Phase 1: Survey of practicing pharmacists

A survey was administered to practicing pharmacists in New Zealand to elicit reports of discrimination in practice. The survey consisted of a questionnaire that was adapted from Hu et al. (2019) reporting discrimination towards surgical residents. ¹¹ In addition to the questions addressed from this study, we added questions (based on the literature review) relating to discrimination based on appearance, sexuality, religion, social skills, and English proficiency. We also adapted the sources of discrimination to reflect pharmacy practice. The questionnaire consisted of demographics and two matrices relating to discrimination and behaviors deemed to be associated with discrimination. Participants were informed that discrimination was defined as any perceived mistreatment due to gender, race, sexuality, religion, or other characteristics. The first matrix requested participants to state the frequency (never, a few times a year, a few times a month, a few times a week, every day, or other) of experiencing the type of discrimination or abusive behaviour listed directed towards themselves. Items to be considered included discrimination based ongender, race, sexuality, appearance, religion, English proficiency, social skills, or behaviours of physical abuse, verbal abuse, or sexual harassment. An item was also included for past, present, or expected pregnancy. The second matrix asked participants to select the source of discrimination or abuse for each item given above. Sources included none, patients, patient’s family, colleague, other healthcare professional, supervisor/leader, or other. Participants were able to select multiple sources, if applicable. Participants were asked to optionally provide an email address if they were willing to participate in a follow-up interview to better understand their responses. The questionnaire was uploaded to Qualtrics for distribution to potential participants. It was piloted with two individuals who belonged to the target population but no changes were made. These responses were not included in the results.

The survey was administered to a sample of practicing pharmacists in New Zealand using a pharmacist preceptor database maintained by the School of Pharmacy. This database contained 247 email addresses of individuals and/or pharmacies in New Zealand. It was unknown, however, how many active emails were captured in the database. Pharmacists were encouraged to share with other colleagues that may be interested in completing the survey, via the introductory email. The purpose of the survey was to characterize discrimination but to also identify participants willing to be interviewed in Phase 2. The first page of the survey included information about the study, expectations, and informed participants that their participation was voluntary and they could withdraw from participating at any time. A reminder email was sent two weeks after sending the first email. The survey remained open for one month. No specific sample size was targeted due to the exploratory nature of the study (e.g. attempts to capture any report of discrimination in pharmacy practice). Survey responses were extracted to SPSS v. 25 and descriptive statistics were used to summarize results.

Phase 2: Respondent interviews

Participants who provided positive interest and contact information in Phase 1 for a follow-up interview were contacted via email. Interviews were conducted to better understand how participants experience the phenomenon of discrimination in practice. A discussion guide was developed to guide the interview and included questions intended to elicit the participant’s narrative about the discrimination they had encountered in pharmacy practice. Investigators asked participants to recall any instance of discrimination they could remember experiencing in pharmacy practice. Then, questions were targeted to better understand the nature of such discrimination by asking questions related to the source of discrimination, how it was delivered (e.g., verbally, written), frequency, emotional impacts, and any actions or reactions provided by participants. All interviews were conducted by members of the investigator team. The lead researcher has extensive training and experience conducting interviews and trained the other two investigators himself. In addition to training, three pilot interviews were conducted with practicing pharmacists from the target sample and the full investigator team to receive feedback on the questions asked, as well as for feedback to be provided to all interviewers. Although no changes were made to the process or interview guide upon completion of the pilot, feedback was provided to interviewer with respect to question wording and probing for more information. All interviews (including pilots) were recorded.

Upon completion of the interviews, recordings were transcribed by one investigator and checked for errors by a second investigator. Full transcripts were provided to the full investigator team for coding. The senior researcher trained the other two investigators to code transcripts. Coding was conducted independently by all three investigators and was conducted via inductive, open-coding. This approach had investigators separate transcripts into words, sentences, or phrases that represented a single thought or idea. Each thought or idea was then given a unique identifying code. Once all coding was complete, investigators met to reconcile discrepancies and produce the final coding framework. Investigators then reviewed all codes collectively and began to categorize closely related codes based on similar meaning. After completion of this stage, investigators met to interpret themes from the categorized data.¹⁴ Transcripts were then reviewed to search for confirming and disconfirming evidence in relation to each theme and representative quotes were extracted. All investigators agreed upon final themes and supporting data.

This study was approved by the University of Otago Human Ethics Committee on January 24, 2020 (D20/005).

Reflexivity

As this study was focused on a sensitive subject nature (e.g. discrimination), it is important to recognize the perspective of the authors interpreting the study results. Two authors are undergraduate pharmacy students and belong to ethnic minorities of Asian descent. Both have encountered discrimination in their respective life experiences, specific to race. One author self-identifies as a member of a sexual minority group and has also encountered discrimination in both work and life experiences, including as a practicing pharmacist. These past experiences may have influenced how investigators interacted with interview participants, the types of probing questions asked, and how results were analyzed. For any instance identified relating to race or sexuality, all investigators had an open discussion regarding the interpretation before coding and development as a theme.

Phase 1: Survey

A total of 43 participants completed the survey. Demographic characteristics of respondents are provided in Table 1. The majority of respondents were experienced (>10 years), worked in urban settings, female (72.1%), heterosexual (90.5%), and identified ethnically as ‘New Zealander’ (63.3%). A total of 29 (67.4%) respondents reported experiencing prejudice or discrimination in pharmacy practice.

Table 2 provides results about the types of discrimination experienced by pharmacists. The most common types of discrimination experienced included discrimination based on gender, appearance, or past, present, or expected pregnancy. The occurrences of these types of discrimination were notably higher than the other types listed. Verbal abuse and sexual harassment were also frequently reported, as compared to the other types of abuse. Table 3 provides results about the sources of discrimination experienced by pharmacists. Most discrimination was sourced from patients, at much greater rates than other potential sources. The exception to this finding was discrimination sourced from supervisors/leaders with respect to expected, actual, or recent pregnancy. Verbal abuse was sourced primarily from patients, patient’s family, supervisors/leaders, and other healthcare professionals. Patients were the primary source of sexual harassment.

Phase 2: Respondent interviews

A total of 13 interviews were included for this phase. Ten interviews were solicited from positive survey responses and three were included from the pilot as minimal changes were introduced after pilot completion. Eleven of the participants were female and two were male. Seven identified as European White, two as Indian, two as Chinese, 1 as New Zealand Maori, and 1 as Middle Eastern. Eleven had greater than five years of experience and two had less than five years of experience. Three themes were interpreted from the interview data: discrimination characteristics, impacts, and prevention.

Theme 1: Discrimination occurs for a variety of reasons from different sources with different behaviors

Participants’ perceived reasons for the discrimination encountered were broad. These included a patient’s own expectations, the participant’s own gender (e.g. being female), ethnicity, age (e.g. young/new graduate), English language proficiency, or a lack or rapport with colleagues. With respect to patients’ expectations, some expected a specific profile of a pharmacist, ‘I would say there are pockets of society that will associate pharmacists with being a white, old man.’ A female spoke of gender discrimination against a colleague who recently gave birth, ‘She couldn’t come back part-time, she could only come back full-time, so she needed to resign.’ For ethnicity, an Asian respondent spoke of discrimination that occurred largely from elderly patients, ‘And it was primarily with elderly patients, where I would come in and before I say a word, they would say immediately, “I don’t want the Asian one.”’ Participants also revealed many different behaviours associated with discrimination, including racial slurs, bullying, dogmatism, and sexual harassment.

Theme 2: Impacts of discrimination are variable

The main message under the theme of impact was that impacts of discrimination on a person are highly individualized/personal. Affected individuals appear to have a wide range of emotional responses (e.g. no response, frustration, anger, sadness, disheartened). These responses appeared to vary in intensity between individuals but all were noted to reflect negativity and cause distress. Individuals also found discrimination negatively impacted their ability to perform at work (e.g. powerless, under-appreciated, stressful, lack of professional growth). For example, discrimination from patients caused one participant to question ‘why they would continue to work so hard’ if they were not being appreciated. Alternatively, one participant stated that ‘the person who feels potentially discriminated against also has a role in the way they think or perceive discrimination - it could just be that the persons had a bad day.’ Impact is therefore likely dependent on the nature of discrimination combined with how one perceives and reacts to it.

Participants discussed coping strategies that also appeared to be largely individualized or situational. Some participants expressed avoidance, ‘my way of coping is to try to be as far from him as possible at work.’ Others offered support in the context of a colleague experiencing discrimination, ‘if anyone says anything even remotely hinting at anything like that [racism], you [the colleague] come to me straight away.’ Others were self-assured, ‘it is not a reflection of who I am’ and this, at times, resulted in ignoring the discriminatory behaviors, ‘I am an inclusive person, I don’t think I see color, shape...I try to focus on the patient in front of me and focus on them and their needs.’

Theme 3: Preventative strategies can be broad and encompass multiple layers of society

The need to prevent discrimination from occurring in the workplace was addressed by many participants. Strategies discussed by participants ranged from individual efforts to workplace policies to promotion of tolerance and respect within local, national, and global societies. A common thread to participants’ responses was that discrimination was not occurring due to being a pharmacist but rather being a pharmacist exposed them to discrimination by some individuals (patients, colleagues, supervisors, other healthcare professionals). As such, prevention efforts need to be addressed at levels higher than simply instituting zero tolerance policies within the workplace. That being said, participants suggested workplace policies are important, as in many cases, there was no clear ‘route map’ of who to approach or how to deal with discrimination when it occurred. Participants largely agreed that pharmacy curricula should include training on encountering discrimination in practice and coping with depletion of personal and professional resilience. One participant suggested ‘revisiting’ the topic throughout each year of the pharmacy program.