Serving two masters - the work as healthcare providers and retail employees in community pharmacies in Sweden

<p dir="ltr">Background: In Sweden, approximately 11,000 employees in community pharmacies dispense 91 million prescriptions annually and assist 370,000 customers daily. Pharmacists are healthcare professionals, yet their work is embedded in a commercial retail environment, following the 2009 deregulation of the Swedish pharmacy market. International and Swedish literature identifies a persistent tension between professional responsibilities, such as medication counseling and safety, and business imperatives, including sales targets and revenue generation. Research internationally and in Sweden identifies tensions between professional responsibilities and business objectives, with reported impacts on increased focus on sales, stress, increased workload, and utilization of pharmacists' expertise. Little is known about the lived experience of Swedish pharmacists, how they navigate this duality in daily practice, and the contextual factors perceived to influence their work. By addressing this gap, knowledge is added about work in market-driven healthcare landscapes.</p><p dir="ltr">Aim: The thesis aimed to explore community pharmacy work in Sweden at the intersection of healthcare provision and retail business. Three main questions are explored: (I) How do employees perceive and navigate their work in Swedish pharmacies? (II) What are the main aspects in the context that influence community pharmacists' perceptions of their work? (III) What are the implications for future work in pharmacies, based on the current state and pharmacy sector stakeholders' suggestions for change? Three empirical studies are included in the thesis: Study I examined employees' perceptions and practices in well-functioning pharmacies; Study II investigated how pharmacists combine healthcare obligations with commercial demands; and Study III explored stakeholder-proposed changes to pharmacy practice and their potential impact on future work.</p><p dir="ltr">Method: An exploratory qualitative design was employed, using semi-structured interviews with pharmacists, pharmacy technicians, managers, industry representatives, educators, and policymakers. Forty-two informants were interviewed across the studies, and the interviews were either in person or online. All interviews were conducted in Swedish and transcribed. The data were analyzed using qualitative content analysis or thematic analysis. The studies were subjected to review by the Swedish Ethical Review Authority.</p><p dir="ltr">Findings: Across the studies, pharmacists described their work as most meaningful when centered on patient care, dispensing, and counselling, reflecting a strong identification with their healthcare role. In Study I, employees in well- functioning pharmacies described high engagement, collegial support, and loyalty to their profession and patients rather than to corporate objectives. Study II identified persistent conflicts between professional and business responsibilities, intensified by time constraints and organizational emphasis on sales targets. Pharmacists managed these conflicts individually through strategies such as compromise, reframing, and stretching mandates, which allowed some alignment of business tasks with professional purpose but did not resolve underlying tensions. Study III found that stakeholders had a multitude of suggestions for changes, including increased staffing, enhanced reimbursement, expanded clinical services, and new offerings. While proposals to reinforce professional work (e.g., paid counselling, extended clinical roles) could strengthen professional autonomy, diversification into non-core services risked diluting professional identity.</p><p dir="ltr">Conclusion: Swedish community pharmacy practice is characterized by the continual negotiation of healthcare and commercial roles within a context where the constellation of institutional logics seems dominated by state and corporate logics. Pharmacists sustain professional identity and patient-centred work through individual adaptation, yet structural conditions perpetuate conflicts of interest between professional and business priorities. Strengthening reimbursement for core services, expanding integration with primary care, and granting greater professional control over work processes could enhance autonomy and reduce tensions. Conversely, service diversification and technology-driven delivery models should be critically assessed for potential impacts on professional status. This thesis contributes empirical knowledge on the lived experience of pharmacy work and offers insights that could be helpful to align commercial and professional imperatives.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Hagsten, K.</b>, Eriksson, A., & Palm, K. (2024). Self-propelled Employees - Co-workership in Swedish Community Pharmacies. Nordic Journal of Working Life Studies, 14(1), 47-66.<br><a href="https://doi.org/10.18291/njwls.142122">https://doi.org/10.18291/njwls.142122<br></a><br></p><p dir="ltr">II. <b>Hagsten, K.</b>, Eriksson, A., Svensson, I., & Palm, K. (2024). The juggling act of pharmacists in Sweden: A qualitative study on balancing healthcare professionalism and retail employment. BMC Health Services Research, 24(1), 1212.<br><a href="https://doi.org/10.1186/s12913-024-11682-w" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12913-024-11682-w<br></a><br></p><p dir="ltr">III. <b>Hagsten, K.</b>, Eriksson, A., Palm, K., & Svensson, I. Ambitions for change: An Institutional logics' perspective on potential changes in Swedish pharmacy practice. [Manuscript]</p>