The focus groups
A total of 17 participants out of the 20 invited participants took part in the study. No new ideas or additional meanings to the issues were introduced after the second focus group session. Hence, the research team agreed at a consensus meeting that information saturation had occurred, including meaning saturation.
Given the structure of the invitees, it was decided to stratify them into groups containing those in the CP roles (n = 8/10, all working in community pharmacies) and other specializing pharmacists (n = 9/10), who were asked to put themselves “in the shoes” of a clinical pharmacist and give their own perspectives. The age range in the total study population was 24–50, and the CP experience ranged from just below 1 to 18 years, with an overall group’s experience of 7.3 ± 6.5 years. Female participants made up the majority in both groups. The demographic characteristics of the study participants are presented in Table 1.
Table 1
Demographic characteristics of the study participants
Characteristic
|
Number
|
Frequency (%)
|
Gender
|
|
|
Male
|
4
|
24
|
Female
|
13
|
76
|
Age (years)
|
|
|
20–24
|
2
|
12
|
25–29
|
6
|
35
|
30–34
|
2
|
12
|
35–40
|
5
|
29
|
> 40
|
2
|
12
|
CP Experience (years)
|
|
<1
|
1
|
6
|
1–5
|
2
|
12
|
6–10
|
3
|
18
|
11–15
|
1
|
6
|
16–20
|
1
|
6
|
CP Experience (years) - Mean (SD)
|
8.1 (5.5)
|
Abbreviations used: CP – clinical pharmacy, SD – standard deviation.
Insert Table 1 here.
Coding
A total of 50 codes were assigned to the transcripts across the nine categories, which were deductively derived from the focus group guide. The top 10 codes had a frequency above 50% (Table 2).
Table 2
Top 10 codes ranked in descending frequency order
Code
|
Effective Communication
|
Emotional Awareness of Others
|
Emotional Self-Awareness
|
Emotional Self-Control
|
Trust
|
Respect
|
Patient-centricity and focus
|
Emotional Self-Management
|
Work under pressure and effective stress management
|
Self-confidence and knowledge
|
Insert Table 2 here.
Coding reliability testing
Greater than 80% agreement was reached for codes in 7 out of 9 categories, while the code assignments in the two remaining categories were settled at the consensus meeting.
Thematic analysis
Given the specifics of the EI topic, numerous code repetitions emerged across categories. Therefore, inductive thematic analysis was employed in three steps: (1) identifying the characteristics of emotionally intelligent clinical pharmacists, (2) identifying issues and challenges in everyday CP practice (as themes) and defining EI strategies to address these challenges (as subthemes), and (3) identifying EI development strategies in the education and professional development of clinical pharmacists.
Definition of an emotionally intelligent clinical pharmacist
Participants recognized, fully reflected, and related the desired EI behaviors to their everyday practice. They identified several key characteristics of emotionally intelligent CPPs (Fig. 1). The codes representing characteristics in the first step in the latter analysis emerged into more developed themes, issues and challenges, and respective EI strategies (Table 3).
Table 3
Themes and subthemes by category
Category
|
Issue/Challenge (Theme)
|
Emotionally Intelligent Strategy (Subtheme)
|
EI importance for CP practice
|
managing stressful situations (drug addicts, aggressive, dissatisfied patients)
|
emotional self-awareness (ESA)
|
|
communication in challenging situations (taboos, e.g., emergency birth control)
|
emotional awareness of others (EAO) - understanding needs
|
|
staying patient-focussed with person-centered approach
|
demonstrating empathy
|
|
understanding patient needs/vulnerable groups
|
self-control and management of our own emotions (not to get provoked and stay calm/composed)
|
|
interprofessional relationships
|
EAO, emotional expression (EE)
|
EI and professional error avoidance
|
work under pressure and stress management
|
building resilience through ESA and emotional self-management (ESM)
|
|
building and maintaining focus
|
ESA and intention-to-be-focussed practices
|
|
effective communication (poor communication as an error)
|
demonstrating tolerance, understanding, and empathy
|
|
building trust
|
EAO, emotional management of others (EMO) and EE
|
|
seeking solutions/fast decision-making
|
ESA and emotional reasoning (ER)
|
EI and prevention of inadequate behaviors towards pharmacists (secondary victims)
|
building trust
|
effective, competent, patient-centered, assertive communication built on ESA, EAO, EMO, and EE
|
|
|
effectively building the capacity to adapt to different people
|
|
creating a positive work environment
|
ESA, EAO, EE, demonstrating empathy, fostering team and self-development, being tenacious
|
|
staying composed
|
ESA, EAO, EMO, demonstrating patience in work with people/emotional self-control (ESC)
|
|
work under pressure and stress management
|
building resilience through ESA, ESC, and ESM
|
EI and good communication within CP teams
|
successful management and leadership
|
clear, precise, positive, and open communication to embrace change
|
|
|
building a feedback culture
|
|
|
ESA, EAO, EE, ER, ESC, ESM, EMO
|
|
creating a positive work environment
|
EAO, showing understanding and demonstrating empathy
|
|
building teamwork and interpersonal relations
|
demonstrating respect, EAO, EE, ESC, ESM, ESA and EMO
|
EI and conflict prevention and resolution
|
recognize the moment and understand the needs
|
EAO
|
|
|
respecting diversity
|
|
|
person-centered care
|
|
patient complaints
|
ESC, EAO, EMO
|
|
the inadequate reaction of the employee
|
leadership support, building team spirit
|
|
|
EAO, demonstrating understanding and empathy
|
|
conflict prevention
|
EAO, ESA, building resilience, ESC
|
|
building leadership capabilities
|
developing ESA, EAO, EE, ER, ESC, ESM, EMO
|
EI and interprofessional collaboration
|
mutual respect
|
good, open communication
|
|
|
step in other's shoes
|
|
|
flexibility/openness
|
|
|
ESA, EAO
|
|
Vanity
|
EAO - being aware of how the others feel
|
|
|
interprofessional understanding and knowledge - the higher the knowledge, the lower the vanity
|
|
|
ESA
|
|
pharmacist's proactivity in a communication cycle: patient‒physician-pharmacist
|
ESA, EAO
|
|
building trust
|
ESA, EAO, EE
|
|
building and maintaining focus
|
ESA and intention-to-be-focussed practices
|
EI and loyalty of users of pharmaceutical services
|
building trust
|
understanding needs
|
|
|
demonstrating empathy
|
|
|
EAO - showing that you care
|
|
high-level, patient-centered care
|
EAO
|
|
|
EMO - being pleasant, kind, polite, with a positive attitude, making people feel well
|
|
|
ESC
|
|
building and maintaining focus
|
ESA and intention-to-be-focussed practices
|
|
|
ER, EE
|
Abbreviations used: EI – emotional intelligence, CP – clinical pharmacy.
Insert Fig. 1 here.
In the participant's opinion, an emotionally intelligent CPP is a competent and self-confident professional who stays calm in every situation, manages situations well, and remains focused on the patient through person-centered interaction. CPPs are aware of their own emotions and the emotions of others and manage them well through effective communication with patients and colleagues, build trust, and work well under pressure while adequately managing stress. Participants in the second focus group put more emphasis on “balance in communication” (S9) and “emotional self-control” (S14) as prerequisites for effective patient-centered care.
Importance of EI for CP practice
Participants in both groups acknowledged that effectively communicating and maintaining focus proved particularly challenging with aggressive, dissatisfied patients due to financial constraints, longer time-to-service, or patients with alcohol or drug abuse problems prone to conflicts. In such circumstances, high EI skills are required to help individuals perceive, understand, and manage their emotions and those of others; stay composed and calm; and act with self-confidence.
Communication is also challenging for vulnerable patient groups, patients with malignancies, elderly patients, or patients in situations where “taboo” topics are discussed, such as patients requiring emergency birth control. It was emphasized that CPP’s understanding of patient needs, being emotionally aware of others, and demonstrating empathy, as well as “well balancing” the expression of one’s own emotions to create bonds and trust, are essential EI strategies in such instances.
“With some oncology or other difficult patients, controlling emotions is so important, so we can protect them and show more empathy. We used to have in our pharmacy a patient support program for oncology patients… Therefore, all kinds of things happened, all kinds of situations and some outpourings of emotions on their part… It affected us personally; emotional balance, control, and empathy were vital…” (S14)
Participants stressed the importance of EI for intra- and interprofessional collaboration, which was later discussed in detail under a separate category.
EI and professional error avoidance
Research has identified numerous EI-related factors contributing to dispensing errors in community pharmacy settings [31]. The example is working under pressure due to CPP work complexity, which, together with other distracting factors, induces stress and hampers focus.
“Sometimes the mistake is not in dispensing the medicine. Sometimes, the mistake is having a wrong attitude towards the patient, a wrong attitude towards a colleague, or wrong communication. … You may not have a chance to correct it. However, how much is it possible to control ourselves, manage our emotions and behavior to be fair to others?” (S2)
The groups suggested that the answer might be in further ESA development, which would support building resilience, better ESM, and enhanced tolerance, demonstrating understanding and empathy so the pressure would ease on either side: the CPP, the patient, and the physician. With enhanced ER, decision-making processes improve and create less pressure. Intention-to-be-focused practices may lead to decreased error frequency and overall outcome improvements.
“The pharmacist's thoughts of the day should be positive, with a clear intention: ‘Today, I will try to be 200% myself, to devote myself to the patients and to do my job with maximum quality’." (S5)
In the event of dispensing errors, participants felt that they could be handled well if support in the organization was in place and if trust had been established with patients and colleagues through practical demonstrations of EAO and EE.
EI and prevention of inadequate behaviors towards pharmacists (secondary victims)
Participants observed that patients' behaviors depend on the CPP’s behavior. Investing in development to lead effective patient-centered communications might build trust and ultimately prevent inadequate behaviors toward pharmacists. Creating a positive work environment through team EI development may cultivate satisfaction on both ends and alleviate tensions even with the most aggressive patients, such as those with drug addiction problems. Furthermore, such an environment fosters teamwork, self-development, and changes in behaviors, with more empathy, patience, and tenacity being demonstrated.
“I think satisfaction is quite important. Satisfaction with the work environment, satisfaction with the job, satisfaction with yourself… with such an attitude, you feel well, happy, satisfied. Then, you pass it on to others, both to the patients and colleagues.” (S8)
Participants felt that ESA, EAO, EMO, and EE competencies were essential for further development, together with ESC, which was more frequently emphasized in the second focus group.
Insert Table 3 here.
EI and communication within CP teams
Building further on the importance of a positive work environment, participants stressed the significance of emotionally intelligent leadership, which stimulates transparent, open, and positive communication and supports embracing change and feedback culture developments.
“Our communication should be an open type communication to have feedback from colleagues… they should feel and have complete freedom to turn to leaders for anything… should feel support and respect… We cannot change people, but we can help them be better here with us, in our organization.” (S1)
To show more understanding, empathy, and respect, participants felt that all EI competencies are equally essential for development.
EI and conflict prevention and resolution
Effective, emotionally intelligent leadership was recognized to be vitally important in preventing conflicts within CP teams. If disputes occur with patients or interprofessionally, “the leader should stand by his team and provide support… that is where his role is…” (S10).
The participants stressed that the building of emotionally intelligent workplaces was equally important.
“A colleague started arguing with me in a team meeting... I could have reacted in several ways, but I chose clear and concrete communication, prevented conflict, and primarily thought about the rest of the team.” (S4)
Participants felt that recognizing the moment and understanding needs are critical in conflict prevention and found enhanced EAO and respecting diversity to be EI strategies to foster those needs.
EI and interprofessional collaboration
A lower level of mutual respect was found to be challenging within interprofessional teams, and some participants felt that “these situations with physicians often occur out of vanity” (S1), as well as due to CPP’s lack of proactive communication. They found ESA, EAO, openness, flexibility in communication, interprofessional knowledge, and experience exchange to be promising strategies for addressing these challenges.
“We solved the prescribing-dispensing-reimbursement issue… It was a collaboration between the pharmacy, the doctor, and the patient's family... In addition, when we achieve that circle, it makes it easier for everyone, for all the participants... if we have open communication with the physician so that we can easily get in touch with him, it becomes much easier for the patient and us…” (S2)
EI and the loyalty of users of pharmaceutical services
Loyalty was recognized by the participants as positively correlated with the quality of patient-centered care. The quality of care was defined as “professionalism, focus on the patient and his health, …, understanding person’s needs, … and building trust” (S1). Therefore, EAO, showing that one cares, demonstrating empathy, and EMO through a positive attitude, kindness, and making people feel well, seems to be a good EI strategy for fostering behavioural change to further increase loyalty.
EI development programs
The third step in the inductive thematic analysis required a specific approach to best structure themes and subthemes for EI development in CP practice emerging from defined codes. Donabedian’s framework was applied (Fig. 1) [32].
Insert Fig. 2 here.
The focus group participants achieved a profound understanding of EI concepts. They demonstrated the ability to identify issues and challenges where EI competencies are essential for fostering effective behaviors (“embracing change in CP practice” – S9, for example”). Participants emphasized their sense of being ill-prepared for CP practice after graduation. They stressed the importance of implementing EI content in curricula at all stages of CP development, including undergraduate and specialization programs.
“Education about EI should be included from the early days of studies because I think that the earlier we develop the skills, the better we will manage everything later, …, both privately and at work. … it all seemed fabulous to me at university - and then, you face a conflicting patient, and you just need to manage... You do not know what hit you or how to react, and you are expected to be professional. ...whatever work we do, we work with people, most often, and everything, again, depends on your EI.” (S1)
The groups identified training with interactive EI sessions combined with behavior modelling (“watching videos of best practice behaviors” – S3) and behavior changing workshops (“role plays in groups of three with rotating roles” – S4, S9) as the best EI development approaches. Learnings are easily implemented in CP practice, and “the follow-up, reflection, and experience exchange sessions should be organized” (S1, S3, S17). Therefore, several participants emphasized the methodology applied in this research as the most suitable for their professional development. Many have found online programs to be good EI development platform options. They stressed the importance of ongoing efforts in the education of faculty members, emphasizing the need for a shift in teaching and practicing methodologies.
Participants stated that EI development programs would enhance all EI competencies and improve CPPs’ stress management, self-confidence, and overall well-being. They foster team spirit, CPP self-dedication, and commitment to their development. They may improve inter- and intraprofessional collaboration, leadership, focus, person-centered communication, and ultimately patient-related outcomes.