Stage one

In the qualitative research paradigm, a variety of data generation methods are commonly used. Potential techniques for generating data for this study included observation, group interviews and individual interviews. Focus groups have been found to be especially effective in studying professional practices as they allow the researcher to access the process through which collective meaning is negotiated and through which group identities are elaborated.119 Barbour states that the group interview convenor:

...should have, as a basis for comparison, groups made up of individuals selected on the basis of some shared characteristic or attribute, but which differentiates them from other groups.’119

Therefore, a series of sector-specific group interviewss was undertaken with practising pharmacists from the community, hospital and primary sectors.

The concept of professional identity refers to who people are as professionals, and the identity that is gained through membership of the professional group. Section 2.4.3 introduced the concept of stereotypes, which are generalised descriptions of groups of people – descriptions which include prototypical attributes, which people can assign to themselves and/or to others.

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When designing the empirical data collection stage of this study, I sought a method that would allow me to explore the concept of professional identity in pharmacy, that is, what pharmacists are like and what characterises them. The development of personas has been used by product developers who want to understand the users of their products. A persona is a representation of a real group of people, usually synthesized from data collected via interviews. Personas may be exaggerated to some extent, but are understood as ‘abstractions or caricatures’ of people’s perceptions of their own work roles, or the roles of others around them, with a few fictional personal details to make the persona a realistic character. In doing so, personas are said to be cognitively compelling because they put a personal human face on otherwise abstract

data.120,121

The persona technique seemed to offer a potential method of enquiry into researching identity for the current study. No previous studies had been found which made use of the persona method in pharmacy practice research, therefore study one was in some respects a pilot study in that it was trying out a new technique in this area.

The group interviews discussions were structured around devising pharmacist ‘personas’, that is, imaginary characters who may be found in the pharmacy profession. Personas are usually captured in one to two page descriptions that capture the characteristics (goals, values,

preferences, working relationships, behaviours) and also environment of a real group of people. In preparation for the group interviews, I devised some ‘example personas’. At the start of each session I described the method to the group and showed them the example personas. To avoid influencing responses, I used ‘cross-sector’ examples, so community pharmacists were shown hospital pharmacist personas and vice versa. Participants were also asked about their

perceptions of the pharmacy profession in general, whether they thought there was one overall type of person who characterised ‘the pharmacist’, or whether they discerned particular types of pharmacist. The sessions were designed to proceed by the group devising one or more

personas which represented the main types of pharmacist the participants thought existed within their sector. The personas were ‘drawn up’ on large sheets of paper, using headings such as ‘goals’ and ‘preferred types of work’, to prompt elaboration of the attributes of the characters being described.

As mentioned in section 3.2.3, this study was exploratory in nature, due to the area being under-theorised previously. In order to gain a valid understanding of the topic in question, I wanted participants to express themselves in their own words, therefore, I used ‘open-ended’ questions and tried to minimise my input into the discussions, beyond sometimes probing for further detail or clarification where relevant and managing the discussion in terms of time.

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The sessions were audio recorded. Eight interviews were conducted, involving 21 pharmacists in total, one group contained just one pharmacist and the remaining were group interviews with between two and five participants in each. The interviews were between half an hour and two hours in length (9.25 hours in total).

Participants in the groups all agreed that there was no one ‘typical’ pharmacist that

characterised an entire sector of the profession – all of the groups perceived several types. Participants applied themselves to the task of devising the personas with enthusiasm, and all group sessions resulted in several personas as well as a large amount of discussion. The personas drawn up were all fictitious, although pharmacists also gave ‘real’ examples of personalities, traits and stories from their experiences with current and previous pharmacist colleagues. Participants also spontaneously discussed their own working practices and personal experiences and views about their work. (See appendix C for the group interviews schedule.)

The group interviews generated 32 personas, captured on paper. I transcribed the audio recordings verbatim and carried out a thematic analysis on the transcripts (which followed the framework approach, which is described in detail in section 3.7 below) which also allowed me to add more detail to the personas. The analysis allowed me to compare the personas and their various attributes and through this process I was able to group together similar characteristics and reduce the personas down to eight ‘characters’ which I considered to represent the personas described in the groups.

Methodologically, carrying out this initial study showed that technique of devising personas can work well in the pharmacy practice research context, in that it seemed ‘meaningful’ to the participants in the study, and generated a considerable amount of data. In terms of the findings, it seemed that participants perceived several different ‘identities’ for pharmacists. The main limitation of this stage was that the sample consisted of participants who were employed by the university (in teaching practitioner, teaching fellow or research posts), or were undertaking post- graduate studies (the clinical diploma or a PhD) although they also all spent time practicing in practice settings (in community pharmacies, in hospitals or in primary care trusts), they were considered less ‘grass roots’ than would be a sample of pharmacists who were not employed in academia.

3.4

Stage two

As noted in section 2.6, professional identity has three dimensions, and this study had three objectives, which relate to investigating each of these. The data generated through stage one related to objective one, finding out how pharmacists view themselves and others within their

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profession. More research was necessary to address objectives two and three – how pharmacists think they are perceived by non-pharmacists, and how non-pharmacists see pharmacists.

3.4.1 Sampling strategy

Analysis of the data generated in stage one suggested considerable diversity within the pharmacy profession in terms of pharmacists’ professional identity. Therefore, in stage two I aimed to extend the sample to include a range of pharmacists who were more ‘grass-roots’ than those in stage one who were all connected to the university. To address objective three, it was necessary to recruit non-pharmacists to the study. While potentially virtually anyone could have contact with a pharmacist, either as a service user or colleague, deciding on a sampling strategy involved balancing an ideal with realistic practical constraints, in terms of time and logistics. After consideration, four groups of non-pharmacists were chosen for recruitment to the study. Firstly, pharmacy support staff, who work alongside pharmacists on a daily basis,

secondly, doctors, who have traditionally been (and remain the main) prescribers of medicines, thirdly, nurses, who often administer medicines, and fourthly lay users of pharmacy services. In terms of the professional and support staff, the sample included participants from all three sectors of pharmacy practice, while the lay users were people who had used either a community pharmacy or a hospital pharmacy.

3.4.2 The interviews

This stage of the study was designed to further explore the concept of professional identity in pharmacy using individual interviews with pharmacists and non-pharmacists. Interview schedules were prepared for each participant group. Pharmacist interviewees were asked questions in relation to their own work and about other pharmacists they had come across, and how they thought their profession was perceived by non-pharmacists. Non-pharmacists

interviewees were asked about their experiences and encounters with pharmacists. The schedules were designed to elicit the opinions of all groups of interviewees on their general impressions of pharmacists, their experiences of pharmacists and what they thought made a good or bad pharmacist, what pharmacists do and what else they could or should do. The literature review helped to inform question design, for example section 2.5.3.2 explains the concept of role models, and pharmacist interviewees were asked for examples of these.

Stage two did not repeat the persona-generation exercise carried out in stage one. As

mentioned, analysis of the data generated had led to the development of eight personas. After consideration about the best way to present these personas to participants, I decided to develop a visual aid which could be used as a discussion prompt during interviews. I searched for

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photographs and put together eight pictures to represent the eight personas. These pictures, and also the interview schedules were refined following discussion with the study supervisors (KH and JH). They were then piloted by showing them to pharmacists within the pharmacy practice research group, who suggested a few minor changes. (Copies of all interview schedules can be found in appendix D and the pictures are appendix E.)

As noted, grounded theory proposes that the data collection and analysis should take place simultaneously, and that the researcher should analyse data and then decide what data to collect next. I endeavoured to bear this in mind during the field work stages of this study, for example, the first version of the interview schedule used did not include any questions about clinical work. However, during one interview, a practice nurse raised the issue of being aware of potential drug interactions when prescribing and dispensing medicines, and she referred to her own ‘clinical knowledge’, which she seemed to differentiate from the knowledge that she perceived the pharmacist to have, and this led to an interesting discussion about her perception of the nature of clinical work and whether she considered pharmacists to be clinical or not. Consequently, I added a question about clinical work to the interview schedule.

The interviews were all digitally sound-recorded, apart from one where the participant declined to be recorded, but was content for me to take as many written notes as I could during the interview. Field notes were generally taken during the other interviews, often on the interview schedule sheets as I would make notes by the relevant question. I kept a research diary throughout the study, and made further notes in this after each interview was finished.

3.5

Ethical issues

The main ethical considerations for a study using interviews as the research method, such as this one, are ensuring that potential participants are provided with sufficient information about the study when they are invited to take part, ensuring that participants understand the general purpose of the study, what participation will entail and that they are happy to take part (that informed consent is obtained), and management of the data in terms of maintaining confidentiality and anonymity.

All participants were provided with written information about the study via the ‘information sheet’, were encouraged to ask me any questions, and gave written consent to participate. To ensure the anonymity of participants, all identifying features of the participants were excluded from the data during transcription and reporting. The only people who had access to the raw data were my supervisors and I. These data, which consisted of audio files, interview

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transcripts, contact details and consent forms are stored in password protected electronic files and paper documents are kept in locked filing cabinets.

Both stages of the study were reviewed and given approval by ethics committees. Stage one was reviewed by the university ethics committee and approval was confirmed on 31/10/2007. Stage two was reviewed by Oldham NHS research ethics committee and approval was confirmed on 14th March 2009. Research and development approval was obtained from NHS trusts and primary care trusts which covered the areas where participants were recruited from. Copies of the documentation can be found in appendix B.

3.6

Recruitment

For professional participants, invitation to take part in the research was emailed to potential participants. Those who agreed to take part were contacted and arrangements made to conduct the interview at a time and location convenient for them, which was usually at the participants’ place of work.

A snowballing strategy was employed, whereby interview participants were asked whether they knew of any colleagues who could be invited to take part in the study. This proved to be an effective strategy, as several participants helped me recruit other participants for interviews, for example:

• Hospital pharmacists and administration staff forwarded email invitations to colleagues in their departments and were also provided with paper copies of invitation letters to distribute.

• A primary care pharmacist arranged for me to give a brief presentation about the study at a training event and invite attendees to take part.

For recruitment of lay pharmacy users, access to three community pharmacies and a hospital outpatients’ pharmacy was obtained via two of the pharmacy interview participants. Pharmacy users were approached in person and the study was explained to them. For both stages of the study, all participants were provided with information sheets about the study and written consent was obtained from all participants. Copies of the information sheets and consent forms provided to participants can be found in appendix B.

3.7

Data analysis

I noted above that grounded theory is part of a more general research approach called

‘comparative analysis’, and also that grounded theory does not specify one single technique for data analysis. Constant comparative analysis is a method of analysing data which involves a

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process of examining the dataset, looking for themes and ‘coding’ it to these themes. Glaser and Strauss emphasise the importance of thorough data analysis, so that the researcher gains awareness of everything in the set of data and is then in a position to draw out the important points, as opposed to conducting analysis in a piecemeal fashion, which would give a ‘false’ representation of the data, as important points would not be represented. 117

Several reference sources were consulted which deal with the practical tasks involved in handling and analysing qualitative data.117,119,122 After consideration, the ‘framework’ method was selected because it seemed to indicate a rigorous analysis process, which would lead to the findings presented from the study being grounded on the experiences of the participants. Also, the developers offer a guide to their method which is clearly expressed, and offers detailed instructions on how to go about each stage of the analysis. The authors define framework as:

an analytical process with five distinct though highly interconnected stages. [Which are] familiarisation, identifying a thematic framework, indexing, charting, mapping and interpretation.122

Once I had prepared my interview transcripts, I set out to work through each of the five stages, and the following paragraphs set out Ritchie and Spencer’s guidance on each stage, followed by an account of what I did.

Stage one - familiarisation.

Ritchie and Spencer state that the aim of this first stage of framework analysis is:

to become familiar with the range and diversity of the data, and gain an overview of the material gathered, and involves immersion in the data: listening to tapes, reading transcripts, studying observational notes....the analyst is...gaining an overview of the richness, depth and diversity of the data [and] beginning the process of abstraction and conceptualization. While reviewing the material, the analyst will be making notes, recording the range of responses to questions...jotting down recurrent themes and issues...122

As I undertook all of the interviews myself, I was close to the data from the beginning of the first interview. As noted, notes were taken during and after interviews, and at this stage early emergent themes were already being noted. I also transcribed all of the interviews, thereby listening to each participant’s account a second time. Each interview transcript was printed out and read. For the individual interviews, a single page summary was produced for each

interview. These summaries were considered alongside the transcripts, on which I also

highlighted salient portions of text, and wrote further notes, and also the research diary and field notes from the interviews.

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In terms of identifying a thematic framework, Ritchie and Spencer state that once the dataset has been reviewed, during the familiarisation stage, the analyst:

... returns to these research notes, and attempts to identify the key issues, concepts and themes according to which the data can be examined and referenced. That is, she or he sets up a thematic framework within which the material can be sifted and

sorted...The first version of an index is often largely descriptive and heavily rooted in a priori issues. It is then applied to a few transcripts when categories will be refined and become more responsive to emergent and analytical themes.122

The framework stage, indexing, is defined as:

...the process whereby the thematic framework or index is systematically applied to the data in its textual form.122

Richie and Spencer note that the framework stages are interconnected and may overlap, and I found that stages two and three were the most intertwined in this study. While reading the transcripts, I carried out a process of listing themes and assigning codes to parts of the data. All the interview data were entered into qualitative analysis software programme Nvivo and the programme was used to assign codes to the transcripts. As Richie and Spencer imply will happen, many of the early ‘codes’ and themes were ‘a priori’, sometimes following questions from the interview schedule, for example ‘what makes a good pharmacist?’ was a ‘theme’ while particular elements, such as ‘having good attention to detail’ or ‘being approachable’ were ‘subthemes’. Once initial codes had been applied to the transcripts, this allowed me to view the data ‘by code’ and re-read it by theme, across different transcripts. While doing this I noted further relevant issues and concepts, some of which then also became themes or subthemes within the index.

Some of the themes which emerged through reading the transcript were issues which I had already come across when reviewing the previous research, for example, pharmacists in this study mentioned that they thought others perceived them as ‘shopkeepers’, although none of the interview questions contained any suggestion of this theme, so this can be considered an ‘emergent’ theme, that was ‘grounded’ in the data, albeit not one that was a ‘new’ idea to me. Other themes were less expected, for example, analysis revealed a considerable amount of data relating to the issue of pharmacists being physically hidden from sight. Overall, the coding scheme developed both deductively, being informed both by pre-existing concerns, questions and hypotheses, and inductively, from the data themselves.