A factor analysis of the multi attribute expectation scale revealed that all items
loaded onto one factor which explained 56.4% of the variance. Cronbach's alpha for the
scale was 0.97. Also, the four antecedents of customer expectations became six factors,
intra personal sources, extra personal sources, past experience 1 (recency, frequency,
times), past experience 2 (duration, completeness), implicit service promises, and explicit
service promises. When examining the effects of the antecedent variables on customer
expectations, the authors found that explicit service promises and word of mouth
communication were the only two variables with a significant association. Association
between the other variables (age, gender, and site) and expectations varied from pharmacy
to pharmacy.


31
pharmacist was to take on a professional role in health care, current role expectations
would need to be modified. In their study the authors developed two scales to measure
the perceived occupational roles of pharmacists. Study participants included pharmacists,
physicians, and the general public.
The first scale contained statements describing possible characteristics of a
pharmacist. Study participants responded to this scale by first circling the one item which
they least wanted the ideal pharmacist to say or do. Next the participants were asked to
circle the item which corresponded to their ideal pharmacist. This continued until the
respondent circled no further items. Next, using the identical nineteen item scale,
participants were asked to circle the one statement most like the pharmacist of today and
the one statement least like the pharmacist of today. The procedure was modified for
pharmacist participants. This group was asked to predict how the other groups viewed
the pharmacist. The second scale was a semantic differential scale with nineteen pairs of
bipolar adjectives. All participants were asked to rate the occupational concepts of
physician, pharmacist, technician, and professional on each of the seven point bipolar
scales.
Results from the first scale showed that for all subjects there was agreement as to
the most preferred and least preferred pharmacist characteristics. Also, there were no
statistically significant differences among any of the groups for latitudes of acceptance and
non commitment in the description of the ideal pharmacist. However, physicians and the
general public of a lower socio-economic status (SES) were statistically different than the
remaining groups in their latitudes of rejection. That is, physicians and the general public


76
environment are the physical set-up of the pharmacy, the focus of the establishment that
includes the pharmacy, and the number and types of personnel working within the
pharmacy. Each is discussed below.
Physical Set-Up. While pharmacies have some common physical features, not all
are set-up in the same way. For example, the dispensing area of the pharmacy is most
often found behind a counter of some sort. However, in some pharmacies the dispensing
area is also on a raised platform, or behind glass windows, or beyond a window, or two
counters back. Because the pharmacist operates in the dispensing area, this physical
location becomes an important issue for interceding. Observations of pharmacists at work
confirmed this point. For example, in one pharmacy the pharmacist was generally found
working at a dispensing counter on floor level, with no other barriers. This pharmacist
was constantly involved in the interactions with customers. With this easy access
dispensing area, customers were able to easily cue the pharmacist when a need arose. In
addition, the closeness of the pharmacist to the customer enabled her to initiate interceding
as she judged necessary. Contrast this with the pharmacy in which the dispensing area is
located two counters back. That is, in one of the observed pharmacies, the pharmacist
primarily worked at a dispensing counter which was located behind the main pharmacy
counter. While this physical set-up may create an efficient dispensing process, it places
two physical barriers between the customer and pharmacist. Observations in this
pharmacy showed that it was difficult for customers to directly cue the pharmacist. In
fact, at one point, thirty-five minutes elapsed before an interaction between a pharmacist
and customer was observed after the pharmacist dispensed the customer's medication.


9
Also, colleges of pharmacy have begun to revise their curricula so that newly graduated
pharmacists are better prepared for the new practice style.
The Omnibus Budget Reconciliation Act of 1990 (OBRA) specified that
pharmacists meet certain requirements each time a prescription is dispensed to a Medicaid
patient. Those requirements involve: record keeping, prospective drug use review, and
patient counseling. In turn, states have revised their pharmacy practice acts to mandate
those services for all pharmacy patients. Complying with OBRA requirements caused
some pharmacists to review and adjust their practice flow. For example, in order to better
provide patient counseling, some pharmacists have rearranged their practice flow so that
they are now the first and last contact for patients. In some pharmacies a separate
counseling area has been constructed.
The introduction of managed care into the pharmacy marketplace has also
impacted the profession and its relationships with its customers. Participation in managed
care contracts changes from year to year, leaving the pharmacy customer no choice but to
change pharmacies. Formularies, put in place by managed care organizations to contain
costs, may have an adverse effect on the pharmacist customer relationship. Pharmacists
must act as a kind of enforcer of the formulary. Physicians may begin to feel that the
pharmacist only calls to question their choice of therapy, not to act as a therapy
consultant.
Finally, health care, including pharmacy, has begun to examine the quality of care
provided. Several groups have an interest in pharmacy quality of care, each with their
own agenda. Regulatory agencies are charged with public safety. These agencies work to


96
Each component of the Model of Pharmacist Interceding makes an important
contribution to understanding customer expectations, keeping in mind that customer
expectations are part of an interaction process. The basic social problem of customer
needs provides us with the starting point of understanding. Customers enter the pharmacy
with some need(s). These needs act as a precursor to the customer's expectation(s). In
other words, a customer with needs has the expectation that their pharmacist will act on
their behalf (i.e., intercede) in the medication use system. If we understand the needs, then
we are able to teach the pharmacist to recognize them.
The next component of the Model includes the basic social process, pharmacist
interceding. Understanding that pharmacist interceding has the phases of assessing and
acting provides another opportunity for intervention. That is, we can teach the pharmacist
how to recognize cues, assess them, and act on them in order to meet the customer's
expectation of intercession. In addition, pharmacist interceding takes place in a
medication use system that imposes certain conditions on the process. Understanding the
issues of pharmacy environment, time, social structural variables, and personality type
provides the pharmacist an opportunity to keep a watchful eye for any effect on
interceding.
The final component of the Model is the outcome or consequence of pharmacist
interceding, the formation of a relationship between the customer and pharmacist.
Knowing that a relationship is the outcome of interceding shows the pharmacist the
importance of interceding.


88
While George is an infrequent patron in his pharmacy, he did express a need for
information during his interview.
Tell me about the medication. What are the side effects, how do you take it, if
there, if you should take it with dinner, with water, what not to take it with, so
that, you know there's obvious stuff like don't take it with alcohol, but if there's
other things that you can take it with that could possibly make you sick of
something, or queasy or uncomfortable. . And if they are aware of other
medications that are out now that will address the same or similar issues.
George expects his pharmacist to be able intercede and provide this information. He tells
of a time when he had a need for information and the pharmacist did not help.
I started asking questions and they couldn't answer it, they didn't know and as a
consequence I thought they didn't know and that was the reason for their being
curt with me. I'm trying to find out what I need to know and they were well your
doctor gave it to you isn't that sufficient.
In this case, the pharmacist did not identify and act on George's need for information.
When asked how the pharmacist could have made things better, George replied as follows.
Answer my questions. And not tell me, if you don't know, it's perfectly okay to
say you don't know. . Just say well Mr. X I'm really not sure. It would probably
be best if you could talk with your doctor about this in more detail. And that's
fine. Then I can choose to come back or not come back to that pharmacy.
George currently patronizes a pharmacy where he likes "this place because the guy
explains everything." The pharmacist is "friendly and open." Also, he remembers a
pharmacy in another city "where the guy would explain what you had, but it wasn't like I
was talking to my best friend or anything, but he did his job." This last sentence seems to
summarize George's professional relationship with his pharmacist. That is, he has a need
for information, and the pharmacist acts to meet that need in the context of the
professional relationship between customer and pharmacist.


36
Mackowiak and Manasse (1984) completed a study comparing the expectations
for ambulatory services in both office based and traditional pharmacies. The study site
was a small Midwestern town in which both pharmacy types existed. The study used a
posttest only and measured differences in expectations and satisfaction between the two
practice types. The study questionnaire was designed to measure patient expectations of,
and satisfaction with, sixteen pharmacy services. To measure expectations the items were
labeled: "I expect the pharmacist", and the satisfaction items were labeled "Level of
satisfaction with the way your pharmacist provides this service is". Researchers attained a
62% response rate. The mean expectation score for all respondents and all services was
3.98, and the average satisfaction score was 3.74. Of the sixteen activities, office practice
customers reported significantly higher expectations scores for ten of the activities.
Satisfaction scores were also significantly higher in nine of the sixteen activities. In
addition to practice type differences, the authors found that frequency of pharmacist
contact was significantly related to higher expectation and satisfaction scores.
In their study, Sirdeshmukh, Pathak, Kucukarslan, Segal, Kier, and Aversa (1991)
presented the results of an exploratory analysis of patient satisfaction/dissatisfaction and
post exchange actions in the high blood pressure prescription market. The study examined
the relationship of patient satisfaction with providers of treatment (e g., pharmacists) and
the drug product to the following variables: expectations and performance, perceptions of
equity, overall perceived satisfaction, and responses to dissatisfaction.
Four focus groups with an average of ten customers each were conducted in
Florida and Ohio. Participants were elderly high blood pressure patients. The interview


99
Recommendations for Pharmacy Practice
When a customer enters a pharmacy, they are usually entering a world that they do
not understand. As health care professionals, pharmacists have a duty to recognize and
act on their customers needs. The Model of Pharmacist Interceding provides pharmacists
with new insight into the needs created by the medication use system for their customers.
The Model shows pharmacists that their customers expect them to intercede (i.e., act on
their behalf) in a system that is complex and confusing. Finally it demonstrates that the
consequence of pharmacist interceding, is the formation of a relationship between
pharmacist and customer. Pharmacists may find that the Model is useful in assessing their
practices.
Recommendations for Future Research
As health care professionals, pharmacists and those involved in pharmacy research
have a responsibility to their customers. This responsibility includes both making sure that
the customer has the right medicine at the right time, and interceding on behalf of that
customer in our complicated medication use system. The ability to intercede on the
customer's behalf will be enhanced by research aimed at further understanding the
problems and processes that pharmacy customers face.


98
study, question asking is a way that customers may identify a need. Need identification
(i.e., question asking) was found to be a component of the Model of Pharmacist
Interceding, not an explanation for the expectations construct.
Other pharmacy researchers have included the expectation construct in a studies of
customer satisfaction. The advantage of this study is the focus on customer expectations,
and the processes surrounding that construct. Results are not muddied by the intrusion of
other constructs.
Limitations
The purposive sample for this study included twenty-seven community pharmacy
customers. While data were collected until saturation, the proportion of independent
pharmacy customers to chain pharmacy customers was a limitation of this study. Because
the choice of type of pharmacy may indicate a difference in customer needs, a more
diverse sample could strengthen and improve the Model. In addition, more women than
men participated in the interviews. While women are the most frequent pharmacy
customers, additional interviews of male pharmacy customers would strengthen the
results. Finally, participants in the study came from all socio-economic backgrounds, but
the addition of participants at the lower end of the education spectrum would be
beneficial, as they may have additional and/or varied needs.


CHAPTER 2
LITERATURE REVIEW
Like all professions, the practice of pharmacy continually evolves. As the
profession changes so do the interactions between pharmacist and customer, and a change
in the way that pharmacists and customers interact may affect customer expectations.
Four events seem to be shaping the current practice of community pharmacy, and
therefore customer expectations. Those events are: (1) the arrival of pharmaceutical care,
(2) the Omnibus Budget Reconciliation Act of 1990, (3) managed care, and (4) the shift
toward an emphasis on quality of care. Each is discussed in turn.
In their 1989 article, Hepler and Strand suggest that pharmacy adopt
pharmaceutical care as the philosophy of practice. They define pharmaceutical care as
the responsible provision of drug therapy for the purpose of achieving definite outcomes
that improve a patients quality of life (p. 12). In order to accomplish this, the
pharmacist must perform certain activities for the patient. These activities include: curing
a disease, eliminating or reducing symptomatology, arresting or slowing the disease
process, and preventing the disease or symptomatology. Pharmacy and its professional
associations have embraced this concept as the philosophy of practice. In fact,
pharmaceutical care has become its own industry. Some companies (e g., Caremark) have
been formed for the purpose of teaching pharmacists to perform pharmaceutical care.
8


CHAPTER 4
FINDINGS: A MODEL OF PHARMACIST INTERCEDING
Customers of community pharmacy participate in a medication use system that is
often confusing and hard to negotiate. They walk into the door of their community
pharmacy with a piece of paper (i.e., prescription) in their hands, having been given a
range of details about the drug(s) they are about to take. The prescription is dispensed,
there is some interaction with the pharmacist or other pharmacy personnel, and the
customer is on his or her way home. But what about the customer's expectations for this
pharmacy visit?
This research shows that the complexity of the medication use system creates
needs (the basic social problem) for community pharmacy customers. For community
pharmacy customers, the needs created by the medication use system are addressed by the
pharmacist acting on their behalf within the system. The pharmacist's acting, called
interceding, is the basic social process which occurs in response to the customers' needs.
Pharmacist interceding, which has phases of assessing and acting, is explained by the
Model of Pharmacist Interceding.
55


93
Each of these instances of pharmacist interceding builds on another, creating a
long lasting personal relationship between Ann and her pharmacist.
Personal service is just what I said, the relationship I have with the pharmacist in
cooperating with me and not, and in knowing me . I've been trading there since
1977.
Pharmacy customers present their pharmacists with a variety of needs. Those
needs give the pharmacist the opportunity to intercede on their customer's behalf. The
cases outlined above show that the consequence of pharmacist interceding is the formation
of a relationship between the pharmacist and the customer.


64
Antecedent Conditions for Pharmacist Interceding
The preceding sections describe a variety of customer needs, needs that the
customer expects the pharmacist to act on. However, before the pharmacist may act or
intercede for the customer two conditions must be in place. First, the need must be
identified and second, the pharmacist must have the expertise to intercede. The sections
below describe those antecedent conditions.
Identifying A Need
In order for the pharmacist to intercede on the customer's behalf, a need must be
identified. Identifying the need occurs through the giving and receiving of a cue. A cue,
according to Oxford's English Dictionary (1993) is a word or phrase which serves as a
signal to another actor to enter the play. A cue, in the context of pharmacist interceding,
operates in the same way. That is, a signal is given by an actor (e g., a customer) to
another actor (e g., the pharmacist) to enter the play (e g., the medication use system).
Cues are the signal to start the process of pharmacist interceding and may come from any
of three actors: (1) the pharmacy customer, (2) other pharmacy personnel, or (3) the
pharmacist.
The Pharmacy Customer. Cues to begin the process most often come from
pharmacy customers themselves. All pharmacy personnel are possible targets for those
cues. Straightforward cues may come in the form of questions. For example, one
customer directly asked the pharmacist how to use his injectable medication. Another



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Copyright 2000
by
Barbara F. Brice


48
reviewed and suggested improvements in the questions. Finally, a practice interview was
completed with the aid of a University of Florida Anthropology graduate student. A
discussion of possible interview improvements followed the close of the practice
interview. Revisions were made, resulting in the final interview guide. The final form of
the interview guide includes introductory remarks, nine, multi-part, open-ended questions
and four biographical questions. Throughout the interviews, probes were used as
necessary to clarify points and/or to further tap any emerging ideas. The final form of the
initial interview guide may be found in Appendix A.
After seven interviews were conducted the interview guide was revised in an effort
to expand the range of responses from the interview participants. Transcripts from the
first seven interviews and continued exploration of the grounded theory methods literature
served as a guide to the expansion of the questions. A group of sixteen questions formed
the basis for the revised interview guide. After development, two faculty members from
the College of Pharmacy reviewed the questions as an additional check. No revisions
were made after faculty review. The final form of the revised interview guide may be
found in Appendix B.
In addition to the questions specifically relating to the area of interest, interviewees
were asked a series of questions (Appendix C) focusing on both demographic and
pharmacy experience variables. The responses to these questions were used to describe
and to assess the breadth of the sample.


quality and customer satisfaction. Because of its seemingly foundational role, a clear
theoretical understanding of the expectations construct may lead to more useful definitions
of service quality and customer satisfaction.
Research centering on customers' expectations may be found in many disciplines,
including marketing and pharmacy. However, like service quality, no consensus has been
reached on a theoretical definition of the expectations construct. Because the expectations
construct has been a frequent topic of research, and because clarification of the construct
is needed, the grounded theory method provides an effective way of examining customer
expectations. Grounded theory will provide a better understanding of how customers
think about their interactions with their pharmacist(s), and what those customers expect
from the interactions.
Theoretical Perspective
Symbolic interactionism, the sociological roots for the grounded theory method,
finds its foundation in the work of Herbert Blumer. Blumer (1969) originally coined the
label, symbolic interactionism, as a way to describe a particular approach to the study of
human conduct and group life.
Blumer (1969) suggests that symbolic interactionism rests on three premises. The
first is that humans act toward things or objects based on the meanings that the things
have for them. These objects include everything that people find within their world,
ranging from physical objects such as a football to guiding ideals such as honesty. The


APPENDIX C
DEMOGRAPHIC AND PHARMACY EXPERIENCE QUESTIONS
1. In what month and year were you born?
2. Occupation:
Retired from that occupation? Yes No
3. Highest grade of school or college that you have completed:
4. Pharmacy Experience:
Number of prescriptions per month:
How often do you visit a pharmacy?
Weekly Monthly Quarterly Yearly Other:
How many years have you been purchasing prescriptions on own?
Type of store patronized: Chain Independent Clinic Other
Do you have a chronic illness?
Type of chronic illness:
How long since diagnosis?
Onset of illness Sudden Gradual Other
5. How do you categorize your health status?
Poor Fair Good Excellent
6. How do you pay for your prescriptions? Self Share Others
109


100
Recommendations for research taken from this study include:
1. Research designed to further expand the Model of Pharmacist Interceding.
That is, specific research should be undertaken to expand and better
understand each component of the Model.
2. Research designed to develop processes that pharmacists may use to assess
the needs of their customers.
3. Research designed to develop interventions that will teach the pharmacist
to recognize and act on their customers' needs.
4. Research designed to develop an understanding of the relationships formed
by pharmacist interceding.
5. Research designed to develop qualitative evaluations of pharmacist
interceding.
6. Research designed to develop methods to educate customers in the specific
way(s) that their pharmacist(s) may intercede, so that the customer may (1)
clearly articulate their needs and (2) better understand their rights in the
medication uses system.
In closing, the Model of Pharmacist Interceding, as presented in this research,
illustrates a substantive theory of customer expectations of community pharmacy services.
The Model not only explains those customer expectations (i.e., that their pharmacist will
intercede) but also provides descriptions of the processes that lead to and from those
expectations. The usefulness of the Model may be found in this thick description and
analysis that creates a clearer theoretical understanding of customer expectations of
community pharmacy services.


104
Parasuraman, A., Berry, L.L., fe Zeithaml, V.A. (1990) An Empirical Examination
of Relationships in an Extended Service Quality Model (Report No. 90-122). Cambridge,
MA: Marketing Science Institute.
Parasuraman, A., Zeithaml, V.A., <& Berry, L.L. (1985). A Conceptual Model of
Service Quality and Its Implications for Future Research. Journal of Marketing. 49. 41-
50.
Parasuraman, A., Zeithaml, V.A., item Scale for Measuring Consumer Perceptions of Service Quality. Journal of Retailing.
64, 12-37.
Parasuraman, A., Zeithaml, V.A., Reassessment of the SERVQUAL Scale. Journal of Retailing. 67. 420-449.
Parasuraman, A., Zeithaml, V.A., Measuring Service Quality: A Comparative Assessment Based on Psychometric and
Diagnostic Criteria. Journal of Retailing. 70. 201-230.
Parasuraman, A., Zeithaml, V. A., <& Berry, L.L. (1994b). Moving Forward in
Service Quality Research: Measuring Different Customer-Expectations Levels. Comparing
Alternative Scales, and Examining the Performance-Behavioral Intentions Link (Report
No. 94-114). Cambridge, MA: Marketing Science Institute.
Patton, M.Q. (1980). Qualitative Evaluation Methods. Beverly Hills, CA: Sage.
Pisano, D.J., Tocco, M.J., fe Vogenberg, F.R. (1997). Performance Improvement:
The Changing Valuation of Pharmaceutical Care. U S. Pharmacist. 22. 103-114.
Ranelli, P.L., Patients: The Role of Place of Residence in Determining the Expectations of Older Adults.
Pharmacotherapy. 17. 148-162.
Sirdeshmukh, D., Pathak, D.S., Kucukarslan, S., Segal, R., Kier, K.L., fe Aversa,
S.L. (1991). Patient Satisfaction/Dissatisfaction and Post-Exchange Actions in the High-
Blood Pressure Prescription Market: A Preliminary Report. Journal of Consumer
Satisfaction. Dissatisfaction, and Complaining Behavior. 4. 84-92.
Spreng, R.A., fe Mackoy, R.D. (1996). An Empirical Examination of a Model of
Perceived Service Quality and Satisfaction. Journal of Retailing. 72. 201-214.


54
While the above criteria relate to qualitative inquiry as a whole, Glaser (1978)
provides some specific guidelines for the evaluation of grounded theory studies.
According to Glaser, "grounded theories have grab and they are interesting" (1978, p. 4).
The theory must fit the area under study. Data are neither forced to fit pre-conceived
categories, nor are they discarded just to keep a theory in place. The constant
comparative method requires that data be compared and contrasted constantly, allowing
an ongoing check on validity. A quality theory will explain the major behavioral and
interactional variations in the area under study. The grounded theory must be relevant to
the core variable that explains the social processes in the substantive area. That is, the
individuals who are the actors in a particular setting should recognize the theory as being
an accurate picture of the action. A good grounded theory is dense. There are a few
theoretical constructs that are supported by a network of properties and categories, that
are integrated to form a tight theoretical framework (Hutchinson, 1993). Finally, a
grounded theory must be modifiable. While the basic social process remains stable, its
variation and relevance may change quickly in the social world. Through coding and the
constant comparative method, the grounded theory can be refined to account for new data
found in further research (Glaser, 1978).


Figure 1.
Model of Pharmacist Interceding.


62
mistakenly changed the strength, but she expected her pharmacist to catch and fix that
problem. While her pharmacist did not catch the problem, the customer still believed that
the pharmacist was in the position to do so. In another instance a customer, with many
medication allergies, relied upon her pharmacist to keep records that would prevent her
from receiving a medication she was allergic to.
Financial Issues. Many times throughout the interviews customers told of times
when, for one reason or another, they felt they had wasted money when completely filling
a prescription. One customer's mother seemed to have many allergic responses to
medication.
The pharmacist, suggested that he would give me a few pills when I got a
prescription for her, give me only a few of the pills and see if she could tolerate
them . Boy was that a lifesaver. Because I threw out so much medicine.
In another case, the pharmacist discovered that the customer seemed to be allergic to the
fillers found in many medications. The pharmacist suggested that this customer get a trial
of two doses each time she had a new prescription, saving her money.
Insurance Problems. Customers look to their pharmacist to solve all manner of
insurance problems. One customer looks to the pharmacist to complete Medicare
paperwork, "which is a boon to older patients." Another looks to her pharmacist to
handle her Medicaid paperwork.
See I'm on Medicaid and I don't take care of my paperwork. They absolutely do
everything for me. ... if I didn't have [name of Pharmacist] I would just be
floundering.
For another customer the issue was whether his insurance company would pay for the
brand name medication that he needed. This customer has a seizure disorder that is


3
role in their health care, and that they want to receive more information from their
providers. Finally, Kaplan and Ware suggest that if patients are not satisfied with their
care, they may turn to alternative therapies and/or therapists.
As the health care system and its focus on quality evolves, it is apparent that the
customers' role in assessing their quality of care has become increasingly important. For
example, the American Medical Association Council on Medical Service includes the
patient's informed cooperation and participation in decision making as an element of
quality medical care (Council on Medical Service, 1986). Also, Christensen and Penna
(1995) suggest that health care quality includes patients' expectations. In addition,
Holdford (1999) examined the relative importance of functional and technical quality on
patient perceptions of pharmaceutical service quality. Finally, Nau (2000) investigated
patients' perceptions of the benefits of participating in pharmaceutical care services.
Problem Statement
While health care in general and pharmacy in particular are making strides toward
including the customer's perspective when assessing quality, the task is not complete.
Current research efforts aimed at defining service quality and/or customer satisfaction
have provided a complicated mix of results. However, one thread seems to weave
through the research and may be a foundation on which to build measures of service
quality and customer satisfaction. That thread is customer expectations. In other words,
the customer expectations construct is repeatedly found in studies concerning service


74
Reassuring
Pharmacists reassure their customers in a variety of ways. One customer, who
indicated that she always checks her health care providers credentials, was reassured
because "his credentials are on the wall." In another case a customer was reassured by the
reaction of the pharmacist to a mistake made in his pharmacy.
It's a terrible thing that happened ... I mean I can't dismiss the severity, but they
were responsive right away . come in and get what you do need, you know, it's
not oh, we're sorry. You know they helped me all the way through it.
The customer felt that because of the pharmacist's reaction to the mistake, pharmacy
personnel would be more careful in the future. Pharmacists reassure their customers when
they make themselves available for questions. They reassure their customers when they
come from behind the counter and sit down to explain and show a mother how to
administer drugs to a fussy infant.
I was just so upset and frazzled over the whole thing. He made me comfortable
about giving him that medicine and stuff... By talking to me and he came out and
actually went into his [the baby's] pumpkin seat and said let me show you how you
could give it to him and he did an eyedropper with a little bit of water and he said
if you put it into the side, he said almost like a kitten and blow on his nose a little
bit, he'll swallow.
Customers are reassured when their pharmacist pre-wams them about changes in their
medication. For example, one customer spoke of a change in the manufacturer of her
child's medication. She was glad that her pharmacist informed her of the change before
she left the store, alleviating the anxiety that she might have felt later without the warning.
Customers are reassured when their pharmacist acts to show concern. For one customer
this meant that the pharmacist called to make sure that she was taking her medicine


20
developed and tested the SERVPERF instrument. In addition, the authors examined the
relationships between service quality, satisfaction, and purchase intentions.
Results of their research suggested that quality should be conceptualized and
measured as an attitude. In addition they contended that the SERVPERF scale explains
more of the variation in service quality than does SERVQUAL. They believed that this is
true because SERVQUAL is based on a satisfaction rather than attitude paradigm and the
SERVQUAL model is not confirmed for all industry types.
The seemingly contrariness (to PBZ) of this study points to need for additional
study of the service quality and customer satisfaction constructs. In addition, even though
the authors do not support the use of expectations in a measure of service quality, they do
support expectations as an element of customer satisfaction.
Boulding
Boulding, Kalra, Staelin, and Zeithaml, (1993) developed a dynamic process of
service quality. They propose a model of service quality that follows customers' formation
and updating of perceptions of service quality. Also, the model delineates the effect of
those perceptions on individual behavioral intention variables. The authors made two
assumptions in the model: (1) a customer's current perceptions of service quality after
receiving the service are a blend of their prior expectations of what "will", and what
"should", happen and the actual delivered service; and (2) customers update their
expectations whenever they receive information about the service firm. This implies that
change and/or personally relevant experience may impact customer expectations. The


12
rather than goods quality; (2) customer's perceptions about the quality of a service come
from a comparison of their expectations with actual service performance; and (3) both the
performance and outcome of the service encounter are part of the customer's quality
evaluation. These underlying themes and the lack of a conceptual foundation for service
quality led PZB to an exploratory qualitative study.
So that they might lay the groundwork for a conceptual framework of service
quality, PZB (1985) conducted an exploratory study of service quality. This study
consisted of in-depth interviews with executives and focus group interviews with
customers. Although the authors proposed a common set of service dimensions for all
service providers, the service categories investigated in this research included retail
banking, credit card, securities brokerage, and product repair and maintenance.
Participating executives were selected from the customer relations, marketing, operations,
and senior management departments of each firm. Three to four executives with titles
such as president, director, and senior manger participated from each firm. A total of
fourteen executives were interviewed about a broad range of service quality issues.
Customers were interviewed in a series of twelve focus groups. Focus group
participants were screened to ensure that they were users of the service in question. The
groups were designed to maintain homogeneity and assure maximum participation.
Questions for the focus groups covered such topics as descriptions of an ideal service,
factors important in evaluating a quality service, and the role of price in service quality.
The results of both the executive and the customer focus group interviews led PZB
to the development of the Service Quality Model (SQM). The model is formed by a series


63
regulated on a brand name medication. Generic drugs have not worked for him. So when
his insurance denied payment for the brand name he looked to his pharmacist to solve the
problem.
I must have the brand name and that's the only one that works. . one of the
biggest things that a pharmacist can do for you is to perhaps, throw himself in the
center and take care of details that you may or may not have the wherewithal or
the knowledge to take care of properly.
Customers also approach their pharmacist to solve problems regarding hard to get
medications, and product malfunctions. One mother turned to her pharmacist when her
infant son had a difficult time keeping his medicine down. Finally, customers often come
into the pharmacy when they are truly hurting. These customers look to the pharmacist to
fill their prescriptions on a priority basis, allowing them to return home to heal that much
faster.
Customers are faced with many unknowns each time they enter the pharmacy.
Participation in a medication use system full of unknowns creates needs for those
customers. Included are needs for information, needs for a problem solver, and needs for
reassurance. Those needs are addressed by a process of pharmacist interceding.
However, before the pharmacist can intercede or address the customer's problem(s), two
conditions must exist. First the problem(s) must be recognized, and second the pharmacist
must have the expertise to address the problem. Those conditions are discussed below.


This dissertation was submitted to the Graduate Faculty of the College of
Pharmacy and to the Graduate School and was accepted a$ partial fulfillment of the
requirements for the degree of Doctor of Philosophy
May 2000
ege of Pharmacy
Dean, Graduate School


25
Woodruff, Cadotte, and Jenkins (1983) provided readers with an alternative model
to the confirmation/disconfirmation model of satisfaction. In their conceptual model
expectations are replaced with experience-based norms. These experience based norms
are the standard of comparison for a brand's performance. They base this "replacement"
on the argument that to date expectation based disconfirmation measures had modest
correlations with measurements of satisfaction. Also, they suggested that if one applied
social equity theory, the basis for comparisons of a brand's performance became the
degree of equity between the customer and their peers. Finally, they suggested that brand
comparison levels be based on the perceived capabilities of several brands in a brand
category. Therefore, satisfaction may be based on both standards and expectations.
In 1991, Zeithaml, Berry, and Parasuraman (ZBP) examined the nature and
determinants of customer expectations of service. The authors found that there is
agreement, in the literature, that expectations serve as standards for future experiences.
However, questions remain on other issues. For example, what is the specific nature of
the expectation standard? Also, how many standards are used? Finally, what are the
sources or antecedents of theses standards?
In order to answer the above questions, ZBP conducted focus group interviews
with customers. This exploratory research laid the groundwork for a conceptual model of
customer expectations of service. Sixteen focus group interviews were held. These group
interviews were divided into different segments as follows: (1) business customer and pure
service; (2) business customer and product related service; (3) end customer and pure
service; and (4) end customer and product related service. Four focus group interviews


59
of their emotional state.
I think a pharmacist [who] works with that pharmacy ought to be aware that there
are times when you go into a pharmacy and you're distraught. I think they ought
to show concern.
Finally, pharmacy customers expect to find "someone you could trust" behind the
pharmacy counter.
Dependability In addition to the emotional issues encompassing the pharmacy
interaction, customers need to be reassured that they can depend on their care giver. The
consistency of the pharmacist plays an important role in a customer's assessment of
dependability.
Not too many rotating pharmacists. I don't like that, that's why I go where I go
because I like to know who I'm talking to.
There was always a different pharmacist so there was no consistent person that
knew me, and that knew the drugs that my daughter was on . and I did not like
that.
Customers want a pharmacist "that they can count on." They want to "know it's going to
be the same people every time." Also, simple things like posting an emergency telephone
number builds the customer's confidence in the dependability of the pharmacist.
I like to know that if I got in trouble I could call he has an emergency number to
call his home.
Professional Issues. Finally, customers need to be reassured that their pharmacist
is a medication professional. They "want to know how up to date he is." They need for
their pharmacist to be able to help them work through the costs versus benefits of taking a
medication.


22
To test the model Spreng and Mackoy examined student assessment of an
undergraduate advising office. Participants filled out a questionnaire prior to meeting with
an advisor. This questionnaire asked about student's desires and expectations regarding
ten attributes of advising. Students also completed a post-advising appointment
instrument. Again all ten attributes were measured. The authors completed confirmatory
factor analysis and structural equations modeling on the data collected by the surveys.
Results indicated that service quality and satisfaction are two distinct constructs.
Summary of the Service Quality Literature
It is clear from this review that a real interest in service quality research exists. It
is also clear that one thread appears in most of these models. That thread is customer
expectations (PBZ, 1990; PZB, 1985, 1988; Swartz and Brown, 1989; Bolton and Drew,
1991; Boulding et al., 1993; Spreng and Mackoy, 1996) In fact, in a review of the
literature pertaining to service quality, Iacobucci, Ostrom, Braig, and Bezjian-Avery
(1996) found that most models of service quality contain an expectations component.
Therefore, it appears that there is support for further study of the expectations construct.
The next section of this chapter provides a review of the literature as it directly relates to
the expectations construct.


85
some interceding, but in this case the process ended.
I've went to the drugstore before and asked a pharmacist, well what do you think
about a certain drug. And the pharmacist would say well it's up to the individual.
Well I didn't want that answer. I wanted an answer like well have you ever taken
this or that and how did it react? Well this is the one I think, why don't you try this
one? I think he should be more knowledgeable and more information, give you
more information.
This pharmacist did not attend to Bonnie's cue, resulting in no interceding. Bonnie tells of
another time when she visited her pharmacy.
I got a prescription one day and I didn't understand it and he didn't have time to
tell me about it. So I thought oh well, he'll give me a slip and I'll know a little bit
more about it, but he didn't. So I started going to a drugstore that was farther
away, but they talked to me when I went in.
This time Bonnie had a need for information that was not met. The pharmacist did not
intercede so Bonnie went looking for a pharmacist who would meet her needs. Bonnie
goes on to say that "the next time I had to have a prescription filled I tried them (again). I
liked the way they explained things to me." This new pharmacist was able to identify,
assess, and act (i .e., intercede) on Bonnie's needs. As a result of the interceding, a
professional relationship has formed between Bonnie and her pharmacist.
I would want to go where I liked the pharmacist. Because the pharmacist I was
going to just got a new job so I may switch.
Bonnie is willing to change pharmacies so that she has the opportunity to work with the
same pharmacist.


66
not notice these cues (i.e., attend to them) then the pharmacist cannot intercede. For
example, one customer mentioned a fear of taking pain medications during her
conversation with the pharmacist. The pharmacist, however, missed the cue and missed
an opportunity to address this customer's need for reassurance. In another instance, a
customer explained that she was having breathing difficulties (the cue). The pharmacist
heard the cue and went on to explain why her medications may be causing the difficulties.
Pharmacist Expertise
Examination of the interview transcripts shows that pharmacist expertise is a
condition that must be present in order for the process of interceding to be successful.
Pharmacist expertise is defined as the set of special skills and knowledge that pharmacists
have obtained because of their training and educational backgrounds.
Medication Experts. Pharmacist expertise includes the ability to understand drug-
drug and drug-disease contraindications for both prescription and over-the-counter
medications. One customer explained, "He said something about me picking up [over-the-
counter remedy] one day and he goes, now did you read that pamphlet, that [over-the-
counter remedy] sometimes has a reaction to [prescription medication]." Another
customer explained.
I'm sure he has to be heads up to any interaction type things that may be going on
so that somebody hasn't actually written something that doesn't go with another
thing. That you would run up a flag on the thing and say look this needs to be
looked into before dispensing.


26
were held with customers from each group. Two interviews were with experienced
customers and two with inexperienced customers. The interviews were held in five cities,
Atlanta, Chicago, Seattle, Rochester, and Dallas. Interviews were conducted by field
research companies in those cities. The interviews were unstructured in manner and
included broad open ended questions.
The analyses of the focus groups results involved a three step process. First, the
researchers conducting the groups met at the end of each interview to informally discuss
their impressions of the interview and to identify any emerging themes. Second, themes
identified by the first focus groups were also informally identified in later interviews.
Finally, a formal content and interpretive analysis of written transcripts was conducted
after all focus groups were completed. With these results the authors constructed a
generic model of customer expectations of service, which serves as an addition to the
Extended Service Quality Model. ZBP's generic model of customer expectations may be
divided into four sections, the expected service component, antecedents of desired service,
antecedents of both predicted and desired service, and antecedents of adequate service.
Each of these is described below.
The expected service component is comprised of three parts, expectations for
desired levels of service, expectations for adequate levels of service, and a zone of
tolerance between the two. Expectations for desired levels of service may be defined as
the level of service that the customer hopes to receive. This is a blend of what the
customer believes can and should be. Expectations for an adequate level of desired
service may defined as the level of service the customer will accept. ZBP (1991)


44
Sample Recruitment
The first seven participants in this study were recruited by contacting individuals
suggested by friends and asking for their participation. Only current or past customers of
community pharmacies were asked to participate. All seven persons contacted agreed to
participate.
Recruiting later in the research process began in two independently owned
community pharmacies in Jacksonville, Florida. I visited the two pharmacies on separate
occasions and spoke with various customers about the research project while they were
waiting for their prescriptions. The pharmacists and staff at both stores had been briefed
about the project and at times they introduced a possible volunteer to this researcher.
However, none of the pharmacy customers that were approached volunteered. Therefore,
I devised another recruiting technique.
The revised technique involved two changes. The first was to add a fifteen dollar
gift certificate to a local restaurant as a token of regard and appreciation for the
participant's time. In addition, a small bag clipper was developed. This bag clipper listed
the researcher's name and phone number, a brief description of the participant's
involvement, three ways to volunteer for the interviews, and a mention of the gift
certificate. Staff at both pharmacies were asked to attach one pink bag clipper to each
pharmacy bag. The bag clippers were put into use for a two week period, resulting in a
total of twenty-three volunteers. Fifteen of those volunteers completed interviews, and
the remaining eight are available for future interviews.


86
Case Two
At the time of her interview, Joan was a thirty-nine year old human resources
generalist. She visited her independent pharmacy four to six times each month. Joan
characterized her health status as good even though she has a chronic illness. She shares
prescription payment obligations with her insurer. Her story provides us with an example
of pharmacist interceding that leads to a professional relationship.
Joan classifies herself as a "very informed medical patient. Because I have a lot of
things wrong with me." This classification drives her need for information. Because they
know her, Joan's pharmacist will provide her with specific information tailored to her
medication profile.
They will mention, don't forget, you need to take this with food, because of your
bad stomach. Okay, or you've never had this before, this may make you drowsy.
Joan also relies on the information sheets provided with each prescription. She reads
those sheets from beginning to end every time she has a prescription dispensed, and she
calls her pharmacist if she has any questions.
Oh, I would never call the doctor. . Because, you know what, the pharmacy
knows more about drugs, I think, than the doctor does. Especially the interactions
to be perfectly honest with you.
Joan also indicated that from time to time she has the need for a problem solver.
She tells of one instance when she had injured her back. Two prescriptions were phoned
to a pharmacy and even though she was in pain she was told that the wait for the
prescriptions would be an hour and a half. Joan had a problem, pain. In this case, the
pharmacist did not identify or cue into the pain. Therefore there was no interceding and


60
But when I talked to my doctor and talked to my pharmacist I realized that the
benefits would outweigh, you know, what I was feeling at the time.
Also, they need for their pharmacist to know their medication history and to act on it.
I feel confidant that, that number one my pharmacist will question if he thinks that
there is something that I might not be able to take . because he knows my
history.
In addition, customers want the pharmacist to respect their privacy and to provide follow
up care when needed.
Need for a Problem Solver
As stated previously, pharmacy customers face a complicated medication use
system, and as with any complicated system problems develop. A variety of customer's
problems were suggested, ranging from a perceived simple special order to complicated
insurance issues.
Special Orders. In one instance, an interviewee recounted the story of needing
calibration solutions for her child's blood glucose machine. The customer visited one
pharmacy prepared with the serial number of the machine and the number for the
company, hoping that if the items were not in stock that they could be ordered. However,
the customer indicated that the individual that she spoke with "didn't have a clue," and he
"never really offered to order them." Fortunately the customer did not give up and she
found a pharmacy that did not have the calibration solutions, but worked through the
system and replaced the whole machine. Now the customer did not expect that the whole
machine would be replaced, but she did need the first pharmacy to attempt to help.


65
asked the pharmacist about the best way to apply an eye ointment. Cues from customers
may come from a statement made during a conversation with their pharmacist, and may be
harder to detect. One customer indicated, during the regular course of conversation, that
she was hoping not to take any pain medication. Still another described the allergy
symptoms that she was having.
Pharmacy Personnel. Other pharmacy personnel (e g., technicians, cashiers) also
participate in identifying needs. In a busy pharmacy they are often the first and last
pharmacy contact for the customer. Customers may present questions to technicians or
cashiers in hopes that they will be passed along to the pharmacist. While all the actors in
the system receive cues, judging the seriousness of cues they receive may be more difficult
for technicians and cashiers. For example, in one case a customer entered the pharmacy to
pick up some medication. Fortunately, the technician noticed that the customer looked
very ill (a cue), called for the pharmacist's assistance, and the customer was immediately
sent to the hospital. However, if the relatively untrained technician had missed the cue, a
bad result might have occurred.
The Pharmacist. Cues may also originate within the pharmacist. Pharmacists may
hear conversations between their technicians and customers that generate concern. They
may notice a drug-drug interaction because they have access to customers' medication
profiles. Finally, simply knowing the purposes and side effects of the medications
themselves may generate a cue to act.
Miscues. Cues without notice lead nowhere. That is, customers may ask
questions, or come into the pharmacy looking extremely ill, but if pharmacy personnel do


72
daughter. The pharmacist was able to help. "I can remember being on experimental drugs
and [the pharmacist] was able to get them." In another case a customer's car was stolen.
The pharmacist was able to replace the medication stolen along with the car.
One customer recounts a story of being in great discomfort from a medical
procedure. At home, she noticed that she had mistakenly asked the pharmacist to fill the
wrong prescription. She returned to the pharmacy, explained her problem to the
pharmacist, and he promptly filled the needed prescription.
I guess that he saw that I was in so much pain and remembered that I was there
. . what he did was, on his own, went on and filled mine, okay while there were
other people there so I could leave.
In each of these cases the pharmacist understood and worked through the rules of the
particular bureaucracy to solve the customer's problem.
Product Use. A variety of products may be found in any community pharmacy,
and the use of those products creates a variety of problems. Several customers reported
having numerous allergies to medications. These allergies created possible health and
financial problems for the customer. The pharmacist was able to alleviate these problems
by: (1) dispensing only a few pills at the first dispensing of a new prescription, and (2)
keeping and using computer records which allowed him to keep a watch for any possible
problems. Pharmacists may also act to solve problems of medication compliance. For
example, a shorter duration antibiotic was suggested to a Mom whose child fought taking
medicine. Some customers may have a problem choosing an appropriate over the counter
therapy. The pharmacist is able to assist the customer in a choice of over the counter
medication.


I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Earlene Lipowsktf Chair
Associate Professor of Pharmacy
Health Care Administration
1 certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Carole Kimberlin
Professor of Pharmacy Health Care
Administration
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Richard Segal /
Professor of Pharmacy Health Care
Administration
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
$
Professor of Nursing
Sally Hutchinson


10
set a minimum level of performance for practitioners. Pharmacists must meet their
requirements. Also, many organizations are developing report cards of pharmacist
performance. These report cards measure performance on items such as generic
substitution, significant drug interventions, and avoidance of therapeutic duplication
(Pisano, Tocco, and Vogenberg, 1997).
Examination of these four events shows a common thread running throughout.
That is, each affects the pharmacist-customer relationship in some way. Pharmaceutical
care works to increase the interaction between pharmacist and customer. Regulatory
agencies specifically direct some of the interaction between pharmacist and customer.
Managed care has perhaps interfered with the relationship by changing the pharmacist into
an insurance benefits policeman. Finally, the advent of the service quality paradigm
emphasizes the importance of the inclusion of the customer in care decisions. This
examination leaves us with the question, what does the customer think? If these factors
have affected the pharmacist-customer relationship, what is it that pharmacy customers
expect, and why are those expectations important?
The remainder of this chapter will explore those questions by presenting the
theoretical literature which explores some of those factors. Specifically, the service
quality and expectations literature will be presented as background supporting the need for
a study of customer expectations of community pharmacy services.


51
Substantive coding continued with the next set of twenty interviews. However, at
this point the coding focused on the use of the forty-four higher level codes developed
from the first seven interviews. In addition to the use of the higher level codes, coding
began to focus on the questions that Glaser (1978) suggests one ask: "What is this data a
study of, what category does this incident indicate, and what is actually happening in the
data" (p.57). It was at this point in the process that the basic social process emerged.
Once the basic social process emerged theoretical coding began. Data were
examined to determine the conditions, causes, and consequences of the basic social
process. This level of coding allowed the theory to become fully formed and integrated.
Memoing and Sorting
"Memos are the theorizing write-up of ideas about codes and their relationships as
they strike the analyst while coding" (Glaser, 1978, p.83). Writing memos is at the core of
doing grounded theory. Memoing allows the researcher to "to theoretically develop ideas
with complete freedom into a memo fund that is highly sortable" (Glaser, 1978, p. 83).
Through memoing the analyst is able to raise data to a conceptual level, develop the
properties of each category, develop hypotheses about relationships between categories
and their properties, begin the integration of ideas, and place the emerging theory among
other theories of more or less relevance (Glaser, 1978). In this study, memoing began
with notes describing the settings of the initial interviews, and the demeanor of the
participants during the interviews. Also, memos were written as ideas emerged about new
codes, the basic social process, and connections between categories.


42
Hypotheses about the data are generated and a core variable of a theory emerges (Glaser
and Strauss, 1967). A grounded theory is complete when the properties, conditions,
strategies, and consequences of that variable are explicated and integrated.
As was indicated in the previous chapter of this work, the expectations construct
has been studied from many viewpoints, however, researchers have not yet reached a
common understanding of the construct. Therefore, grounded theory provides a method
for examining the expectations construct directly from the data. The result of this study, a
substantive theory of customer expectations of community pharmacy services, provides a
clear common starting point for future expectations research.
Sample
Choosing a sample for qualitative interviews does not always follow the same rules
(eg., random sampling) as choosing a sample of participants to complete a quantitative
survey. In qualitative research sampling is often purposeful. That is, the sample of events,
settings, or persons is chosen to provide information that is not readily available from
other choices (Maxwell, 1996). Using a random sampling technique to draw a small
sample may introduce chance variation.
Purposeful sampling has four possible goals. The first is to achieve
representativeness in the chosen sample. That is, the sample will be systematically chosen
for typicality and relative homogeneity. This may provide confidence that any conclusions
actually represent the members of the population from which the sample was drawn. A


57
Each medication came with a sheet that explained in greater detail and that was
great.
In fact one customer indicated that the printouts are even more important for maintenance
medications.
I like to get the detailed printout sheets, especially on maintenance, because ... I
still like getting them because there might be things that you've forgotten about.
Some customers are interested in even more detailed information about their medication
(e.g., maximum dosage, name of manufacturer, how many different types of dosage).
I want to know a lot, I want to know a lot. Because this is my body and if I'm not
informed, then I inadvertently could do something that I wouldn't want to do.
However one pharmacy customer did indicate that "you can go overboard and waste a lot
of paper on things". In other words, this customer saw no need for the printout every
time a prescription is refilled.
Side Effects. Pharmacy customers seem to be particularly interested in receiving
information about a medication's side effects. Learning about possible side effects
prepares the customers for what lies ahead.
It would help a lot. Not to have it come down on you suddenly, and you not know
what drug's doing what.
Parents, in particular, need advance warning about a possible side effect from their
children's medication. "Is there anything I should notice about their behavior?"
Additional Information. Pharmacy customers expressed a need for their
pharmacist to inform them about any changes in the color, shape, or size of their
medication. In addition, they want the pharmacist to inform them about any new
information regarding their medication. Tips on administering medication are also


92
Case Six
At the time of the interview, Ann was a sixty year old paralegal. Ann visits her
independent pharmacy about three times a month. She does have a chronic illness but
characterizes her health as good. Ann shares payment responsibilities with her health
insurance company.
Like Betty, Ann expressed needs in all three categories. She expressed a need for
information about new products, and a need for her pharmacist to recommend an over the
counter product. Ann needs to be listened to when she was feeling bad, and to feel safe in
her pharmacist's choices. She also needs her pharmacists to help her solve problems. For
example, Ann was having difficulty taking medications. It seems that she was allergic to
them. It was her pharmacist, however, that "determined that I was allergic to fillers, not
so much the medication but the fillers." Finally discovering the source of the allergy was
important, but the allergy problem was still present. So, Ann's pharmacist interceded
again.
And what we did, and he suggested it, when would get a prescription for a drug,
he would give me two pills, and he said use this ... If it worked, then he would go
ahead and fill the prescription.
Ann reports other instances in which her pharmacist interceded. At one time she spent six
weeks looking for a splint for her thumb, but found none that fit. Her pharmacist upon
learning about the problem, "fooled around with it until he got it to work." At another
time her pharmacist assisted her in getting medication for her father while they were out of
town.


28
customers. Implicit service promises are simply cues, which the service provider makes,
which lead to an inference about what the service encounter will be like. Word of mouth
communications were another antecedent of desired and predicted levels of service. Past
experience with the service is the final antecedent of desired and predicted levels of
service.
ZBP (1991) found that customer's expectations for adequate levels of service have
five antecedents. Those antecedents include transitory service intensifiers, perceived
service alternatives, customer self-perceived service roles, situational factors, and
predicted service. The first antecedent, transitory service intensifiers may be defined as
"temporary individual factors that lead the customer to a heightened sensitivity to service"
(p. 16). Perceived service alternatives are simply the customer's perceptions of the
availability of a comparable service. That is, what is the competition? The third
antecedent, customer self-perceived service role relates to the customer's involvement with
the service. It is the degree to which the customer perceives they influence the service.
At times a service provider cannot control the situation in which the service is provided.
The customer believes that these situational factors, the fourth antecedent, are not the
service provider's fault and they may accept a lower level of adequate service. Predicted
service is the level of service that customers believe they are likely to receive. It is
important to note that this definition of predicted service is synonymous with the definition
of expectations found in the satisfaction/dissatisfaction literature.
The development of these various levels of expectations for service led ZBP
(1991) to revise the gap model first presented in PZB (1985). The fifth gap was revised to




REFERENCES
Banahan, B.F., Sharpe, T.R., & Smith, M.C. (1980). Consumer Expectations
Compared to the Reported Use of Pharmacy Services in Rural Areas. Contemporary
Pharmacy Practice. 3. 90-94.
Blumer, H. (1969). Symbolic Interactionism: Perspective and Method. Englewood
Cliffs, NJ: Prentice-Hall.
Bolton, R.N., & Drew, J.H. (1991). A Longitudinal Analysis of the Impact of
Service Changes on Customer Attitudes. Journal of Marketing. 55. 1-9.
Boulding, W., Kalra, A., Staelin, R, & Zeithaml, V. (1993). A Dynamic Process
Model of Service Quality: From Expectations to Behavioral Intentions. Journal of
Marketing Research. 30. 7-27.
Brown, L. (Ed ). (1993). The New Shorter Oxford English Dictionary. Oxford:
Clarendon Press.
Christensen, D., Pharmacy Services. In Principles and Practice of Managed Care (pp. 89-101). Alexandria,
VA: Academy of Managed Care Pharmacy.
Council on Medical Service. (1986). Quality of Care. Journal of the American
Medical Association. 256. 1032-1034.
Cronin, J.J., & Taylor, S.A. (1992). Measuring Service Quality: A Reexamination
and Extension. Journal of Marketing. 56. 55-68.
Davies, A.R., & Ware, J.E. (1988). Involving Consumers in Quality of Care
Assessment. Health Affairs. 8. 35-50.
DeSimone, E.M., Peterson, C.F., fe Carlstedt, B.C. (1977). Pharmacist-Patient
Interaction and Patient Expectations. American Journal of Pharmaceutical Education 41.
167-177.
101


90
Because of the interceding Moira has formed a personal relationship with her
current pharmacist.
I go down to Shands and [pharmacist] familiar with that. He knows what's going
on. He knows that partly because I've told him and he's listened and remembered.
Case Five
Betty was a sixty-one year old homemaker at the time of her interview. She
patronizes an independent pharmacy, and visits about every two weeks. She does have
some chronic illnesses, but says she is in good health. Betty shares the responsibility of
payment for her medication with her insurance company.
Betty expressed all three needs throughout her interview. She looks to her
pharmacist to solve problems with insurance coverage, out of stock items, and vacation
supplies of medication. She needs her pharmacist to provide her with extensive drug
information, to advise her of interactions with her current medications, and to suggest
over the counter medications. Betty needs reassurance that her pharmacist "is up to date
on his, with the knowledge of medicines that are coming up." This reassurance comes in
the form of credentials in plain sight. Betty wants her pharmacist to show concern when
she comes in distraught. She also revealed the condition of pharmacist expertise during
our conversation when she said that her pharmacist should "be an expert in what type of
medicine he's giving me."
Throughout our conversation Betty shared several instances that provided a
pharmacist the opportunity to intercede.


ACKNOWLEDGMENTS
This project could not have been completed without the support and guidance of
my committee chairperson, Dr. Earlene Lipowski, who allowed me the freedom to explore
and to choose a research method that best fit my and the project's needs. She fully
supported my research journey and has given me a wonderful example to follow. Thanks
also go to Dr. Sally Hutchinson, who applied her expertise and who kindly joined in and
supported my exploration of grounded theory. I thank my other committee members, Dr.
Carole Kimberlin and Dr. Richard Segal, for their time, help, and support. I thank Dr.
Doug Ried for his time and input. I am especially thankful for my family, Lee, Kate, and
Rob. Their love and support cannot be measured or described adequately enough. I
thank my parents, Bob and Vera Flynn, for creating in me a need to read. I am very
grateful for the support of my friends, Suzi Maue and Sabrina Scott. As fellow graduate
students they understood my needs. I also thank all of my fellow pharmacy administration
graduate students. I thank all of the folks at Mandarin Presbyterian Church. Their prayers
and encouragement made a difference. I thank Delayne for all of the transcription work,
and Debbie for being my phone buddy. I thank Bruce Allen for helping me draw the
model. I thank Drs. Jerome Hallan, Nick Wilson, and Larry Jean, faculty members in the
College of Health at the University of North Florida. It was their encouragement that led
IV


46
pharmacies, and one (4%) patronized a clinic pharmacy. Four (15%) of the participants
patronized both chain and independent stores, while one (4%) patronized both a chain and
military pharmacy. Of those asked (n=18), twelve (67%) participants visited their
pharmacy at least every two weeks. Two (11%) visited monthly, three (17%) quarterly,
and one (6%) visited yearly. Participants estimated that their average medication use
ranged from one-half to twenty-five prescriptions per month. Most (twenty-three or 85%)
indicated that they had some sort of chronic medical condition. Finally, of those asked
(n=18), six (33%) rated their health status as fair, six (33%) as good, and four (22%) as
excellent. One (9%) participant rated her health as poor to fair, and one (9%) as fair to
good.
Theoretical Sampling
Theoretical sampling is defined as "the process of data collection for generating
theory whereby the analyst jointly collects, codes, and analyzes his data and decides what
data to collect next and where to find them, in order to develop his theory as it emerges"
(Glaser and Strauss, 1967, p. 45). Theoretical sampling allows the researcher to sample
not with a preconceived notion, but with real, specific guidance from what is occurring in
the research setting (Glaser, 1978). In this study, theoretical sampling was employed after
the interview participants were chosen. Theoretical sampling of the interview transcripts
and field notes allowed me to pursue and expand the codes emerging from the data. This
in turn led to the discovery of the basic social problem and process which form the core
for the developing theory.


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
UNDERSTANDING CUSTOMER EXPECTATIONS OF
COMMUNITY PHARMACY SERVICES
By
Barbara F. Brice
May 2000
Chairperson: Earlene Lipowski
Major Department: Pharmacy Health Care Administration
Customers of health care have often been ignored when assessing the quality of the
medical care that they receive. Historically, customers simply followed doctor's orders
and did not participate in assessing the quality of the care that they received. As the focus
of the health care system in general and pharmacy in particular evolves, both are making
strides toward including the customers' perspective when assessing quality. However,
current efforts to include the pharmacy customer in quality assessment seem to lack a
theoretical underpinning. Therefore the purpose of this grounded theory research was to
generate a substantive theory that explains customer expectations of community pharmacy
services, as those expectations may be a foundation on which to measure service quality.
A convenience sample of 27 community pharmacy customers was interviewed. In
addition, observations of the pharmacist-customer interaction took place in four


47
Data Collection and Recording
Data for this research were collected through a series of semi-structured interviews
and observations. Interviews were conducted at a time and place designated by the
interviewee, and lasted from forty-five minutes to an hour and a half. Each interview was
tape recorded and subsequently transcribed into the Word Perfect computer software.
Customer pharmacist interactions were observed on five separate occasions, with
observation times ranging from two and one-fourth hours to six hours. I sat or stood in an
inconspicuous place in each of the four pharmacies. Twenty-three pages of field notes
describing the pharmacy environment as well the customer pharmacist interactions were
recorded. Observations took place in two independent pharmacies, one chain pharmacy,
and one grocery store pharmacy.
In addition to the customer interviews described above, four community
pharmacists were asked to record their thoughts regarding the process that they used in
problem assessment. One pharmacist provided his notes to me. Another pharmacist was
interviewed via the telephone and I reduced the conversation to writing.
Interview Guide
An initial interview guide for this study was developed using a four step process.
First, a review of the literature was undertaken. Next, with the aide of the research
objective, the literature, and suggestions from Patton (1980), I developed nine, multi-part
expectations interview questions. Then, faculty members in the College of Pharmacy


27
hypothesized that a customer's expectations for an adequate level of service would be
more variable than their expectations for desired levels of service. They based this
hypothesis on the assumption that desires come from an accumulation of experiences,
while adequate levels are a function of competition among other variables.
The zone of tolerance is the difference between a customer's expectations for a
desired level of service and their expectations for an adequate level of service. The
authors found (from the focus group interviews) that changes in the zone of tolerance are
more a function of expectations for adequate levels of service. Also, the zone of tolerance
may vary for the five dimensions of service quality: reliability, responsiveness, assurance,
empathy, and tangibles.
Expectations for desired levels of service are defined as the level of service that the
customer hopes to receive. Focus group interviews provided six antecedents for desired
levels of service. The first, enduring service intensifies may be defined as "individual
stable factors that lead the customer to a heightened sensitivity to service" (ZBP, 1991, p.
15). One type of enduring service intensifier is derived service expectations. In this
instance a customer's expectations are driven by another party. Another enduring service
intensifier is a personal service philosophy. This is a customer's underlying attitude about
the meaning of service. The second antecedent is personal needs. Personal needs are "the
states or conditions essential to the physical or psychological well being of the customer"
(ZBP, 1991, p. 15).
Four of the antecedents of desired service were found to impact predicted service.
Explicit service promises are statements which the service provider makes to its


2
customers evaluating their own health care. The validity of customer ratings of health
care was questioned on four points: (1) the data provided by customers reveals more
about the customer than the quality of care; (2) customers are able to tell how much was
done, but not how well it was done; (3) customers' and physicians'judgements regarding
quality are different; and (4) customers' ratings of quality just reflect whether their
provider was nice (Davies and Ware, 1988). However, in a review, Davies and Ware
(1988) consider the evidence both for and against customer participation in quality
assessments of care. The evidence collected in their review suggests that data from health
care customers can be useful in assessing the quality of medical care. For example, they
found that for common problems customers can distinguish between good and less than
good technical aspects of care. Also, customers' perceptions of quality affect their choice
of health care provider. Finally, they found that customers are the best source of data on
the interpersonal aspects of care (Davies and Ware, 1988).
Kaplan and Ware (1995) also discuss the patient's role in health care quality
assessment. They suggest that there are five reasons to include patients in the evaluation
of their care. First, they suggest that patients' evaluations are the most practical source of
information. Second, patient or customer satisfaction with services has been shown to
affect both the patient-physician relationship and the patient's health status. Dissatisfied
patients change physicians, change health plans, sue their providers, do not follow
treatment recommendations, and avoid medical care altogether. Third, they indicate that
research has shown a link between clinical measures of health and patient-reported
outcomes. Fourth, they suggest that there is evidence that patients want to expand their


UNDERSTANDING CUSTOMER EXPECTATIONS OF
COMMUNITY PHARMACY SERVICES
By
BARBARA F. BRICE
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
2000


community pharmacies. Data were collected and analyzed using the grounded theory
method. Findings show that pharmacy customers participate in a medication use system
that they do not fully understand. This misunderstanding creates needs, the basic social
problem, for those customers. Included are needs for information, needs for a problem
solver, and needs for reassurance. This set of needs is addressed by the pharmacist acting
on the customer's behalf in the medication use system. The pharmacist's acting, called
interceding, is the basic social process that occurs in response to the customers' needs.
However, two conditions, need identification and pharmacist expertise, must precede
pharmacist interceding. Because interceding is a process, two phases occur: assessing and
acting. Also, several conditions influence interceding. They include pharmacy
environment, time, social structural variables, and personal characteristics. The
consequence of pharmacist interceding is the formation of a relationship between
pharmacist and customer. The proposed Model of Pharmacist Interceding illustrates the
connection between customer needs, pharmacist interceding, and the pharmacist-customer
relationship. Understanding the Model of Pharmacist Interceding provides pharmacists
with new insight into the needs created by the medication use system for their customers.
It shows pharmacists that customers expect their intercession in this system, and it
demonstrates that a relationship is the consequence of pharmacist interceding.
IX


43
second goal of purposeful sampling is to specifically examine cases that are critical for the
theoretical framework underpinning the study. A third goal is to pick a sample that will
enable the researcher to make comparisons of the reasons for differences between those
sampled. A fourth goal of purposeful sampling is to sufficiently capture the population's
heterogeneity, with the aim of representing the range of variation within that population
(Maxwell, 1996). The initial sample for this study was purposively chosen from
community pharmacy customers with a range of pharmacy experiences.
In order to assess the range of pharmacy customers to be sampled, the pharmacy
expectations literature was examined. Past studies of pharmacy customer expectations
examined customer's gender (DeSimone, Peterson, and Carlstedt, 1977; Kucukarslan,
1998), race (Kucukarslan, 1998), and age (DeSimone, Peterson, and Carlstedt, 1977;
Mackowiak and Manasse, 1988; Norwood, Seibert, and Gagnon, 1976). Kucukarslan
(1998) included an assessment of education level in her study of expectations.
Kucukarslan (1998) and Ranelli and Coward (1997) examined whether customers had
acute or chronic illnesses, and the average number of prescriptions purchased. Also
included in past studies of customer expectations were type of pharmacy patronized
(Ludy, Gagnon, and Caiola, 1977; Mackowiak and Manasse, 1984; Kucukarslan, 1998)
and frequency of pharmacy contact (DeSimone, Peterson, and Carlstedt, 1977;
Mackowiak and Manasse, 1984). Each person interviewed was asked about these
characteristics and an effort was made to represent the range in variation of the
characteristics.


6
and they are guided in action and orientation by the meaning of those things. Meanings of
those things, including themselves, are formed, sustained, weakened, and transformed
through social interaction. Because people cluster in different groups, have different
occupations, and belong to a myriad of associations, they approach each other differently,
live in different worlds, and are guided by different sets of meanings.
Symbolic interactionism provides the foundation for the grounded theory method,
and as such guides the research questions, the interview questions, the data collection
strategies, and the data analysis techniques of the method. The grounded theorist searches
for the social processes present in human interaction. Grounded theory is useful in studies
where little is known about a particular subject or where much is known but clarification is
needed. Because grounded theory uses an inductive, from the ground up approach, a new
understanding of behavior may emerge, and the generated theory will be inherently
relevant to the world from which it emerges (Hutchinson, 1993).
In this study, the interaction between community pharmacy customers and their
pharmacist(s) was investigated using the grounded theory method. Grounded theory
research endeavors to understand the common issues facing the group of people under
study. A group's common experience leads to shared meaning and behaviors which in turn
leads to a specific social psychological problem. While this basic social problem is shared,
group members may not be able to articulate it. It is the job of the grounded theorist to
uncover the problem. Therefore, pharmacy customers were interviewed and observed in
order to identify and understand the basic social problem they face, and the basic social
process used to address that problem. The data collected from the interviews and


83
defined as an association between pharmacist and customer which focuses on the
customer's medication use. This relationship is role based, and is formal in nature. In a
professional relationship, there is recognition of the partners and a purposive exchange.
Pharmacists and their customers recognize each other, have some affinity for each other,
but focus their interactions on getting the prescription dispensed: accurately, efficiently,
and safely.
Personal Relationships
Personal relationships may also be a consequence of pharmacist interceding. While
personal relationships included some of the same elements as a professional relationship
(i.e., recognition and accurate, efficient, safe prescription dispensing), they also include an
increased level of personal involvement. Pharmacy customers who formed a personal
relationship related instances in which their interactions with their pharmacists included
discussions of family and work matters, and they more often referred to their pharmacist
as a friend. Also, at this level, customers reported that their pharmacist acts to provide an
extra degree of service.
Cases
So that the reader may have a better understanding of the consequences of
pharmacist interceding as well as the Model of Pharmacist Interceding as a whole, the


35
A chi-square analysis of the results showed that there was a statistically significant
difference in expectations regarding most activities between those assigned to the satellite
and those assigned to the traditional pharmacy. Also, patients were significantly more
satisfied with the satellite pharmacy. Finally, waiting time, satisfaction with hospital
service in general, time spent with the pharmacist, and the total number of activities
performed by the pharmacist during an interaction were all significantly correlated with
satisfaction.
In order to better understand demand for comprehensive pharmaceutical services,
Banahan, Sharpe, and Smith (1980) studied customer expectations and use of those
services in a rural area. Trained personnel interviewed a responsible adult in 603
households in a three county area of Mississippi. The interview questions covered a wide
range of health care topics, including: demographic characteristics; use of and attitude
toward pharmacy services; current health status and behavior; and general satisfaction
with current medical services, among others.
Results showed that patients most often expected services related to medications
and medication use (eg., 65.9% expected counseling on side effects). While most of the
results were reported as frequencies, the authors did note some differences among groups.
For example, respondents that either strongly or somewhat strongly agreed that
pharmacists should counsel on side effects were more likely (p<0.01) to report that the
pharmacist did explain side effects. Also, respondents who expected their pharmacist to
provide health information (other than on drugs) were more likely (p<0.01) to report
asking those questions.


45
In addition to the bag clippers, friends and interviewees were tapped for possible
volunteers. Eight additional individuals volunteered for interviews. Five have completed
interviews, and the remaining three are available for future interviews.
Sample Description
Twenty-seven individuals participated in interviews during the course of this
research. Twenty-one (78%) of the participants were female, and six (22%) were male.
In regard to age, eight (30%) were under the age of forty. Nine (33%) of the interviewees
were between the ages of forty and fifty-nine, and ten (37%) were age sixty and above.
Ages ranged from twenty-eight to eighty-seven years. The majority, twenty-four of
twenty-seven (89%) of the participants were white. Two (7%) were African American
and one (4%) was Hispanic. The sample group included two (7%) individuals who had a
high school diploma, and seventeen (63%) individuals who had some college experience.
Eight (30%) of the participants had at least a four year college degree.
There was an attempt to interview pharmacy customers who would have a range
of pharmacy related experience. To that end, three (11%) of the interviewees paid for
their medications themselves. Twenty (74%) of the interviewees shared payment with
another source (e g., insurance), and three (11%) of the interviewees depended on an
outside source to completely cover the cost of their medication. One (4%) individual
shared payment responsibility on some medications, and on others another source (i.e., the
military) paid the bill. With regard to the type of pharmacy patronized, five (19%) strictly
shopped at chain pharmacies. Sixteen (59%) of the participants shopped at independent


18
Swartz and Brown
In their 1989 article Swartz and Brown explored the evaluation process for
professional services. Both providers and customers of a professional service (primary
health care) were covered in their analyses. Health care customers were surveyed by
means of a telephone interview. Health care providers (i.e., physicians) were surveyed by
means of a mail questionnaire. The focus of the survey instruments was the perceptions of
both customers and physicians toward health care and primary health care providers.
Participants were presented with a series of statements regarding physicians, health care,
and the public's view of each. They were asked to indicate their level of agreement or
disagreement using a five-point scale.
Results indicated that for both customers and physicians, the assessment of quality
is a function of both expectations and experiences. The authors used their results to
construct a conceptual model for evaluating professional service quality. This model
showed that a series of gaps were likely to occur when measuring service quality. Gap A
was the difference between customer expectations and their actual experience. Gap B was
the difference between customer expectations and physician perceptions of their patient's
expectations. Gap C was the difference between customer experiences and provider
perceptions of patient experience. Finally, Gap D was the difference between a physician's
personal thoughts about the patient and what they perceive the patients' views to be.


me to apply to the University of Florida. I thank Mel and Dennis, for allowing me access
to their customers and their practices. I thank Leanne and Traci for allowing me to
observe. I thank Broni for sharing her pharmacist tools. A capital thank you goes to all
pharmacy customers. Clearly without them there would be no project. Finally, I am most
grateful to God who led and continues to lead me on my path through life.
v


77
Physical barriers may not always interfere with the process of interceding. In one
pharmacy, where the dispensing area was located on a raised platform, one customer was
not deterred. He simply placed his prescription on the top of the counter and spoke with
the pharmacist. In this same pharmacy, the pharmacist consistently greeted customers
from the platform, almost as if it were an observation post from which he could keep an
eye on the pharmacy. Rather than deterring interaction, the platform seemed to facilitate
interaction.
Pharmacy Focus. The focus of the store in which the pharmacy is located may also
influence the process of interceding. Some pharmacies are departments within stores that
sell a wide variety of merchandise, and some are within stores that focus on medicine and
other health related items. One customer indicated that "you go into some of them . .
and it's just a little department shoved in the back somewhere. And that doesn't feel
important enough to me." For this customer, the focus on medicine signals that it is okay
to express a need for pharmacist interceding. Customers who patronize a pharmacy that
focuses on health care more often described their pharmacies as warm, homey, or
comfortable. Perhaps this environmental factor enables the customer to feel comfortable
expressing a need.
Pharmacy Personnel. Another environmental factor which may influence
pharmacist interceding is the number and types of personnel working in the dispensing
area. Pharmacies tend to employee three types of personnel to work within the dispensing
area: pharmacists, pharmacy technicians, and cashiers. Clearly the addition of layers of
personnel between the pharmacist and customer may influence the process of interceding.


78
In one store that employed all three levels of personnel, customers had infrequent chances
to cue the pharmacist about a need. The levels of employees acted as a barrier to the
pharmacist. That is, customers generally interacted with cashiers or technicians before they
were able to interact with a pharmacist. However, in another three level store, the
pharmacist had frequent interactions with customers. This may indicate that the number
of employees between the pharmacist and customer becomes a barrier only when other
factors come into play. Those factors might include store policy and pharmacist time.
Time
The process of pharmacist interceding may be affected in several ways by time.
That is, time is a multi-faceted issue that affects both customers and pharmacists.
Customer's Time. Effective use of time is important to customers. One customer
indicated just how important her time is.
The other one [insurance plan] would cost me less money out of my paycheck each
year and I chose to pay, more money to stay at [name of pharmacy]. That's how
valuable my time is.
This customer had previously related instances in which she felt her time had been wasted
at other pharmacies. She chose a pharmacy where she perceived the wait time was low.
Other customers also indicated that they are interested in fast service. This desire for fast
service may adversely affect the pharmacist's ability to appropriately intercede on the
customer's behalf.
Pharmacist's Time. Pharmacist's interceding is also affected by the amount of time
available for the process. The amount of time available may be affected by the


7
observations provides a better understanding of how pharmacy customers interact with
and assign meanings to their interactions with their pharmacist and the medication use
system.
Research Purpose
The purpose of this study was to build a substantive theory that explains customer
expectations of community pharmacy services.
Research Questions
1. What is the basic social problem faced by community pharmacy customers?
2. What basic social process is used to address this problem?
Significance for Pharmacy
Findings from this study will be useful on several fronts. First, the grounded
theory will provide pharmacy researchers with a common starting point for future
expectations research. Second, because the theory is specifically focused on the
expectations of community pharmacy customers, community pharmacists will be able to
use the theory as an aide in examining their own practices. Finally, understanding
customer expectations may enable pharmacy educators to develop better tools for telling
pharmacy customers about the services their pharmacist may provide.


This project is dedicated to Lee, Kate, and Rob. Their love supports and guides
me always.


108
10. What is the "worst" thing about having to take prescription medication. The best?
How could it be better?
11. What is the most important thing that your pharmacy can do for you? The least
important?
12. Have you ever had a change in your health plan that necessitated a change in
pharmacies? How did you choose the new pharmacy? What were your
expectations for service in that new store? Facilities? Services? Personnel?
13. Suppose you move to a new town. How do you choose a new pharmacy? Why?
14. Suppose someone asked you for a recommendation. Describe the pharmacy that
you would recommend. Facilities? Services? Personnel?
15. Do you currently patronize one pharmacy? More? Why?
16. How would you describe yourself in regards to your illness? For example, are you
proactive, passive, aggressive?


33
In regards to statements about pharmacist consultations for drugs, poisons, and
sickroom supplies, both customers and physicians viewed all pharmacist roles favorably.
Both customers and physicians indicated that pharmacists should use a patient's records to
detect drug-drug interactions and should advise patients on prescription and non
prescription medications. Of interest were the roles that customers indicated they would
pay for. Customers (27.6%) indicated that they would be willing to pay for the availability
of surgical and sick room supplies. Also, customers (14%) indicated that they would be
willing to pay for information regarding emergent treatment of poisonings.
Patients and physicians differed in their rankings of the pharmacist's role in
preliminary diagnosis, screening, and treatment. Customers viewed these roles more
favorably but were not strongly in favor of the pharmacist acting in these roles. Physicians
viewed any role of the pharmacist as a general health information source negatively.
Customers were neutral for this category. Finally, neither physician nor customers
positively viewed pharmacists in the role of drug selection, dosing, or administration.
DeSimone, Peterson, and Carlstedt (1977) gathered data regarding the interactions
between pharmacists and their patients. The authors believed that patient initiated
interactions with his or her pharmacist showed a level of need as well as an expectation
that the pharmacist could fulfill that need. Sixteen pharmacists participated in the study
which gathered the following information: (1) patient age, (2) patient gender, (3) whether
the patient came to or called the pharmacy, (4) whether the question concerned a
prescription or non-prescription drug, and (5) the question category.


CHAPTER 6
THE CONSEQUENCES OF PHARMACIST INTERCEDING
Pharmacy customers present their pharmacists with a variety of needs, and
pharmacists respond to these needs by interceding or acting on behalf of their customers in
our medication use system. But what are the consequences of that interceding? Data
from this study indicate that a relationship is formed between customer and pharmacist.
That is, a connection or association is formed between the two. While some
commonalities among the data were found, not all customer- pharmacist relationships are
alike. Findings from this study show that relationships may be classified into one of two
types: professional and personal. In the following sections, a description of the two
relationship types is presented. This is followed by six cases or in depth descriptions of
the processes described by the Model of Pharmacist Interceding.
Professional Relationships
The formation of a professional relationship between customer and pharmacist
seems to be common to all pharmacy customers. In other words, the minimum
consequence of pharmacist interceding is the formation of a professional relationship
between the customer and pharmacist. For this study, a professional relationship may be
82


APPENDIX B
REVISED INTERVIEW GUIDE
1. Please think about your last visit to a pharmacy to pick up a prescription. You
arrived at the pharmacy and opened the door. What happened next? What did the
pharmacy look like? Where were the people? Who were the people? What were
you doing? What were they doing? What was said? When was it said? What was
the most important thing that happened during your visit? What was missing in
regards to the people, facilities, pharmacist?
2. What should happen when you visit your pharmacy? Why? (Facilities, People,
Services)
3. What should NOT happen when you visit a pharmacy? Why? (Facilities, People,
Services)
4. Please think about a pharmacy visit when things did not go as you wished. What
happened? What was different? Who was involved? Facilities? Services?
Personnel?
5. Now imagine the ideal pharmacy visit in your eyes. Please describe that ideal visit
to the pharmacy. How is it different than a "usual" visit to the pharmacy?
Facilities? Services? Personnel?
6. Are there any times when your expectations might be different? For example a new
vs refill prescription, chronic vs acute illness, or emergency vs not emergency visit.
7. Think back to the first time you remember having a prescription filled. What
happened? What was missing? What was the prescription for? A chronic vs acute
illness? How did you feel? What is the most important thing that happened?
8. Describe your experience as a pharmacy customer. Do you have an acute or
chronic illness? How long since your diagnosis? How often do you visit a
pharmacy? Do you shop at a chain, clinic, and/or independent pharmacy?
9. How does having to take a prescription make you feel?
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5
meanings of things to people are central in their own right and cannot be ignored when
studying human behavior. Blumer (1969) suggests that to disregard the meanings of
things in favor of factors declared to produce behavior is a serious neglect of the role of
meaning in the formation of behavior.
The second premise, according to Blumer (1969), is that the meaning of things
derives or arises from the social interaction of people. Therefore, meanings are social
products. They are created through the defining activities of people as they interact.
Finally, Blumer (1969) states that meanings are handled and modified by an
interpretive process that is used by individuals as they deal with the things that they
encounter. There are two steps in the interpretive process. First, through a process of
self-communication, an individual points out to himself the things that have meaning.
Second, through this process of self-communication, interpretation becomes a matter of
handling meanings. The individual acts to select, check, suspend, regroup, and transform
meaning based on the situation. Therefore, interpretation is a formative process in which
meaning is used and revised as necessary for guiding and forming action. Meanings
perform a part in action through the process of self-interaction.
Blumer (1969) suggests that as a human society, people are engaged in living
through symbolic interactionism. Living is a process of ongoing activity in which humans
develop lines of action for the many situations they encounter. People are involved in an
immense process of social interaction to which they must fit their developing actions.
Through the process of social interaction, individuals indicate to others what to do, and, in
turn, interpret the indications made by others. Humans live in a world of objects or things,


81
For example, one customer indicated that her pharmacist "appears to be very stiff, but he's
very nice to me. Very nice to me." Perhaps this customer's personality, open and friendly,
allows the pharmacist to be open to the possibilities of interceding.
Summary
Because of the complicated medication use system in which they participate,
pharmacy customers develop needs. Those needs include a need for information, a need
for reassurance, and a need for a problem solver. Together they comprise the basic social
problem that pharmacy customers face. The basic social process which addresses those
needs is pharmacist interceding. Pharmacist interceding may be defined as the pharmacist
acting on behalf of a customer in the medication use system. Pharmacist interceding as a
process includes the phases of assessing and acting. The process is preceded by two
conditions, problem identification and pharmacist expertise, and it is influenced by a group
of factors including, pharmacy environment, time, social structural variables, and personal
characteristics. But what happens after the pharmacist intercedes? What are the
consequences of pharmacist interceding? That final piece of the model is discussed in the
following chapter.