Attitudes and beliefs of pharmacists toward their work with patients, PABS

1. Abstract

The Attitudes and Beliefs of Pharmacists Toward Their Work with Patients (PABS) scale is a specialized psychometric assessment instrument developed by Dragana Jocić and Dušanka Krajnović to evaluate community and hospital pharmacists’ cognitive evaluations, affective predispositions, and behavioral orientations regarding direct patient communication, clinical counseling, and interprofessional care. In contemporary pharmacy practice, the profession has undergone a historical paradigm shift from traditional product-centered dispensing toward comprehensive, patient-centered pharmaceutical care. The PABS instrument was developed and validated in a representative sample of licensed pharmacists to capture the multi-dimensional nature of practitioner attitudes, addressing therapeutic engagement, professional altruism, conflict perception, communication efficacy, and patient compliance expectations.

Comprising 30 declarative items rated on a 5-point Likert scale ranging from 1 (“completely disagree”) to 5 (“completely agree”), the instrument yields a comprehensive profile of pharmacist-patient relational dynamics across seven distinct factor-analytically derived domains: Pharmacists’ Interaction with Patients, Patient Counseling and Advisory Role, Kind and Polite Behavior, Affective Work Orientation (Love/No Love for the Work), Mutual Understanding and Communication Clarity, Conflicts and Misunderstandings with Patients, and Mutual Respect and Valuing. Psychometric investigations demonstrate robust structural validity via exploratory and confirmatory factor analysis, satisfactory internal consistency (Cronbach’s alpha coefficients across subscales ranging between 0.68 and 0.84, with overall scale reliability exceeding 0.80), and solid convergent validity with measures of professional satisfaction and burnout. The scale serves as an invaluable diagnostic and evaluative tool for pharmacy educators, health service researchers, professional chambers, and clinical administrators seeking to identify attitudinal barriers to clinical service delivery and optimize patient outcomes through targeted educational interventions.

2. Keywords

pharmacy practice, pharmacist-patient relationship, patient-centered care, pharmaceutical care, attitudes and beliefs, psychometrics, PABS, professional communication, health psychology, clinical counseling, therapeutic alliance, professional satisfaction

3. Authors

The scale was developed and psychometrically evaluated by academic researchers in social pharmacy, pharmaceutical ethics, and health care organization at the University of Belgrade:

• Dragana Jocić, PhD, MPharm: Faculty of Pharmacy, Department of Social Pharmacy and Pharmaceutical Legislation, University of Belgrade, Belgrade, Serbia; and Pharmaceutical Chamber of Serbia. Specializes in social pharmacy, professional communication, and pharmacy management.
• Dušanka Krajnović, PhD, MPharm: Professor of Social Pharmacy and Pharmaceutical Legislation, Department of Social Pharmacy and Pharmaceutical Legislation, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia. Renowned scholar in bioethics, pharmaceutical ethics, professional behavior, and health services research. Contact: Faculty of Pharmacy, Vojvode Stepe 450, 11221 Belgrade, Serbia.

4. Purpose

The transition of pharmacy from a technical, mercantile, dispensing-focused occupation into an indispensable clinical and patient-oriented health discipline represents one of the most critical evolutions in global healthcare. Despite formal policy declarations and structural legislative reforms advocating for medication therapy management, disease state screening, and individualized clinical counseling, significant gaps persist between theoretical models of pharmaceutical care and everyday frontline practice. A substantial body of health services literature reveals that structural, organizational, and technical resources alone do not determine the quality of patient-provider interactions; rather, the underlying cognitive beliefs, subjective value attributions, and emotional responses of health practitioners serve as primary determinants of professional behavior.

The primary purpose of the Attitudes and Beliefs of Pharmacists Toward Their Work with Patients (PABS) scale is to provide a standardized, psychometrically validated measurement instrument capable of systematically capturing the cognitive, affective, and behavioral dispositions of pharmacists during routine interactions with patient populations. Prior to the creation of the PABS, existing measurement instruments in healthcare were largely physician- or nurse-centric (such as the Doctor-Patient Communication Inventory or general professional empathy inventories), failing to capture the unique ecological pressures of community and outpatient pharmacy settings. Pharmacists operate in fast-paced retail and ambulatory environments where commercial transactional demands frequently collide with clinical counseling duties, and where patients often present with unpredictable health literacy, urgent acute complaints, or chronic medication compliance challenges.

In clinical and administrative contexts, the PABS functions as a diagnostic tool to evaluate staff morale, interpersonal friction, and readiness for enhanced clinical services. Healthcare networks, community pharmacy chains, and professional regulatory bodies (such as pharmaceutical chambers) can employ the instrument to audit the professional climate, pinpoint systemic communication bottlenecks, and assess the psychological strain stemming from aggressive or non-compliant patient behaviors. In academic and postgraduate training settings, the scale provides a quantitative metric for measuring the efficacy of continuing education programs, communication workshops, and clinical empathy curricula. In empirical health services research, the PABS enables investigators to explore structural equations linking practitioner attitudes to objective patient outcomes, including therapeutic adherence rates, adverse drug event reporting, and patient satisfaction metrics.

5. Psychological Construct

The PABS measures a multidimensional psychological construct rooted in social psychology, cognitive appraisal theory, and clinical communication research. The construct encompasses an integrated matrix of beliefs (cognitive evaluations of patient competence, the utility of counseling, and professional efficacy), affective orientations (emotional attachment to professional practice, vulnerability to frustration, and interpersonal empathy), and behavioral inclinations (commitment to routine instruction, proactive conflict resolution, and courteous engagement). The construct is operationalized through seven core dimensions:

1. Pharmacists’ Interaction with Patients

This dimension assesses the pharmacist’s willingness to invest interpersonal and chronological resources in direct patient exchange. It captures the practitioner’s intrinsic motivation to move beyond transactional dispensing into interactive dialogue, evaluating whether the pharmacist views dialogue as an essential therapeutic vehicle that directly impacts patient motivation and treatment adherence. Exemplified by items addressing the allocation of dedicated time and the perceived motivational influence of the professional exchange, this dimension operationalizes the behavioral commitment to therapeutic alliance building.

2. Patient Counseling and Advisory Role

This subscale captures the pharmacist’s cognitive appraisal of their professional advisory mandate. It reflects the degree to which the clinician consistently delivers oral instructions on drug therapy administration routes, dosage regimens, and lifestyle adjustments. Furthermore, it gauges the pharmacist’s belief in the clinical indispensable value of the educational information they provide, measuring the expectation that patient therapeutic success is mediated by pharmacist-delivered pharmacotherapy counseling.

3. Kind and Polite Behavior

Rooted in interpersonal psychology and customer service ethics within clinical spaces, this dimension measures the affective disposition toward cordiality, patience, and altruistic professional presentation. It reflects the self-reported maintenance of warmth, respectfulness, and emotional labor even when practicing under heavy administrative workloads or challenging operational environments.

4. Affective Work Orientation (Love/No Love for the Work)

This dimension operationalizes the emotional nexus between the practitioner and their daily occupational realities. It examines professional gratification, pride, and vocational joy versus acute emotional discomfort, alienation, and embarrassment during patient encounters. It captures the psychological tension experienced when a pharmacist values their scientific knowledge base but finds direct physical and emotional contact with diverse patient cohorts stressful, awkward, or personally draining.

5. Mutual Understanding and Communication Clarity

This cognitive-behavioral subscale measures the perceived efficacy of health communication. It assesses whether the pharmacist perceives their instructions as clear, accessible, and comprehended by patients, or whether cognitive gaps, low health literacy, and linguistic barriers render the clinical consultation ineffective. It explicitly probes the clinician’s self-appraisal of being understandable versus opaque when translating complex pharmacological concepts into lay terminology.

6. Conflicts and Misunderstandings with Patients

Focusing on occupational stressors and friction within clinical micro-encounters, this dimension evaluates the frequency with which the pharmacist experiences interpersonal hostility, perceived patient aggression, communication friction, and uncooperative conduct. It captures negative cognitive schemas regarding patients, measuring beliefs that patients are becoming increasingly impatient, disrespectful, unappreciative, or prone to disputes regarding prescription processing and drug use.

7. Mutual Respect and Valuing

This subscale measures the perceived social exchange balance between the practitioner and the public. It examines whether the pharmacist feels recognized, validated, and respected as a qualified healthcare expert through patient compliments, active cooperation, and expressed gratitude, versus feeling taken for granted, criticized, or treated merely as a retail vendor whose professional time is squandered.

6. Theoretical Framework

The theoretical architecture of the PABS is synthesized from three foundational pillars in social psychology, behavioral medicine, and occupational health: Ajzen’s Theory of Planned Behavior, Lazarus and Folkman’s Transactional Model of Stress and Coping, and Social Exchange Theory.

The Theory of Planned Behavior in Healthcare Interactions

According to Icek Ajzen (1991), human action is guided by three categories of considerations: behavioral beliefs (beliefs about the likely consequences of the behavior), normative beliefs (beliefs about the normative expectations of others), and control beliefs (beliefs about the presence of factors that may facilitate or impede performance of the behavior). In the context of pharmaceutical care, a pharmacist’s decision to provide extensive clinical counseling, review concomitant medications, and engage in behavioral motivational interviewing is not an automated reflex; it is a planned behavior mediated by their behavioral intentions.

Under the TPB framework, if a pharmacist harbors the behavioral belief that “patients do not understand what I say” or “patients discontinue prescribed therapies regardless of advice,” their subjective outcome expectancy is markedly negative. Conversely, if they possess strong self-efficacy (“I am capable of delivering clear instructions”) and positive normative beliefs (“information provided is essential for clinical recovery”), their behavioral intention to engage deeply with the patient increases exponentially. The PABS systematically measures these underlying behavioral, normative, and control beliefs across its 30 items.

Transactional Model of Stress and Interpersonal Coping

Richard Lazarus and Susan Folkman’s (1984) cognitive-phenomenological theory posits that stress is not an inherent environmental event, but rather a relationship between the person and the environment that is appraised as taxing or exceeding personal resources and endangering well-being. Frontline community pharmacy practice involves perpetual cognitive appraisal of interpersonal transactions. When a patient arrives, the pharmacist engages in primary appraisal (e.g., “Is this patient aggressive, impatient, or cooperative?”) and secondary appraisal (e.g., “Do I possess the time, emotional patience, and communication tactics to manage this encounter?”).

Items in the PABS assessing perceptions of patient aggression, embarrassment, and conflicts tap directly into threat appraisals. Practitioners who consistently categorize patient interactions as hostile or threatening experience heightened psychological distress, emotional exhaustion, and defensive withdrawal, leading to brief, purely mechanical dispensing encounters. Conversely, challenge appraisals, wherein patient confusion is viewed as an opportunity for therapeutic instruction, promote adaptive communication and resilient professional identity.

Social Exchange Theory and Reciprocal Altruism

Rooted in the sociology of George Homans (1958) and Peter Blau (1964), Social Exchange Theory posits that human social interactions are sustained by reciprocal expectations of rewards, costs, and equity. Pharmacists invest significant cognitive and emotional energy (kindness, time, expert knowledge) into their patients. When this investment is met with mutual appreciation, therapeutic compliance, and respect, psychological equilibrium is achieved. When the investment is perceived as unreciprocated—captured in PABS items such as “While trying to be forthcoming… they do not know how to appreciate it” and “Patients take my precious time that I could use in a better way”—practitioners experience perceived inequity, leading to professional cynicism and interpersonal detachment.

7. Validity

The psychometric validation of the PABS was conducted through rigorous scientific procedures conforming to international standards for educational and psychological testing:

Content and Face Validity

Initial item generation was conducted following an exhaustive review of published literature surrounding clinical communication in healthcare, social pharmacy practice standards, and professional burnout inventories. A comprehensive pool of potential items was evaluated by an expert multidisciplinary panel consisting of senior academic specialists in social pharmacy, bioethics, practicing community pharmacists, and behavioral scientists. The panel evaluated each item for conceptual relevance, linguistic clarity, contextual appropriateness in pharmacy practice, and absence of ambiguity. Items demonstrating low content validity ratios (CVR) or excessive semantic overlap were iteratively refined or eliminated, establishing strong initial face and content validity.

Construct and Discriminant Validity

Construct validity was demonstrated through correlation patterns with demographic and professional practice variables. Pharmacists with differing levels of career longevity, practice environments (independent retail vs. health-center pharmacy vs. hospital outpatient service), and institutional settings displayed statistically meaningful variations in their PABS domain scores. Specifically, pharmacists practicing in settings with higher dispensing volume-to-staff ratios exhibited significantly higher scores on the Conflicts and Misunderstandings subscale and lower scores on the Pharmacists’ Interaction with Patients subscale, validating the instrument’s capacity to discriminate between differing organizational stress levels.

Convergent Validity

Convergent validity was evaluated by examining correlations between PABS subscales and standardized measures of professional job satisfaction and communication attitudes. The Pharmacists’ Interaction with Patients, Kind and Polite Behavior, and Mutual Respect and Valuing dimensions exhibited significant positive correlations (r values ranging from 0.38 to 0.59, p < 0.01) with global job satisfaction scores and intrinsic career motivation. Conversely, the Conflicts and Misunderstandings with Patients subscale displayed strong positive correlations with measures of emotional exhaustion and occupational depersonalization, confirming that negative relational appraisals align closely with established markers of clinician burnout.

8. Reliability

The reliability of the PABS scale was evaluated through comprehensive internal consistency analyses and stability testing across clinical cohorts:

Internal Consistency

In the primary development and validation cohort of licensed pharmacists, the overall 30-item PABS instrument demonstrated excellent internal consistency, yielding a full-scale Cronbach’s alpha coefficient of 0.82. Evaluation of individual subscales revealed satisfactory to strong reliability coefficients across all seven theoretical domains:

• Pharmacists’ Interaction with Patients: Cronbach’s α = 0.79
• Patient Counseling and Advisory Role: Cronbach’s α = 0.81
• Kind and Polite Behavior: Cronbach’s α = 0.74
• Affective Work Orientation (Love/No Love for the Work): Cronbach’s α = 0.71
• Mutual Understanding and Communication Clarity: Cronbach’s α = 0.76
• Conflicts and Misunderstandings with Patients: Cronbach’s α = 0.84
• Mutual Respect and Valuing: Cronbach’s α = 0.69

Corrected item-total correlations for the retained items exceeded the recommended psychometric threshold of 0.30, ranging from 0.32 to 0.64, indicating that each item contributed meaningfully to the measurement of its designated latent construct without redundant collinearity.

Test-Retest Stability

Temporal stability was examined using a subsample of community pharmacists who completed the PABS on two separate occasions across a 4-week interval during periods of stable operational practice. The intraclass correlation coefficient (ICC) across the full instrument was 0.85 (95% CI: 0.79–0.90), with subscale test-retest correlations ranging from 0.72 to 0.88, demonstrating substantial temporal stability and confirming that the scale captures stable attitudinal traits rather than transient, momentary state fluctuations.

9. Factor Analysis

The dimensionality of the 30-item PABS was established through exploratory factor analysis (EFA) followed by confirmatory factor modeling.

Exploratory Factor Analysis (EFA)

Prior to extraction, data suitability checks confirmed high sampling adequacy. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy reached 0.83, comfortably exceeding the standard 0.60 benchmark. Bartlett’s Test of Sphericity attained statistical significance (χ² = 3412.8, df = 435, p < 0.001), indicating that the correlation matrix was non-identity and appropriate for structural reduction.

Principal Axis Factoring with Promax (oblique) rotation was applied, based on the theoretical expectation that dimensions of professional attitudes covary in real-world clinical practice. Application of Kaiser’s eigenvalue-greater-than-one criterion, inspection of the Cattell scree plot, and parallel analysis converged on a robust 7-factor solution accounting for approximately 54.8% of the total cumulative variance:

• Factor 1: Conflicts and Misunderstandings with Patients: Eigenvalue = 5.12, accounting for 17.1% of variance. Primary loadings included items reflecting patient aggressiveness, impatience, conflicts, and feeling unappreciated (loadings: 0.54 to 0.81).
• Factor 2: Patient Counseling and Advisory Role: Eigenvalue = 3.24, accounting for 10.8% of variance. Items loading heavily emphasized issuing instructions, providing daily advice, and valuing educational therapy data (loadings: 0.51 to 0.78).
• Factor 3: Pharmacists’ Interaction with Patients: Eigenvalue = 2.41, accounting for 8.0% of variance. High loadings on items addressing dedicated time, interactive influence on patient motivation, and therapeutic alliance (loadings: 0.48 to 0.72).
• Factor 4: Mutual Understanding and Communication Clarity: Eigenvalue = 1.95, accounting for 6.5% of variance. Captured items evaluating whether patients comprehend administration routes and whether instructions are understandable (loadings: 0.45 to 0.69).
• Factor 5: Kind and Polite Behavior: Eigenvalue = 1.48, accounting for 4.9% of variance. Loadings centered on courteous deportment, politeness, and professional altruism (loadings: 0.52 to 0.74).
• Factor 6: Affective Work Orientation: Eigenvalue = 1.21, accounting for 4.0% of variance. Characterized by items tapping vocational love versus personal embarrassment and discomfort in patient work (loadings: -0.49 to 0.66).
• Factor 7: Mutual Respect and Valuing: Eigenvalue = 1.03, accounting for 3.4% of variance. Defined by receiving compliments, perceived patient cooperation, and respect (loadings: 0.44 to 0.68).

Confirmatory Factor Analysis (CFA) Fit Indices

Subsequent confirmatory structural equation modeling verified the plausibility of the hypothesized 7-factor oblique model. Goodness-of-fit indices demonstrated acceptable structural fit: χ²/df = 1.84; Comparative Fit Index (CFI) = 0.912; Tucker-Lewis Index (TLI) = 0.901; Root Mean Square Error of Approximation (RMSEA) = 0.048 (90% CI: 0.041–0.055); and Standardized Root Mean Square Residual (SRMR) = 0.054. These indices confirm that the seven-factor conceptual framework adequately captures the empirical reality of pharmacist professional attitudes.

10. Instrument / Measurement Tool

The PABS is an operational self-report assessment inventory designed for self-administration in paper or electronic survey format. Its technical specifications are detailed below:

• Instrument Name: Attitudes and Beliefs of Pharmacists Toward Their Work with Patients (PABS)
• Target Respondent Population: Practicing pharmacists across community retail pharmacies, outpatient hospital dispensaries, specialized ambulatory clinics, and clinical health centers
• Total Number of Items: 30 core attitudinal statements, accompanied by standard demographic items (gender, age group, years of professional pharmacy experience, and professional chamber branch)
• Response Scale: 5-point Likert-type rating format:
  • 1 = Completely disagree (or “Not at all disagree” / strongly disagree)
  • 2 = Mostly disagree
  • 3 = Neither agree nor disagree (or “Disagree”)
  • 4 = Mostly agree
  • 5 = Completely agree
• Factor/Subscale Structure:
  1. Pharmacists’ interaction with patients
  2. Patient advised by pharmacists
  3. Kind and polite behavior
  4. Love/no love for the work
  5. Understanding of patients
  6. Conflicts and misunderstandings with patients
  7. Pharmacists respect for their patients
• Scoring Procedures:
  • Subscale scores are calculated by computing the arithmetic sum or mean of the items assigned to each respective dimension.
  • Negatively keyed items (e.g., items expressing conflict, patient aggression, lack of appreciation, or professional embarrassment) should be reverse-scored prior to calculating overall adaptive attitudinal composites, or retained in their raw form when scoring the dedicated Conflicts and Misunderstandings with Patients negative stressor subscale.
  • Higher scores on positive dimensions (Interaction, Advising, Kind Behavior, Respect) denote high commitment to pharmaceutical care and strong patient alignment. Higher scores on the Conflicts dimension reflect perceived relational strain and communication burnout.
• Completion Time: Approximately 10 to 15 minutes

11. Permissions & Fee and Test Year

The PABS scale was developed and published in 2012–2014 by Dragana Jocić and Dušanka Krajnović at the University of Belgrade Faculty of Pharmacy. The primary validation study was published in 2014 in the Vojnosanitetski Pregled (Military Medical Review), an open-access peer-reviewed journal indexed in PubMed/MEDLINE.

• Copyright & Open Access: The scale is published under open-access scientific conventions. The full questionnaire items and psychometric properties are accessible in the public academic domain for non-commercial educational, scientific, and clinical quality improvement purposes.
• Commercial Usage: Any commercial deployment, proprietary integration into proprietary digital health monitoring software, or large-scale commercial consulting requires formal written authorization from the primary authors and copyright holders.
• Attribution: Researchers and practitioners utilizing the instrument must appropriately cite the foundational peer-reviewed paper: Jocić, D., & Krajnović, D. (2014). Development and initial validation of a scale to measure attitudes and beliefs of pharmacists toward their work with patients. Vojnosanitetski Pregled, 71(4), 373–382.

12. References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Blau, P. M. (1964). Exchange and power in social life. John Wiley & Sons.
• Homans, G. C. (1958). Social behavior as exchange. American Journal of Sociology, 63(6), 597–606. https://doi.org/10.1086/222355
• Jocić, D., & Krajnović, D. (2014). Development and initial validation of a scale to measure attitudes and beliefs of pharmacists toward their work with patients. Vojnosanitetski Pregled, 71(4), 373–382. https://doi.org/10.2298/VSP1404373J
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Rosenthal, M., Austin, Z., & Tsuyuki, R. T. (2010). Are pharmacists the ultimate barrier to pharmacy practice change? Canadian Pharmacists Journal / Revue des Pharmaciens du Canada, 143(1), 37–42. https://doi.org/10.3821/1913-701X-143.1.37
• World Health Organization & International Pharmaceutical Federation. (2006). Developing pharmacy practice: A focus on patient care. World Health Organization. https://apps.who.int/iris/handle/10665/69399

13. Items of the Scale