Explaining Professional Pharmacy Service Provision and Sustainability in German Community Pharmacies

Professional pharmacy services (PPS) can offer a venue for re-professionalising pharmacy practice, but despite being regarded as necessary, useful, and professionally rewarding, PPS implementation has been slow. Whilst barriers and facilitators have been extensively researched, little is known about how they are related. Likewise, the mechanisms and causal relationships explaining PPS provision, success and sustainability are lacking. This includes the influence of healthcare professional and business orientations, which are inherent in pharmacy and regarded as conflicting. Hence, this thesis aimed to address these aspects by applying a critical realist informed research design. Based on a two-phase realist review drawing on theories of motivation, decision-making, and entrepreneurship from a small business perspective combined with research on PPS provision, and analysis of semi-structured interviews with German pharmacy owners, explanatory frameworks for PPS provision were developed. The results support existing knowledge about small firm decision-making behaviour and identify decisions for or against PPS provision as ecologically rational. The explanatory frameworks demonstrate that the PPS development process can be separated into front-end and implementation stages and place the identified mechanisms and contextual factors, which influence decisions for provision, delivery, success, and sustainability of professional services alongside the process. Results show that the process stages are conceptually different, manifested in the relative importance of role orientations per stage, with motivation and decision-making at the front-end being mainly business-oriented, driven by supporting the goal of income generation, and healthcare professional orientation being a stronger influence on actual service delivery. Being able to appropriately align role orientations for goal achievement was identified as a personal or organisational capability. Such ‘role ambidexterity’ was linked to service success and sustainability and can be actively managed to achieve competitive advantage