RESEARCH

Providing Patient-Focused Care Within a Managed

Care and Pharmaceutical Care Environment:
A Person/Situation Interactionist Model for
Community Practitioners

by David A. Latif

Managed care has dramatically changed how health

care is delivered, received, and financed. Risk-shar-
ing systems based on capitation, partial fee with-
holds, efficiency incentives, and other payment methods have
revolutionized the whole medical delivery system. As a result
of managed care, pharmacy benefit management companies
(PBMs) have revolutionized the business of dispensing drugs
via their considerable influence over doctors and the prescrip-
tions they write. The community pharmacy has been signifi-
cantly affected by PBMs, both through fear of a loss of cus-
tomers if they do not join the network and through the loss of
revenue if they do join.
During the past decade or so the pharmacy profession has
OBJECTIVE: To propose an interactionist abies (e.g., organizational reward sys- been experiencing another paradigm change, a transition from
model of community pharmacists' tem) than by examiningeither one sepa- a profession that has traditionally emphasized a drug-product
patient-focused care to help research- rately. A major component of the model
focus to one that is more patient-focused") Pharmaceutical care
ers examine patient care activities under uses Kohlberg's cognitive moral devel-
opment theory, which has been signifi- reflects the transition to a patient-focusedprofession, and thus
the twin paradigm changes of managed
care and pharmaceutical care. cantly and pragmatically linked to health these two terms will be used interchangeably in this paper.
professionals' clinical performance. Pharmaceutical care is defined as "the responsible provision of
SETTING: Community pharmacies. Research propositions are offered and drug therapy for the purpose of achieving definite outcomes
directions of future research discussed.
that improve a patient's quality of Iife."4 Despite the transition,
DESCRIPTION: The model suggests that
KEYWORDS: Interactionist approach, pharmaceutical care has not become an integral part of the day-
more accurate predictions concerning
community practitioners' patient care patient-focused care, moral reasoning, to-day operations of most community pharmacists.5,6Therefore,
by simultaneous-
activities can be made cognitive moral development it might be useful to consider and develop a conceptual frame-
ly examining both individual variables work for studying the potential influences on community phar-
(e.g., self-efficacy) and situational vari- J Managed Care Pharm 2000: 233-239
macists' patient-focused care.
Previous approaches to the study of workplace behavior in
Alit/u)!"
. general and clinician performance in particular have tended to
emphasize either the individual role or situational variables as
DAVID A. LATIF, M.B.A., Ph.D., is Assistant ProJessoroj Phw'macy determinants of workplace behavior.7']O Such approaches are
Admillistmtion, Department oj Biopharmacelltical Sciences, Bernard]. Dunn problematic because neither captures the important interaction
School oj Pharmacy, ShCllandoah University, Winchester, VA.
between individual and situational variables. Stated differently,
AUTHOR CORRESPONDENCE: David A. Latif, lvl.B.A., Ph.D, Assistant workplace behavior is a function of both the person and the
ProJcssor oj Pharmacy Administration, Department afBiopharmaceutical
environment. Typical of this theory is a laboratory experiment
1]

Sciences, Bernard]. Dunn Schaal aJPharmacy, Shenandoah University,

by Monson et a!., who attempted to predict talkativeness by
Winchestel; VA 2260.1; Tel: 540-678-4341; fa.x:: 540-665-.1283; E-mail:
dlatiJ@su.edu.
placing extroverts and introverts in either a strong or weak
work setting.12 A strong situation is one in which most organi-
Copyright@ 2000 Academy oj Managed Care Pharmacy, Inc. All light$
zational members respond to organizational expectations to
reserved.
perform in particular ways.13 For example, a pharmacy may
give bonuses for prescription volume. As a result, a majority of
-.- ~- ~--~-- ---,--~
~

-.
-
.-

Vol. 6, No.3 May/June 2000 jMCP Journal of Managed Care Pharmacy 233
 Providing Patient-Focused Care Within a Managed Care and Pharmaceutical Care Environment:
A Person/Situation Interactionist Model for Community Practitioners

~:::nct'~I=-. Interactionist Model of Community Pharmacists' Patient-Focused Care Behavior

Dispositional
inOuences on

1 patient-focused
care

Patient-focused
Cognitive moral
~ Actual patient-
care decision . focused care
making -.. development stage

t
behavior

r Situational
inOuences on
patient focused
-
~

care

pharmacists may believe prescription volume is more important
to the pharmacy than unrewarded behavior such as counseling
patients. The authors concluded that only when the situation
was weak did extroversion predict talkativeness. When the sit-
uation was strong, extroverts were not significantly more talka-
clinical performance. 14.18 Moral-reasoning assessment is an
assessment of conceptual adequacy of moral thinking that
attempts to tap the basic conceptual frameworks that individu-
als use to analyze sociaVmoral problems and judges the proper
course of action. Simply stated, when tasks are nonstandard-
19

tive than introverts. Thus, predictions of talkativeness based on
either individual factors (extroversion or introversion) or situa-
tional factors (strong or weak work settings) would result in
fewer precise predictions of behavior than would examining
both simultaneously
The study of community workplace behavior may be
incomplete without an examination of the simultaneous effects
of both individual and situational factors. For example,
although a community pharmacist is often guided by the pro-
fession's code of ethics, the behaviors deemed most important
by the pharmacy may take precedence when conllict arises. If
a care and thus moderate the relationship between moral reason-
a conllict arises between the time required for counseling
patients and the time required for prescription dispensing, pre-
scription dispensing may be emphasized by the pharmacist at
the expense of counseling simply because the pharmacy
rewards that behavior.
This paper proposes an interactionist approach to the study
of how community pharmacists make decisions in patient-
focused care. It recognizes that both situational and individual
factors play critical roles in decision-making behavior, arid it
offers conceptual framework and a model using an interac-
a.
tionist approach to the study of community pharmacists'
patient-focused care.
A major component of the proposed model is Kohlberg's
cognitive moral development (CMD) theory, which has been
pragmatica!1y and significantly linked to health professionals'
ized and ill-defined (as the situations faced by community
pharmacists often are), individuals who are more advanced in
their moral reasoning skills seem predisposed to behave in a
more professional manner.'5.'8
Based on empirical evidence, the proposed model suggests
that moral reasoning is significantly and pragmatically associat-
ed \vith the patient-focused care activities of community phar-
macists.16 Because behavior does not take place in a vacuum,
however, other variables, both individual and situational, are
expected to inlluence community pharmacists' patient-focused
ing and this care. Situational factors would include the phar-
macy organization's reward system, pharmacists' perceptions of
significant others approving the provision of patient-focused
care, and workload pressures. In addition, three individual fac-
tors are proposed to inlluence patient-focused care: self-efficacy,
ego strength, and locus of control.
The proposed interactionist model of community pharma-
cists' pharmaceutical care decision-making behavior assumes
that moral reasoning plays a major role in this behavior (see
Figure 1). First, the pharmacist is confronted with a patient-
focused care decision. The pharmacist's moral reasoning level
determines the process of deciding the appropriate level of
patient care to provide. Moral reasoning skills are not enough to
predict and explain actual patient-focused care behavior. Both
situational (e.g., organizational climate) and individual (e.g.,

234 Journal of Managed Care Pharmacy jMCP MayiJune 2000 Vol. 6, NO.3
 Providing Patient-Focused Care Within a Managed Care and Pharmaceutical Care Environment:
A Person/Situation Interactionist Model for Community Practitioners
self-efficacy) factors are expected to interact with the moral rea-
soning of community pharmacists before arriving at the actual
patient-focused care behavior.
_ Barriers to Community Pharmacists'
AdoptingPharmaceutical Care
Partly because of the individual and situational barriers to pos-
itive patient-focused care, pharmaceutical care has not yet
become a reality for community pharmacy practice. Penna has
identified several situational barriers to providing patient-
focused care. These include a drug-product focus, the lack of a
service orientation, and a lack of pecuniary incentives3
Additional situational factors have been identified as barriers to
comprehensive patient care. Raisch reported that excessive
workload, lack of privacy, patient attitudes, and store layout are
the biggest impediments to pharmacists' providing counseling
services to their patients20
Embracing a patient-focused paradigm may be particularly
challenging for community pharmacists because often the phar-
macy organization's climate is incongruent with the provision of
pharmaceutical care. Organizational climate refers to how organ-
izations indicate to their members the behaviors that are impor-
tant for organizational effectiveness.21 According to Schneider et
aI., an organization's climate is reflected in two primary areas:
how the organization goes about its daily business (is it flexible,
innovative, stodgy?); and what goals the organization pursues
(quantity, cost containment, patient satisfaction, market
share)22
Because the primary revenue source of a community phar-
macy is dispensing, a conflict may arise if the time needed to
provide high level of patient care takes away from the time
a jective factors that can condition work attitudes, which results in
needed to dispense prescriptions.23 Consequently, the pharma-
cy organization is rewarded for prescription volume, and vari-
ous situational pressures may dictate that dispensing prescrip-
tions takes precedence over the provision of pharmaceutical
care. Factors such as individual differences have been shown to
potentially attenuate community pharmacists' embracing phar-
maceutical care. For example, Berger et a!. reported in a nation-
al study that one in five pharmacy students experiences a phe-
nomenon known as communication apprehension, which indi-
catesa level of extreme fear or anxiety associated with either real
or anticipated communicationH'25 A pharmacist who is appre-
hensive about communicating with others may have difficulty
embracing the profession of pharmaceutical care because it
requires verbal interaction. Other individual difference barriers
include the pharmacist's resistance to change and the ability
(perceived or real) to provide comprehensive patient care, as
well as the motivation to do SO.6.26
Odedina et a!., using a Theory of Reasoned Behavior Action
framework, reported that although community pharmacists had
high intentions to provide pharmaceutical care, they generally
Vol. 6,
reported low provision of care.27-28 Suggested explanations of
a
the discrepancy between intention and actual behavior include
low perceived social norm by physicians, low perceived behav-
ioral control, and low self-efficacies regarding the provision of
pharmaceutical care. Despite the barriers to its attainment,
pharmaceutical care has been incorporated into the mission
statements of all pharmacy associations, including the Joint
Commission of Pharmacy Practitioners. Thus, it has become the
hallmark of the patient-focused care paradigm.
_Interactionist Approach to Workplace Behavior
A debate has endured over the past years as to which is
60-70
a stronger influence on workplace behavior-the person or the
situation.29 Presently, many behavioral scientists acknowledge
that both personal and situational factors influence behavior.2130
The degree of influence of each factor in the production of
workplace behavior continues to be the subject of debate.
In recent years, most research on workplace attitudes and
behavior has been situation-based.31 The situationist approach
proposes that an individual's workplace behavior can be best
predicted and explained by assessing the characteristics of his
or her situation. ]3,32 For example, job-design researchers have
posited that job characteristics are the major determinants of
work attitudes and behavior.33,34 These researchers hypothesized
that in order to increase employee job satisfaction, employee
job-enrichment interventions must take place.
Other situational-based researchers have taken a social infor-
mation-processing perspective, They have argued that job atti-
tudes and behavior can be transformed by social influence and
contextual cues32,35 This line of inquiry leads to emphasizing sub-
more contingency-based models of workplace behavior.
In an insightful critique of the situationist position, Bowers
analyzed 11 studies that assessed the relative variance attributed
X
to situations, to individual differences, and to Situations
Individual Difference interactions, He concluded that, in 1.1 of 19
comparisons, individual differences contributed more to behavior
explanation than did situations (x=12.71 % versus x=10.17%).
However, the mean percentage of the variance attributable to the
7
Situations X Individual Difference interaction was 20,77%
The individual-differences, or dispositional, approach to
workplace behavior argues that a person's behavior can best be
predicted and explained by measuring his or her personality
traits, values, motives, abilities, and affect, because these vari-
ables are stable and are reflected in behavior.u1 Because these
individual differences are not readily observable, they are
inferred from temporal consistencies in observable behaviors'"
Staw and Ross, for example, reported significant stability of job
attitudes and consistency across many situations3] The authors
used the National Longitudinal Survey of Mature Males and
found that a person's job satisfaction in 1966 was a significant
May/June 2000 jMCP Journal of Managed Care Pharmacy 235
No.3
 Providing Patient-Focused Care Within a Managed Care and Pharmaceutical Care Environment:
A Person/Situation Interactionist Model lor Communit\l Practitioners
predictor of his job satisfaction in 1971, even after controlling
for pay, occupation, and employer. Gerhart used a younger sam-
ple of males and replicated the Staw and Ross study,29.36Gerhart
controlled for job complexity and reported results similar to
Staw and Ross.31.36
In further support of the proposition that individual differ-
ences account for a majority of the variance associated with
behavior is the fact that much of the empirical evidence sup-
porting the situational side of the behavioral equation is based
on experimental studies conducted in laboratory settings.
13
Bowers cogently argued that two problems are associated
with using laboratory experiments as a way of studying the rel-
ative contribution of traits and situations to behavior. First,
researchers often manipulate the experimental treatment condi-
tions until the different conditions have their desired effect.
Bowers stated that setting up conditions to have an effect and
then arguing for the dominance of situations over traits is an
inferential leap. The problem is that when laboratory studies do
what they are supposed to do-demonstrate a main effect-it
places constraints on the display of individual differences. The
result. is often the appearance that traits are irrelevant in the
study of workplace behavior.
Second, Bowers noted that the major component of the lab-
oratory experiment-random assignment of subjects to treat-
ments-violates a basic tenet of human behavior in organiza-
tions: that humans select themselves into and out of workplace
settings? An interactionist theory of workplace behavior
advanced by Lewin posits that behavior is a function of the
person and the environment. This theory states that both situ-
ational and dispositional factors influence workplace behav-
ior.1I Stated differently, interactionism argues that an individ-
ual's workplace behavior is as much function of the situation
a Nonprofessional employees, such as assembly-line workers at a
as the situation is a function of the person.' Because workplace
behavior does not take place in a vacuum, more accurate infor-
mation concerning outcome behavior can be obtained by
examining both situational and dispositional factors. Bowers
summed up the interactionist approach by stating that: "The
situation is a function of the observer in the sense that the
observer's cognitive schemas filter and organize the environ-
ment in a fashion that makes it impossible to ever completely
separate the environment from the person observing it. A rel-
"?
evant example using the interactionist approach to the study of
community pharmacists' clinical performance is depicted in
the following example. A consultant to a large chain pharmacy
organization has been asked to determine the reasons that
some of the chain's pharmacists' provide patient-focused care
while others do not. The consultant, while examining the envi-
ronmental half of the behavioral equation, concludes that a
significant barrier to a pharmacist's emphasizing patient-
focused care is an organizational climate that does not foster
this behavior.
236 Journal of Managed Care Pharmacy jMCP May,fJune 2000
In other words, the climate of the pharmacy organization is
incongruent with the basic tenets of patient-focused care: pre-
venting, identifying, and resolving patients' drug therapy prob-
lems. Assume that upon further examination, the consultant to
the chain pharmacy organization discovers that the chain's reward
system is not conducive to the provision of patient-focused care.
It rewards, or at least is perceived by its pharmacists as reward-
ing, prescription volume over patient care. This may result in a
lower level of patient-focused care. According to Kerr, the orga-
nizational reward system is often used as a way of encouraging
behaviors that the organization deems important to its effective-
ness. Kerr states that employees of organizations "seek informa-
tion concerning what activities are rewarded, and then seek to do
(or at least pretend to do) those things, often to the virtual exclu-
sion of activities not rewarded."3' Thus, based on an examination
of the environmental side of the interactionist approach, the con-
sultant may report to the chain pharmacy organization that the
organizational reward system and climate are barriers to their
pharmacists' provision of comprehensive patient care.
The other half of Lewin's interactionist theory of workplace
behavior focuses on dispositional determinants. II Because
behavior is a function of the person and the environment, indi-
vidual differences can be expected to playa significant role in
pharmacists' clinical performance. Individual differences may
significantly influence workplace behavior in a profession such
as pharmacy for two reasons: First, because one cornerstone of
a profession is autonomy, individual pharmacists can be expect-
ed to exert more influence over their behavior than nonprofes-
sional employees. For example, because of their knowledge of
drugs, pharmacists may be given a great deal of latitude in rec-
ommending or not recommending drug therapy regimens.
car factory, probably are not afforded the same latitude in mak-
ing assembly-line work decisions.
Second, research indicates that individual differences are
less predictive of behavior in "strong" situations in which
intense situational pressures to behave in a particular manner
are present. 12.38 Although a community pharmacy setting may be
classified as a "strong" situation, dispositional factors can be
expected to playa major role in the production of professionals'
workplace behavior because many professional behaviors are
conditioned by the beliefs and values of the individua]39 For
example, those pharmacists at higher moral-reasoning levels
may exhibit greater degrees of consistency between clinical
decision making and actual behaviors, regardless of the inher-
10,15.39
ent situational pressures.
As a result of examining pharmacists' behavior from an
interactionist perspective, the consultant to the chain may
report that, while the reward system and organizational climate
are barriers to pharmacists' providing patient-focused care,
some pharmacists who are predisposed to a high level of patient
Vol. 6, No.3
 Providing Patient-Focused Care Within a Managed Care and Pharmaceutical Care Environment:
A Person/Situation Interactionist Model for Community Practitioners
care may ignore the inherent situational pressures of the phar-
macy and thus provide a high level of patient care despite these
pressures. However, most community pharmacists are inOu-
enced, either positively or negatively, by the pharmacy org-
anization's climate. Thus, the provision of pharmaceutical care
has the best chance of becoming an integral part of pharm-
acists' day-to-day activities if the climate fosters patient-
focused care.
_Interactionist Model of Pharmacists'
Patient-Focused Care Decision Making
Based on the premise that workplace behavior is a function of
the person and the situation, the proposed model of communi-
ty pharmacists' patient-focused care posits that clinician deci-
sions are explained by an interaction of individual and situa-
tional components. It impJicitly assumes that neglecting to pro-
vide high level of patient-focused care violates the ethical
a
covenant embodied in the pharmaceutical care concept.40 The
proposed model is based on Trevino's interactionist model of
ethical decision making in organizations.1O An integral compo-
nent of the model includes pharmacists' moral reasoning skills,
which have been empirically shown to positively influence clin-
ical performance. l5-l8
Moral reasoning emanates from the field of cognitive devel-
opment and provides a theory that explains the human deci-
sion-making process prior to behavior." Rather than being con-
cerned with what is socially or morally right or wrong, moral
reasoning is concerned with the processes individuals go
through to arrive at decisions. Moral reasoning is based on
Kohlberg:SCMD theory, which is a stage theo!)' of moral develop-
ment." Through extensive interviewing and observation of ado-
lescents, Kohlberg derived a model that conceptualized ethical
judgment based on a series of developmental stages. Kohlberg's
theory of moral development posits that individuals advance
along a stage-sequence continuum that represents a series of
cognitive levels akin to the rungs of a ladder. Most individuals
move upward through these developmental levels, beginning
with "preconventional morality" up to "conventional morality"
and sometimes to the highest level, "postconventional moraJi-
ty." Each level has two developmental stages, and individuals
progress upward in an invariant sequence. In other words, an
individual progresses from stage to stage in a logical sequence.
Theoretically, stages cannot be skipped. Table 1 provides high-
Jights of the six stages.
Both theoretical and empirical evidence support the propo-
sition that higher moral reasoners wi1l put the patients' con-
cerns above personal or company interests and, as a result, may
provide patients with a high level of care regardless of the situ-
ational pressures encountered.
]5-18
The psychology of moral reasoning provides a useful theo-
retical framework for understanding how pharmacists arrive at
Vol. 6,
_1f~":IIII=-_ Six Stages in the Concept of Cooperation
I /
Stage I-The morality of obedience: Do what you're told.
Stage 2-The morality of instrumental egoism and simple exchange:
Let's make a deal.
Stage 3-The morality of interpersonal concordance: Be considerate,
nice, and kind, and you'll make friends.
Stage morality of law and duty to the social order: Everyone
4-inThesociety is obligated and protected by the law.
to
Stage 5-The morality of consensus-building procedures: You are
obligated by the arrangements that are agreed to by due-
process procedures.
Stage morality of nonarbitrary social cooperation: Morality
6-The
is defined by how rational and impartial people would
ideally organize cooperation.
Source: RestjR and Narvaez D, Mora! development in the professions:
psychologyand applied ethics. Hillsdale, Nj: Lawrence Erlbaum
Associates, 1994, 5.
decisions. It provides the basis [or a number of propositions
that may be tested in future research.
Prior theoretical and empirical research lead one to expect
community pharmacists to reason at the conventional \evel of
cognitive moral development.4!,;) Thus, most pharmacists are
greatly inOuenced by the organizational climate of the pharmacy
when determining the appropriate \evel of patient-focused care.
Proposition one, A majority of community pharmacists
reason at the conventional level of cognitive moral development
(stages 3 and 4). On the other hand, community pharmacists
who do reason at the postconventionallevel of cognitive moral
development are expected to behave consistently with their
internally held beJiefs.
Proposition two. Community pharmacists at the postcon-
ventionallevel of moral reasoning (stages 5 and 6) will be more
likely to exhibit consistency between patient-focused care judg-
ment and behavior than those pharmacists at lower stages.
Proposition three, Community pharmacists who partici-
pate in ethics-training programs based on cognitive moral-
reasoning teaching strategies will significantly increase their
moral-reasoning scores,
Empirical research suggests that specific training interven-
tions can increase the cognitive moral development scores of
participants.43
Proposition four. Community pharmacists who score high
on the self-efficacy scale wi1l be more likely to exhibit consis-
tency between patient-focusedcare judgment and behavior than
those pharmacists who score low on that scale.
Individual differences are also expected to affect the pro-
vision of patient-focused care. Three dispositional factors are
No.3 May/June 2000 jMCP Journal of Managed Care Pharmacy 237
 Providing Patient-Focused Care Within a Managed Care and Pharmaceutical Care Environment:
A Person-Situation Interactlonist Model for Community Practitioners
proposed to influence this behavior: self-efficacy, ego-strength,
and locus of control. Self-efficacy is a construct that expects bet-
ter performance for individuals who think they can perform
well on tasks!4 Self-efficacy is associated with work-related per-
formance in adaptability to new technology, faculty research
productivity, and behavioral modeling!."47 Odedina reported
that those community pharmacists who ranked high on the self-
efficacy scale were more likely to provide a high level of phar-
maceutical care than those scoring low on the construct.6
Proposition five. Conventional community pharmacists
with high ego strength are more likely to exhibit consistency
between patient-focused care judgments and behavior than
conventional pharmacists with low ego strength.
Ego strength refers to strength of conviction or self-regulat-
ing skills. lndividuals with high ego strength ratings are expect-
ed to be less vulnerable to situational pressures and more like-
ly to follow their convictions than those low on the scale. Rest
and Navaez demonstrated that Stage 4 individuals with high
ego strength were more likely to resist the temptation to cheat
than those Stage 4 individuals with low ego strength."
Proposition six. Conventional internal locus-of-control
community pharmacists are more likely to exhibit consistency
between patient-focused judgment and behavior than conven-
tional external locus-of-control pharmacists.
Rotter's internaVexternal scale measures perceptions of con-
trol over life's events. An "internal" believes that outcomes are
the result of one's own efforts, while an "external" believes out-
side forces such as luck or destiny account for outcomes.4S
Proposition seven. Conventional and preconventional
high-prescription-volume pharmacists will exhibit less consis-
tency between patient-focused care judgment and behavior
than postconventional high-prescription-volume pharmacists.
Because workplace behavior is function of both disposi-
a organizational values and norms as welJ.38 Consider, for exam-
tional and situational factors, certain work-related pressures are
expected to influence community pharmacists' patient-focused
care behavi.or.3,2o,49 For example, pharmacists who experience
high workload pressures, such as routinely dispensing a high
volume of prescriptions per day, may provide their patients with
a level of patient care that differs from that of pharmacists who
dispense a lower volume.
Proposition eight. Conventional and preconventional com-
munity pharmacists are more likely to be influenced by signifi-
cant referent others concerning their patient-focused care be-
havior than postconventional pharmacists.
Pressures exerted by patients, supervisors, and physicians are
expected to influence community pharmacists' patient-focused
care behavior. Some patients may be more receptive to the pro-
vision of pharmaceutical care than others. Supervisors may feel
pressure to increase short-term profitability through increased
prescription volume. In addition, pressure may be exerted by the
physician on the pharmacist to dispense a particular prescription
238 Journal of Managed Care Pharmacy jMCP May/June 2000
for a particular condition, even if an alternative drug therapy is
more effective. These situational factors are' expected to moder-
ate or interact with dispositional factors in the production of
community pharmacists' patient-focused care.
Proposition nine. Conventional and preconventional com-
munity pharmacists are more likely to be influenced by the phar-
macy organization's reward system concerning their patient-
focused care than are postconventional pharmacists.
The pharmacy organization's climate and culture are expected
to influence community pharmacists' patient-focused care. The
reward system, in particular, is expected to shape the pharmacy's
climate and culture. Whereas an organization's climate is readily
observable by the policies, practices, and rewards of the organi-
zation, its culture is not so directly visible. Culture may be
defined as the shared beliefs, values, and assumptions existing
within an organization.'o An organizations culture can be inferred
from its climate. For example, if a community pharmacy rewards
prescription volume and not pharmaceutical care activities (cli-
mate), its pharmacists may come to believe that management val-
ues prescription volume over pharmaceutical care (culture).
Therefore, depending on how reward systems are developed,
administered, and managed, they can help shape culture specifi-
cally because of their influence on worker motivation, satisfac-
tion, and membership. If community pharmacists are rewarded
for prescription volume, this pay-and-performance link can dra-
matically influence the pharmacys culture through its clear com-
munication of the performance norms of the organization.
_ Conclusions and Future Research
The proposed interactionist model of community pharmacists'
patient-focused decision making may be useful in predicting
changes, not only in pharmacists' values and behavior but in
ple, what happens when a new pharmacy school graduate,
whose primary reason for becoming a pharmacist was to help
prevent, identify, and resolve his patients' drug therapy prob-
lems, enters a community pharmacy. If the members of the
pharmacy cohesively and intensely value dispensing more than
patient care, will the new pharmacist's values change, and
patient care become a lower priority? Will his/her behavior
change-that is, will he or she begin to spend more time on dis-
tributive functions than initially anticipated? Or will the new
pharmacist inspire his or her colleagues to emphasize patient
care and, eventually, recruit more patient-oriented pharmacists7
The goal of this paper has been to illuminate the need for
and propose an interactionist model for community pharma-
cists' patient-focused decision-making behavior within the pres-
ent paradigm changes resulting from managed care and phar-
maceutical care. Future research on predicting and explaining
pharmacists' pharmaceutical care performance can benefit from
a consideration of both dispositional and environmental factors,
Vol. 6, No.3
 Providing Patient-Focused Care Within a Managed Care and Pharmaceutical Care Environment:
A Person/Situation Interactionist Model for Community Practitioners
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