Research in Social and

Administrative Pharmacy j (2013) jj

Review Article
A meta-narrative review of recorded
patientpharmacist interactions: Exploring biomedical
or patient-centered communication?
Muna S. Murad, M.Sc.a,
Trish Chatterley, M.L.I.S.b,
Lisa M. Guirguis, M.Sc., Ph.D.a,*
a
Faculty of Pharmacy and Pharmaceutical Sciences, 3-171, Edmonton Clinic Health Academy, University of Alberta,
11405 87 Avenue, Edmonton, Alberta, Canada T6G 1C9
b
John W. Scott Health Sciences Library, University of Alberta, Canada

Abstract
Background: Pharmacists worldwide require improved patient-centered communication skills as they
transition from a dispensing role to enhanced involvement in patient care. Researchers have studied
pharmacist communication through audio and video recordings of patientpharmacist encounters. A
meta-narrative review of research using these recordings will oer insight into the extent of biomedical vs.
patient-centered communication in patientpharmacist exchanges.
Objectives: This review aimed to characterize research on patientpharmacists interactions using audio or
video recordings and explore the 1) focus of research questions, 2) study design, 3) data analysis methods,
4) main ndings and 5) presence of patient-centered vs. biomedical models of interaction.
Methods: Drawing on the principles of meta-narrative systematic review, a literature search was performed
to identify studies published in English. No publication date limits were implemented. Key search terms
included: audio recording, video recording, communication, patient counseling, patient
interaction, discourse analysis, conversation analysis, narrative analysis, and content analysis.
The search was conducted in ve databases: Medline, Embase, International Pharmaceutical Abstracts
(IPA), Web of Science, and Academic Search Complete.
Results: Forty-one articles met the inclusion criteria and represent 32 unique collections of patient
pharmacist recordings. The 23 quantitative studies focused on what was in the interaction, whereas the 5
qualitative studies characterized specialized pharmacy practice and 13 studies used conversational analysis
to describe how patients and pharmacists interact. The majority of research described the content of
recorded interactions in community pharmacies. Twenty-three studies presented evidence of a biomedical
model, whereas 8 studies characterized a patient-centered focus.
Conclusions: A developing body of research used recordings to describe the content of patientpharmacist
communication and explore the quality of the interactions, validation of coding tools, impact of an
intervention, and patientpharmacist power asymmetry. Study ndings, particularly the identication of

* Corresponding author. Tel.: 1 780 492 9693; fax: 1 780 492 1217.
E-mail address: lguirgui@ualberta.ca (L.M. Guirguis).

1551-7411/$ - see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.sapharm.2013.03.002
2 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120

biomedical vs. patient-centered communication, were guided by the quantitative, qualitative, or

conversational analysis research paradigm.
2013 Elsevier Inc. All rights reserved.

Keywords: Audio recordings; Video recordings; Patient centered care; Patientpharmacist interactions; Biomedical

Introduction increased patient satisfaction, treatment adher-

ence, improved medical outcomes, and decreased
Evidence demonstrates that pharmacists care
number of malpractice claims.914
enhances patient health.1 Pharmacy practice
To transition to patient-centered care, phar-
worldwide is evolving from dispensing and educat-
macists require strong communication skills.15
ing patients to providing patient-centered care
Two recent review articles have examined pa-
where pharmacists assess the appropriateness of
tientpharmacist communications. Shah and
medication therapy, ensure patients have an un-
Chewning found that research has focused on
derstanding of their drug therapy, encourage ad-
one-way communication from the pharmacist to
herence to medications, and monitor patient
the patient.3 Puspitasari et al took an interna-
outcomes.2 In the pharmacy literature, patient
tional perspective and found pharmacist counsel-
pharmacist communication has been conceptual-
ing rates vary worldwide from 8% to 100%,
ized as a transmission action or a transaction.3
with more counseling for new rather than rell
Transmission is a one-way process from sender to
prescriptions.16 Pharmacists more routinely pro-
receiver. Biomedical communication usually fol-
vided information on directions for use, dose,
lows a transmission model where the pharmacist
medication name, and indications than on side ef-
concentrates mainly on providing medication-
fects, adverse events, and storage.16 Both studies
related information. The transaction model is
reported diverse research methods with a focus
a two-way process, where shared meaning is nego-
on self-report surveys, non-participant observa-
tiated between two participants such as in patient-
tion, interviews, and shopper studies that were
centered communication where the pharmacist
cross-sectional in nature. These studies frequently
identies and responds to patients ideas and emo-
focused on the pharmacist and did not capture ac-
tions regarding their illness.3
tual patientpharmacist interactions. Shah and
The main dierence between the patient-
Chewing reported only one audio analysis that
centered and biomedical models is the level of
was conducted by Blom et al17 Puspitasari et al
patient engagement.4 The biomedical model en-
mentioned the same research in addition to a study
hances the control and status of the pharmacist,
by Evans and John18 and Livingstone.19
whereas the patient-centered model enhances the
An analysis of patientpharmacist recordings
control and status of the patient. During biomed-
would allow for detailed study of patient-centered
ical communication, the pharmacist focuses on
care. Audio or video recordings of patient
the treatment of the disease with little attention
pharmacist interactions can capture the detail
given to the role of psychological or social inu-
of what happens in real interactions between
ence.5 In the patient-centered model, the patient
patients and pharmacists, how these interactions
collaborates with the pharmacist to: 1) identify
transpire, and provide evidence as to why com-
treatment goals; 2) choose from regimen options;
munication occurs.20 Standardized questionnaires
3) monitor symptoms and evaluate regimens;
and interviews test hypotheses by measuring
and 4) revise regimens if problems occur.6 In the
pre-specied constructs. Respondents construct
patient-centered model, the pharmacist works di-
a belief or attitude that may vary in diering situ-
rectly with a patient and in conjunction with other
ations.21 Qualitative interviews allow for greater
practitioners to take responsibility for achieving
exploration, but as with structured surveys, rely
the optimized outcomes of drug therapy.7 It in-
on recall of events. Observational research with
volves the development of an individualized care
simulated patients (e.g., pseudo-patients, secret
plan to achieve the intended goals of therapy
shoppers) or pharmacy observations have an im-
with appropriate follow-up to determine patient
portant role in determining what happens in
outcomes.8 Several studies have found an associa-
a patientpharmacist interaction whether it is the
tion between patient-centered communication and
 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
implementation of a new technique or content of
pharmacists advice.22 Mesquitta found that phar-
macy research using simulated patients did not
dene and therefore could not measure patient
pharmacist communication skills or competencies.22
Patientpharmacist audio recordings allow for
unique study of how or why patientpharmacist
interactions take place; this research is not
possible with other methods. Examining patient
pharmacist communication as an interpersonal
dyadic interaction may help us understand col-
laborative problem-solving activities, and interper-
sonal relationship development within the context
of mutual trust, rapport, and familiarity between
the participants.3
There is an emerging body of research that
used recordings of patientpharmacist interac-
tions as a data collection method and wanted to
determine how this research technique has been
employed in pharmacy practice research. The
analysis of recordings uses a variety of methods
from quantitative coding of the interaction,
qualitative inductive methods, and discourse
analysis.20 Discourse analysis is a methodological
approach that is often used in the study of
communication in health care consultations. It
involves the study of spoken and written lan-
guage and how language use reects social order
and individuals interactions within society.23
This technique focuses on turn-taking, repair of
conversation breakdown, topic management
and non-verbal behaviors. The analysis approach
and resulting ndings may characterize patient
pharmacist communication as biomedical or
patient-centered. The current study used an ad-
aptation of the meta-narrative review, which is
a coherent body of work that shares a common
set of concept, theories, methods and instrument,
to present our results.24 Meta-narrative reviews
are best suited to study topic areas where existing
studies have been conceptualized dierently and/
or conducted by many dierent researchers. The
research using recordings from pharmacy prac-
tice arises from quantitative, qualitative and dis-
course analysis traditions which inuences how
research has been conceptualized and designed,
and therefore also the key ndings that result.
This review aims to characterize the 1) focus of
research questions, 2) study design, 3) data anal-
ysis methods, 4) main ndings, and 5) presence of
patient-centered vs. biomedical models of inter-
action in recorded patientpharmacist interac-
tions with attention to the inuence of the
research tradition.
3
Methods
Data sources
A literature search was performed by a medical
librarian to identify studies published in English.
No publication date limits were implemented.
Searches were conducted in the following data-
bases: Ovid Medline, Ovid Embase, International
Pharmaceutical Abstracts (IPA), Web of Science,
and Academic Search Complete. Two dierent
approaches were used to identify relevant studies:
search terms related to patientpharmacist en-
counters (such as patient counseling and pa-
tient interaction) were combined with either
search terms related to the medium of collection
(i.e., audio or video recordings), or to search
terms about the method of data analysis (e.g.,
discourse analysis, conversation analysis,
narrative analysis, content analysis, etc.).
Keywords about the methods of data analysis
were added to include several articles that were
found in cited references and not on the rst
electronic search. In addition, reference lists of
included articles where reviewed to identify addi-
tional relevant studies. The search results are
shown in (Fig. 1).
Study selection
Two authors identied citations by screening
titles and abstracts for potential relevance. The
full text article for each potentially relevant
citation was obtained for further evaluation.
Studies were eligible for inclusion if they examined
patientpharmacist interactions using audio or
video recordings, were published in English as
a peer-reviewed full-text article, and used real
patients or simulated patients. Papers were ex-
cluded that used pharmacy students and interns or
used audio or video materials solely for teaching
purposes. The full text articles were examined to
determine eligibility for inclusion; any discrep-
ancies regarding inclusion were resolved by dis-
cussion. One author extracted details on research
question, method, analysis, and main ndings and
a second author veried extraction.
Defining patient-centered vs. biomedical model
Studies were dened as patient-centered if the
study specically stated it measured patient-
centeredness or if the pharmacists applied several
elements of patient-centeredness during their con-
sultations with patients such as: incorporating the
patient perspective into treatment discussion,
4 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
Fig. 1. Search results.
active listening, asking open-ended questions, and
verifying patient understanding.2528 Articles rep-
resenting the biomedical communication model
lacked patient-centered elements or exhibited
pharmacists dominating the interactions with pa-
tients playing a passive role. These studies often
concentrated on the content of counseling.
Results
The search identied 586 studies. Of these
articles, 162 were duplicates and additional 383
articles were excluded after independent assess-
ment by the two authors. Authors agreed on the
allocation of all articles therefore 41 articles met
the inclusion criteria. These represent 32 unique
collections of recordings. One study was published
in the 1980s, 10 in the 1990s, 22 after 2000, and
eight after 2010. The research was predominately
published in the quantitative research paradigm
(20 studies; Table 1) followed by qualitative re-
search (5 studies; Table 2) and discourse analysis
(13 studies; Table 3). The remaining three studies
(Table 4) used expert groups to develop criteria
for the quality of patientpharmacist interactions
(2 studies) or a mixed method approach (1 study).
The following sections discuss the research ques-
tions, study designs, data analysis, and ndings
as conceptualized in each research tradition.
Research questions
The research questions were driven by the
research method. The quantitative research ques-
tions (Table 1) can be categorized as 10 studies fo-
cusing on the content of the interaction,17,18,2935
4 on evaluating the quality of interactions with
a validated tool36 or to validate a tool,34,37,38 two
on patient recall,39,40 two that test a hypothesis,41,42
one to evaluate an intervention,43 and one on vali-
dating the quality of stimulated patient recall.44
The ve qualitative studies explored pharmacists
in new roles,25,45,46 maintenance of professional ex-
pertise47 and communication breakdown.48 The re-
search in discourse analysis asks one of two primary
questions regarding either the structure of patient
pharmacist communication or the exploration of
phenomena including acceptance of advice,49
conict talk,50 patient expertise,51 compliance
Table 1
Quantitative studies
Author/year Research questions
reference No.
Bentley et al41 To determine whether
pharmacists appearance
and communication impact
patient evaluations
(satisfaction, service
quality, trust and future
intention).
Bisell, Ward, To determine the variations in
and Noyce29 demand for, and response
to pharmacy-only
medicines requested.
17
Blom et al To identify the content of
patient counselling.
Cavaco and Romano30 To describe pharmacist-
customer communication
during blood pressure and
cholesterol services.
Method
Online video: Videos of
patientpharmacist
interactions were viewed.
Observers completed an
online survey, USA.
Community pharmacies, UK.
Audio recordings of
pharmacists/medicine
counter assistantspatients
interactions. Non-
participant observation.
Community pharmacies,
Netherlands. Audio
recording of patients-
pharmacists/technicians
contacts.
Community pharmacies,
Portugal. Audio recording
of patientpharmacist
interactions.
Analysis
179 video recordings were
analyzed quantitatively.
The transcripts were analyzed
quantitatively, n 427
requests.
6784 recordings were
analyzed quantitatively
using a novel scoring
system.
83 transcripts were analyzed
quantitatively using a
system adapted from
Roter Method of
Main ndings Biomedical/
Patient-centered
communication
A higher pharmacist Biomedical
communication
Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
performance (i.e., greater
attentiveness, information,
and patient involvement)
was associated with higher
pharmacist evaluations
while dress or presence of
white coat was not.
Pharmacists were more likely N/A
to provide advice than a
counter assistant. 70% of
interactions did not involve
a pharmacist. 10% solely
involved a pharmacist.
Rates of advice with
medicine sales ranged from
17 to 97% in 10
pharmacies. Patient
assessment was not
consistent.
Pharmacists provided advice Biomedical
for 36% of prescriptions
that was focused on drug
instructions and not
solicited. Pharmacists
provided more oral
information than
technicians.
The average of blood pressure Biomedical
and cholesterol counseling
was 5:35 min and 7:05 min
respectively. In both cases,
(Continued)
5
Table 1 (Continued )

6
Author/year Research questions Method Analysis Main ndings Biomedical/
reference No. Patient-centered
communication
Interaction Process pharmacists asked more
Analysis (Roter52) questions (mainly closed
ones), while patients gave

Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120

more information.
Deschamps, Dyck, To describe content and Controlled university lab 20 transcripts were Pharmacist provided: side Biomedical
and Taylor31 organization of patient setting, Canada. Video quantitatively coded eect information (100%),
counselling. recording of standardized (scheme adapted from indication (100%), name of
patientpharmacist recognized medicine medicine (95%), and
interactions. counseling guidelines). scheduling (95%). average
duration 3:20 min.
Pharmacist asked an
average of 8  4 close-
ended and 1  1 open-
ended questions.
Evans and John18 To compare and contrast Community pharmacies, UK 123 (63 from UK and 60 from Pharmacists asked two Biomedical
pharmacist medicine &USA. Audio recordings US) transcripts were questions per interaction
counseling in UK and of patientpharmacist analyzed quantitatively. and 95% were closed-
USA. interactions. ended. Mean counseling
was 123 s in US and 69 in
UK. Pharmacists provide
11.2 information items per
interaction in US and 6.5
items in UK.
Evans et al39 To identify if clients can recall Community pharmacies, UK. 98 transcripts of audio Only 24% of information Biomedical
information oered by Audio recordings of recordings and phone oered by pharmacists was
pharmacists. patientpharmacist interviews were analyzed later recalled by patients.
interactions and patients quantitatively. Patients were more likely to
interviews. recall procedural advice
and repeated information.
Flynn et al32 To evaluate the dispensing Community pharmacies, 100 video recordings were Of 100 prescriptions N/A
accuracy and counseling USA. Video recordings of analyzed quantitatively. dispensed, 22% had
provided. patientpharmacist dispensing error rate. A
interactions. total of 43 shoppers (43%)
received verbal counseling,
including 16 cases in which
the shopper prompted
counseling.
Greenhill et al62 To determine applicability of
Calgary-Cambridge guide
to pharmacy consults.
Greenwood, Howe, To assess patient centeredness
and Holland36 and content of the consult
using validated tools.
Livingstone19 To examine the nature of
verbal interactions between
elderly people and
pharmacists.
McMillan, Cameron, To develop and test an
& Power37 evaluation tool for GP and
pharmacist consults with
patients.
Paluck42 To determine predictors of
the quality of patient
pharmacist
communication.
Community pharmacies, 18 transcripts were analyzed
hospital and GP clinic, quantitatively using
UK. Audio recorded of Calgary-Cambridge guide.
patientpharmacist
consults.
Patients home, UK. Audio 18 transcripts were analyzed
recordings of patient quantitatively: Henbest and
pharmacist interactions. Stewart Rating (assess
patient centeredness) and
SEGUE scale. (Set the
stage, Elicit information,
Give information,
Understand the patients
perspective, and End the
encounter, a checklist of
medical communication
tasks)
Community pharmacies, UK. 43 transcripts were analyzed
Audio recordings of quantitatively.
interactions between
elderly patients and
pharmacists.
Video recordings of GPs and 18 GPS and 12 pharmacists
pharmacists consult with video recordings were
patients. Scotland. analyzed quantitatively.
Community pharmacies, 765 interactions were
Canada. Audio recordings quantitatively analyzed
of patientpharmacist with a novel scale
interactions.
Calgary-Cambridge guide can Biomedical
be applied with minor
alterations to opening,
agenda setting, question
responses, and social talk.
Pharmacists may require
training on patient centered
Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
skills.
Scores were comparable to Patient-Centered
physicians in that they
demonstrated high patient-
centeredness, and covered
all appropriate areas. Both
scales are suitable for
pharmacist patient
interactions.
Pharmacists provided Biomedical
medicine information to
12.5% of elderly patients
that focused on aspects of
the dosage regimen. Mean
interaction was 71 s.
Pharmacist tool omitted 2 N/A
examination questions.
Tool could discriminate
between GP but not
pharmacist performance
level.
Four of the variables N/A
predicted communication
quality (pharmacists
attitude, year of
graduation, adherence
expectations, and outcome
expectations).
(Continued)
7
Table 1 (Continued )
Author/year Research questions
reference No.
Sigrist et al43 To evaluate an intervention
to improve patient
interactions about non-
prescription analgesics.
Smith, Salkind To assess quality of primary
and Jally34 health care advice given by
pharmacists.
Smith33 To explore pharmacists
communication focus and
style relative to health
promotion.
Smith35 To investigation the referral
patterns of pharmacists.
Stewart et al38 To develop and validate tool
to assess the quality of
pharmacist prescribers
consults.
Werner and Benrimoj44 To determine whether audio
recordings can improve the
reliability of data recalled
by simulated patients.
8
Method Analysis Main ndings Biomedical/
Patient-centered
communication
Community pharmacies, 14 Intervention pharmacies The intervention improved Biomedical
Switzerland. Audio with 98 consults; 14 control the content and quality of
recordings of pseudo- pharmacies with 91 the patient-pharmacist/sta
Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
patient-pharmacy sta. consults. Novel interactions. Interactions
Sta training quantitative scoring. for restricted medicines had
workshop 15 h the greatest improvement.
Community pharmacies, UK. 50 audio recordings were 54% of consults achieved Biomedical
Audio recordings of quantitatively analyzed satisfactory scores on 75%
patientpharmacist with a novel scale. of the nine characteristics
interactions. while 25% were
satisfactory on 2 or fewer
characteristics.
Same as above. 711 transcripts were analyzed Pharmacists advice focused Biomedical
quantitatively. on the products rather than
symptoms. Pharmacists
asked 3 questions focused
on symptoms (79% closed)
and promptly answered
patient questions (97%).
Same as above. 108 of 716 transcripts had Pharmacists referrals were Biomedical
referrals and were analyzed determined by the
quantitatively. symptoms presented. Most
common referrals were
conditional and direct to
GP.
Community pharmacies, UK. 14 video recordings were Pharmacists scored 3/5 N/A
Video recordings of analyzed quantitatively overall on quality.
patientpharmacist with a novel tool. Generated evidence for
interactions. reliability and validity.
Community pharmacies, 1340 audio recordings were Approximately 10% of N/A
Australia. Audio analyzed quantitatively interactions had
recordings of simulated using simulated patient discrepancies resulting in a
patientpharmacist tool. 10%20% change in the
consults. score from the manual data
(a signicant change).
 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120 9

paradigm,53 eective strategies for verifying under-

standing,26 and the role of assistants.23 In all para-
Biomedical

digms, six studies used theory explicitly to guide the

exploration of patientpharmacist communica-
tion.20,4650 The quantitative studies focused on
the what, the qualitative studies explored new
or specic roles, and the conversational analysis

received more information.

1. The most frequent topics:

Patients who participated

information. All recalled
2. 47% of patients omitted

information was correct.

focused on the how patients and pharmacists
discussion of symptoms

discussing matters not

general health topics,

interact.
covered during GP
and treatment and

consultations.

Design and methods

Researchers used video recordings in nine
studies31,32,37,38,41,48,50,54,55 and audio recordings
in the remaining 32 studies to collect patient
pharmacist interactions. In the qualitative48 and
discourse analysis research,2628,55 videos were
2. 49 interviews were analyzed
1. 212 audio recordings were

transcribed for analysis; thus video did not appear

analyzed quantitatively.

to add to the analysis. In the quantitative studies,

three studies coded elements only available in
video,37,38,41 while two examined content.31,32
quantitatively.

Simulated patients in university practice laborato-

ries or community pharmacies were employed in
four articles. In seven articles audio recordings
were collected in hospitals,45,48,56,57 ve in pa-
tients homes,36,45,49,50,53 and the remaining re-
search studies were conducted in community
UK. Audio recordings and
Two community pharmacies,

Interviews with patients.

pharmacies. No clear pattern emerged between

observations of patient
pharmacist interactions.

research paradigm and research location. The dis-

course research was most likely two have multiple
analyses conducted on one dataset (Table 3). One
dataset was used in both a quantitative31 and dis-
course analysis study.55 Ten studies combined two
or three data collections methods such as: ques-
tionnaires, non-participant observations and in-
terviews. Multiple methods of data collection
were most prevalent in the qualitative para-
1. To identify the information

digm.25,4648 We did not identify any longitudinal

information given by the

studies. The single intervention study found that

and advice given by

health belief model and use of open-ended ques-

2. To test recall of

tions improved the content and quality of patient

interactions.43 The bulk of this research has been
pharmacist.
pharmacist

conducted in the United Kingdom followed by

the United States of America.
Consent procedures were outlined in the ma-
jority of studies, but 10 out of 41 studies (i.e., 7
datasets) did not report consent procedures or
approval from an ethics review commit-
tee.25,29,32,37,45,51,5658 One study reported ethical
approval, but not consent procedures.47 Nine of
Wilson et al40

the studies posted a sign to inform the patients

of the recording, assuring them of anonymity
and condentiality with ve studies using this as
the sole form of consent.29,34,35,40,54 Oral consent
Table 2
Qualitative studies
Author/year Research questions
reference No
Babalola and Erhun48 To identify areas of
communication breakdown
caused by pharmacist.
Chen and Britten45 To investigate feasibility of
using primary care
pharmacists as medicine
counselors.
Leontowitsch et al46 To describe feasibility and
acceptability of concordance
in pharmacy.
Montogomery et al25 To describe the characteristics Community pharmacies,
and content of pharmacists
providing pharmaceutical
care.
Stevenson, To explore how pharmacists
Leontowitsch, maintain their professional
and Duggan47 expertise
a
Unless noted, qualitative studies use thematic analysis approach.
Method
University teaching hospital, 20 transcripts were qualitatively Miscommunication occurred
Nigeria. Audio, video
recordings of medicine
histories and questionnaire.
GP surgeries and patients 25 transcripts were analyzed
homes, UK. Audio recording
of patientpharmacist
interactions.
Community pharmacies, UK. 26 transcripts were analyzed
Audio recording of patient
pharmacist consults.
Observations and interviews
with pharmacists and
patients.
Sweden. Audio recordings of
patientpharmacist
interactions. Non-participant
observations.
Same as Leontowitsch 2005
above.
Analysisa
coded and analyzed using the
socio-linguistic model.
qualitatively.
qualitatively.
16 transcripts with ve
pharmacists were analyzed
qualitatively using
interpretive approach.
27 transcripts were analyzed
qualitatively.
10
Main ndings Biomedical/
patient-centered
communication
Biomedical
because of a noisy
Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
environment or the
pharmacist used technical
and vague statements, did
not integrate patient
perceptions, did not explain
intent, or gave conicting
advice
The clinical pharmacists Patient-centered
experienced few problems
with the consults. Patients
were willing to discuss their
medicines in detail with
pharmacists.
Pharmacists adapted their own Patient-centered
model of concordance (i.e.,
open-ended exploration to
understand and incorporate
the patient perspective into
treatment discussions).
Customers reported a high
level of satisfaction.
Counseling behaviour was Patient-centered
characterized by variable
listening, asking questions, a
willingness to help, use of
computers, and identication
of patient needs.
Engaging patients did not Biomedical
reduce the pharmacist
expertise. Patient desired
diering levels of
engagement/expertise.
Table 3
Discourse analysis studies
Author/year Research questions Method Analysis Main ndings Biomedical/
reference No patient-centered
communication
Salter et al49 To what extent the advice Participants home, UK. 29 transcripts were analyzed Pharmacists usually oered Biomedical
given by pharmacists is Patientpharmacist by discourse analysis. advice and information in a

Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120

acknowledged and accepted medicine reviews were didactic manner despite
by patients. observed and recorded. patient displays of
Pharmacist and patient competence. Advice was
interviews. often resisted/rejected by
patients.
Dyck, Dechamps, To determine number of Controlled university lab 20 transcripts were analyzed Pharmacists discussed side Biomedical
and Taylor55 adverse eects mentioned setting, Canada. Video by conversation analysis. eects and management
and how pharmacists recording of standardised strategies with an average of
articulated likelihood patientpharmacist 4  2 unique side eects.
occurrence. interactions. Vague, verbal descriptors of
frequency were used.
Garner and Watson59 To study consults between Community pharmacies, 168 transcripts were analyzed Of 773 utterances, 61% were Biomedical
medicines counters Scotland. Audio recordings by discourse analysis. information eliciting, 13%
assistants (MCA) and of MCA-patient counseling. information giving, 14%
customers for non- advice giving and 11%
prescription medicine. other. Most frequently
asked who is taking the
medicine and other current
medications.
Nguyen50 To examine multiparty conict Community pharmacies, USA. 1 transcript was analyzed with Conict gradually occurred N/A
talk in a pharmacy consults. Video recordings of patient in-depth conversational with indirect and reluctant
pharmacist interactions. analysis. communication. It was
resolved with appeals to an
outside third party
(physician) and delicate
alignment.
Pilnick51 To determine the inuence of Pediatric outpatient oncology 43 transcripts were analyzed Patient expertise reduces the Biomedical
patient expertise on the clinic, UK. Audio-recording using conversation analysis/ expected interactional
patientpharmacist of patient/carerpharmacist ethnography. dominance of the
interaction. interactions. pharmacist. Patient and
pharmacist dominance
varies within an interaction.

11
(Continued)
Table 3 (Continued )
Author/year Research questions
reference No
Pilnick57 To characterize patient
pharmacist counseling as
instructing, advising or
giving information.
Pilnick56 To describe the structures of
patientpharmacist
interaction.
Pilnick, A.58 To examine how pharmacists
initiate advice giving.
Salter53 To examine the inuence of the Patient homes, UK. Audio
compliance paradigm on
medicine review.
Watermeyer27 To describe how pharmacists
talk about antiretrovirals
(ARVs) with patients.
Method
Same as above. 45 transcripts were analyzed
Same as above.
Same as above.
29 transcriptions were
recordings of patient
pharmacist interactions.
Non-participant
observation.
Pharmacy in a public ARV
Clinic, South Africa.Video
recording of patient
pharmacist interactions.
Analysis
Pharmacists instruct patients
using conversation analysis.
Same as above.
Same as above.
Pharmacist led structures
analyzed using discourse
analysis.
26 transcripts were analyzed
by conversation analysis.
12
Main ndings Biomedical/
patient-centered
communication
Biomedical
on medicine use rather than
providing general
Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
information or personalized
advice.
Structure: Opening/greeting, Biomedical
approach and arrival at
advice giving, acceptance/
rejection, delivery and
response to information
(assuming patient is not
knowledgeable), close and
exit.
4 approaches to advice giving: Biomedical
patient request, pharmacist
gives information
immediately, pharmacist
oers or states intention,
and step-wise approach to
evaluate the situation rst
Biomedical
interactions which explore
patients ability to comply
with medicines. Patients
resisted inquiries that
threatened their
competence.
Pharmacists discussed ARVs Patient-centered
in three contexts: ARV for
the rest of patients life, to
save patients life and to feel
better.
Watermeyer To identify the eective
and Penn26 strategies for verifying
patient understanding of
ARV dosage instruction.
Watermeyer To examine the structure of
and Penn28 patientpharmacist
interactions.
Ylanne and John23 To describe the role of
medicine counter assistants
(MCA) when dealing with
patients.
Same as above. Same as above. Strategies to verify patient Patient-centered
understanding include
asking for patient
demonstration, using
specic questions, asking if
information was
understood, and monitoring
Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
patients verbal and non-
verbal responses.
Same as above. Same as above. Patientpharmacist Patient-centered
interactions had a clear
structure that contained
multiple cycles of delivery of
instruction, patient
response, and verication of
understanding.
Community pharmacies, UK. 29 transcripts were analyzed MCA are involved in three N/A
Audio recordings of patient- using discourse analysis. ways: dealing solely with the
MCA/pharmacists patient, checking advice
interactions. with the pharmacist while
dealing with the patient, and
keeping the patient on hold
until the pharmacist is ready
for counseling.
13
 14
Table 4
Studies employing other methods
Author/year reference No Research questions Method Analysis Main ndings Biomedical/
patient-centered

Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120

communication
Bissell, Ward, and Noyce60 To identify the criteria to Community pharmacies, 10 of 624 transcripts were Audio recordings provided N/A
assess appropriateness of UK. Audio recordings of used to assess the the context for a
common ailments patientpharmacist feasibility of a set of stakeholder process on
management. interactions. Non- expert criteria. the development of
participant observation. guidelines for
appropriateness.
Hargie, O. D. W., Morrow, To identify what constituted Community pharmacies, 350 video recordings were Eleven communication Patient-centered
N. C., & Woodman, C.54 eective communicative UK. Video recordings of analyzed qualitatively by categories were identied
performance by patientpharmacist pharmacists, and and ranked: building
pharmacists. interactions. quantitatively by rapport, explaining,
researchers. questioning, listening,
non-verbal, advising,
opening, closing,
assertiveness, disclosing
personal information,
and persuading. Eective
consults were more likely
to use patient centered
skills.
Skoglund, Isacsan, and To explore the patient Community pharmacies, 42 audio recordings and Patients had a passive role Biomedical
Kjellgren61 pharmacist Sweden. Audio transcripts were analyzed and asked three
communication when recordings of patient qualitatively and questions. Pharmacists
dispensing prescription pharmacist interactions. quantitatively with a asked an average of 4.6
analgesics. focus on structure, questions and 2% were
content, and interaction. open-ended. Pharmacists
dominated the
interaction.
 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
was solely obtained in three studies,30,42,46 and
oral consent was combined with a sign in one
study.59 The remaining studies used a written con-
sent in combination with oral consent and signs.
Data analysis
Quantitative methods dominated (Table 1)
followed by discourse analysis (Table 3). Only 3
studies analyzed their data by other methods.54,60,61
All studies in the discourse analysis and qualitative
paradigms analyzed transcripts whereas 10 quantita-
tive studies (Table 1) conducted their analysis on the
audio itself by characterizing the content32,40 or by
employing a scoring tool.17,34,37,38,4144 Studies using
a quantitative paradigm quantied the frequency of
encounter reason, content of oral drug information,
oral drug information received, and pharmacists
and patients behavior at the counter. Furthermore,
the number, type, and content of questions asked by
pharmacists were reported. Validated tools were
used to analyze data in several studies,30,31,36,62 while
ve authors developed their own coding tools. All
studies characterized elements of pharmacist com-
munication, several also explicitly analyzed patients
contribution to the interaction30,4547,49,51,53 and two
studies examined patient recall.39,40
Main findings
Main ndings were driven by the questions
asked in each research paradigm. The quantitative
studies characterized what happened between
patients and pharmacists. Pharmacists consulta-
tion focuses mainly on medications instruc-
tion.17,19,31,33,40 Several studies quantied the
number and type of questions asked by pharma-
cists and found that pharmacists asked more
closed questions than open ones.18,30,31 A compar-
ison showed that pharmacists provided more in-
formation and advice than technicians.17,29 In
addition, the percentage of what the patients re-
called after counseling was calculated and found
to be approximately a quarter of what the phar-
macists said in one study39 and half in the second
study.40 Patients mainly recalled instructions and
repeated information.39,40 Quantitative methodol-
ogy was used to develop and test evaluation tools
for pharmacists consultations with patients37,38
and to measure patient-centeredness.36 Better
pharmacist communication quality and greater
patient satisfaction resulted when patient-
centered skills were applied during counseling.41,42
The qualitative paradigm provided rich descrip-
tions of novel pharmacists practice or areas.
15
Specialized pharmacists communication included
patient engagement and acceptance.25,45,46 Pharma-
cists expertise was important and not diminished by
engaging patients in decision-making.47 Breakdown
in patientpharmacist communication was due to
the pharmacist or pharmacy environment.48
Discourse analysis reported how pharmacists
communicate with patients. The structure of the
interaction was primarily focused on the pharma-
cist providing medication information. Patients
expertise was disregarded by pharmacists,49 re-
duced pharmacists expected dominance,51 and
led to patients disregarding advice49 or inquires
that threatened their competence.53 Pilnick found
that conict was resolved with referrals to physi-
cians. Watermeyer and Penn identied four ways
to verify patient understanding (Table 3).26
Ylanne and John described three ways pharmacist
assistants interact with patients (Table 3).23
Several studies investigated the characteristics
of pharmacists and/or patients that may inuence
the nature or extent of communication. Pilnick
found that patient expertise reduces the expected
interactional dominance of the pharmacist.51 The
quality of patientpharmacist communication was
aected by the environment and positively im-
proved if pharmacists applied patient-centered
skills18,41,42,48,54 such as: patient involvement, lis-
tening, and integrating patients perception.
Presence of patient-centered vs. biomedical
communication
The research paradigm with its resulting ques-
tion and measurement model had an impact on
whether or not patient-centered or biomedical
communication was characterized. Eight studies
found evidence of a patient-centered model in
patientpharmacist interaction, whereas 23
patientpharmacist interactions exhibited a bio-
medical focus. Patient-centered communication
primarily took place in specialty clinics and by
pharmacists with additional training or a specic
clinical focus.2528,36,45,46 The community-based
pharmacy study that identied patient-centered
behaviors used pharmacists to characterize eec-
tive communication performances.54
Quantitative studies focused on the clinical
content resulting in a focus on biomedical com-
munication. If patient-centered communication
was present it was not quantied with the excep-
tion of Greenwood, Howe, and Holland36 who
used validated scales with the specic intent of
characterizing patient-centered communication.
16 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
Qualitative research, which studied specialized
pharmacists, found patient-centered communica-
tion.25,45,46 Other topic questions on communica-
tion breakdown48 and pharmacists expertise47 led
to a focus on biomedical communication. Dis-
course analysis described eight studies with a
biomedical and three with patient-centered
communication style. The patient-centered com-
munication style was found in a specialty clinic
and these studies described how pharmacists
counsel patients about their antiretroviral medi-
cations.2628
Discussion
Forty-one studies were identied that analyzed
video and audio recordings of patientpharmacist
interactions. A greater number of articles were
found than were identied in prior reviews4,16 be-
cause additional keywords were included such as
discourse, conversation, narrative, and content
analysis and the search was conducted in both so-
ciological and health sciences literature databases.
Research on recordings of patientpharmacist in-
teractions reside within multiple research elds
with distinct traditions within pharmacy as well
as sociology and linguistics.
The majority of studies were published in the
last ten years, suggesting a growing interest in
patientpharmacist communication. The vast ma-
jority of the research was conducted using audio
recordings in community pharmacies and was
descriptive in nature. Consent procedure was
described in the majority of studies with a majority
using written consent. The ve studies that used
a pharmacy sign as the sole means to alert patients
occurred in 2000 and earlier. Few studies used
simulated patients during data collection. Only
three of the 10 studies that employed videos
analysed non-verbal behavior. Transcripts of
recorded patientpharmacist interactions were
used in the analysis process in both qualitative
and discourse methodologies. Half of the quanti-
tative studies analyzed the transcripts and the
remaining quantied the content directly from the
recording with scoring tools. In most of the
studies, results were analyzed quantitatively while
discourse analysis and qualitative methods were
employed in the remaining articles.
Much of the literature covered in this review
suggests, (1) that the evidence of biomedical vs.
patient-centered models in the studies ndings
depends on the research questions and analysis
methods; (2) the majority of studies using a bio-
medical approach looked at the content of patient
counseling and quantied their ndings; (3) eight
studies found pharmacists applied several ele-
ments of patient-centeredness during their
consultations with patients. These results also
resonate with the views of several papers that
recognize the need for closer attention to patient-
centered care in current-day pharmacy.15,6365
One of the included studies showed that patients
reported a high level of satisfaction when the
pharmacists adapted their own model of concor-
dance.46 However, the results also conict with
the previous nding in the medical literature that
while the vast majority of patients prefer the
patient-centered approach, a signicant propor-
tion still prefers a biomedical communication
model.66 No single demographic or clinical char-
acteristic reliably predicts patients communica-
tion style preferences,66,67 and prior research
shows that pharmacists are often unaware of
what patients expect and evaluate as being impor-
tant when they visit the pharmacy.68,69 Krass et al
have shown that pharmacists use of one well-
intended question may trigger dierent patient re-
sponses.70 Patients variation in responses may be
due to of their personal interpretation of the sug-
gested relationship70 or health beliefs.71
Furthermore, the ndings of this review show
that patientpharmacist interactions are not con-
sistently analyzed as a dyad. Since patients and
pharmacists individually determine the quality of
their interactions, it is important to incorporate
both parties prior experiences.3 A very limited
number of studies in this review described how
the quality of patientpharmacist interactions is
positively aected with pharmacists centered
care skills. This review described the studies that
analyze recorded patentpharmacist interaction
and it shows that audio and video recording meth-
odology allows researchers to draw conclusions
about the real-time eects of interaction between
patients and pharmacists.20 However, recordings
can create an articial environment, as pharmacist
and patient are aware that they are being recorded
due to the consent procedures. This causes a be-
havioral change, the so-called Hawthorne eect.
Some studies recorded patientpharmacist inter-
actions in the absence of a researcher in order to
decrease the Hawthorne eect.25,29,53,60
Few studies used simulated patients in their
research. We identied only three data sets and four
studies that used simulated patients. Two used real
pharmacists in a lab where the pharmacist was
 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120 17

aware of the interaction31,55 and two were recorded a literature search conducted in several databases
in the community pharmacy setting where pharma- in both the health and social sciences. A detailed
cists were unaware of simulated patients but were description of research questions, methods, anal-
informed that a visit would come within a desig- yses and ndings is presented. This is the rst
nated timeframe.43,44 Using simulated patients review to discuss this number of studies that
can enhance the reliability and validity of the collected and analyzed audio and video recordings
data22 and allow for comparisons between pharma- of patientpharmacist interactions.
cist responses to the same patient query. Simulated
patients can judge the performance of the pharma-
cist in a reliable way. Finally, the simulated patient Future research directions
has increased face validity if the pharmacist does
The diversity of this body of research could
not know or suspect the presence of a simulated
lead in many directions. First, researchers should
patient.
carefully match the research objective, method of
Few studies used more than one method of
recording, and research methodology. There are
data collection but two studies used both quanti-
few pharmacy specic validated coding tools that
tative and qualitative analysis methods. Mixed
would help quantify pharmacists and patients
methods data collection and analysis may provide
communication. Simulated recall of information
more thorough and insightful ndings.72 Several
presented in patientpharmacist interactions may
studies employed qualitative methods of data col-
provide rigorous evaluation of patients and phar-
lection (e.g., interviews) and also presented quali-
macists perceptions of biomedical vs. patient-
tative data (such as verbal data rather that
centered communication. Future research using
numerical data). Using qualitative methods in
discourse analysis may consider investigating the
pharmacy communication research is important
structure of exchange between the patientphar-
for understanding social situations from the view-
macist dyad as well as characterizing structural
point of all parties involved. Non-specic the-
dierences in communication in diering contexts
matic analysis was the predominant analysis
(e.g., new vs. rell prescriptions). It would be
approach. One study used an interpretive ap-
helpful for the profession, patients, and re-
proach whereby the researchers developed a sense
searchers to understand how pharmacists and
of the whole dataset before generating impres-
patients organized the interviews and how this
sions of the individual parts.
may have inuenced patients medication taking
In several studies data was analyzed using
behaviors. It is not known how pharmacists
discourse analysis. In these studies, this method
determine patients communication preferences
is described as qualitative. However, discourse
and subsequently adjusts their communication
analysis can be both a quantitative and qualitative
styles according to patient preference. As the
method.73 Discourse analysis resulted in rich de-
structure of patientpharmacist interactions is
scriptions of patientpharmacist interactions and
uncovered, it will be important to link pharma-
contributed to new understandings of how pa-
cists communication to patient health outcomes.
tients and pharmacists manage conict, power,
and expertise when communicating about medica-
tion. The questions and thick analysis resulting
Conclusion
from discourse analysis may not directly lend
themselves to practice enhancements, but may There is a developing body of research using
guide the understanding of existing communica- audio and video recordings to describe the content
tion practices. of pharmacists communication in addition to
exploring the quality of the interactions, valida-
tion of coding tools, the impact of an intervention,
and an enhanced understanding of the patient
Strengths and limitations
pharmacist power asymmetry. Evidence for bio-
Possible limitations include not searching for medical vs. patient-centered models in the studies
dissertations or unpublished work and the re- ndings depends on the nature of the research
striction to only English language articles. The questions and analysis methods. The quantitative
data is widely varied and not suciently mature to studies focused on the what, the qualitative
allow for denite conclusions. There are several studies explored new or specic roles, and the
points of strength in our review. It is based on discourse analysis focused on the how patients
18 Murad et al. / Research in Social and Administrative Pharmacy j (2013) 120
and pharmacists interact. Future research should
focus on how pharmacists partner with patients to
apply patient-centered care in diering contexts
and explore the links between communication and
patient health outcomes.
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