Exploring pharmacist–customer communication: the established blood pressure measurement episode
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- Cavaco, A.N. & Romano, J.P. Pharm World Sci (2010) 32: 601. doi:10.1007/s11096-010-9413-x
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Objective To characterize the communication ritual in the pharmacist–customer dyad during a blood pressure measurement and counselling episode. Setting A Portuguese urban community pharmacy. Method An exploratory, cross-sectional design was used. Participants were purposively selected and data collected via audio recording, as well as demographics and clinical information via questionnaire. Encounters’ verbal content was transcribed verbatim, utterances identified, time stamped, and classified according to a coding scheme of fifteen categories. All data was statistically analyzed using SPSSv17. Main outcome measures Four dialogue structures: speaker turn, interactivity, turn density and turn duration measurements. Results From a total of 51 participants, 72.5% were female with a median age of 66 years. The average systolic blood pressure was 140 mmHg, while the diastolic was 78 mmHg. The blood pressure measurement episode lasted for 5:35 min, with an average of 81 utterances. From all utterances registered, 55.3% were produced by the customer. Visits averaged 38 speaker turns, with an interactivity rate of approximately 7 turns per episode minute. For pharmacists, turn duration averaged 7.0 s and turn density 2.1 utterances. The customers’ turns comprised a mean of 8.0 s, with 2.4 utterances. Longer episodes were related to more speaker turns and greater customer turn density and duration, but lower dialogue interactivity. The interactivity rate was also lower when the customers’ utterances increased. Pharmacists asked more questions (essentially closed ones), while the customers gave more information. No significant associations were observed between elderly/non-elderly and gender in relation to all communication variables. However, an increased number of speaker turns and closed-questions were associated to a higher systolic pressure. Conclusion It seems that pharmacists tend to control the content of the dialogue, while customers have more influence on the visit duration and interactivity. Specific hypertensive episodes induce a higher information search. Since the closed questioning format was prevalent, it seems that open information exchange was limited, mainly serving confirmation purposes rather than having a true exploratory nature. Although talk dominance is balanced, further analysis is required to better inform these results, which would confirm the low interactivity and the reduced information-seeking behaviour showed in the counselling episodes.
KeywordsBlood pressure measurementCommunity pharmacyPharmacist–customer communicationPortugal
Impact of the research findings on practice
Pharmacists need to increase proactive questioning behaviour, since customers are likely to communicate mainly by passive response.
Pharmacists need to improve their exchange with customers when justified, beyond challenging situations e.g. high systolic blood pressure episode.
When counselling, Portuguese pharmacists seem not to be influenced by customers’ demographics, which is a good indicator of a professional practice.
During the last three decades, pharmacist–customer communication in community pharmacies has received attention from researchers . These studies were mainly designed to characterize the content of the information provided by the pharmacist to the customer and how the message was shared in the dialogue. Several communication theories have been used to create talk coding instruments, despite the fact that exchange basic assumptions may vary [1, 2]. For instance, transmission (1-way communication) and transactional (2-way communication) actions describe dissimilar interpersonal processes of communication . Most studies based their research from the first model, characterizing the information given by the pharmacist to the customer, with the last having limited influence in the dialogue. Since talk is transactional by nature, there is a research gap in pharmacy communicational exchange. Communication is a cooperative process, where shared meaning is negotiated between the dyad and the participants are considered mutually responsible for the communication effect and effectiveness . Based on transactional 2-way theory, pharmacy customers can expose their own fears and doubts, creating a social and emotional link with the health professional.
Most community pharmacy studies have focused on counter-based communication through observational methods, mail surveys, and phoned interviews [1, 4–7]. However, the application of these methods for communicational research have shown limitations, as they cannot capture properly the dyadic interaction created; for instance, paralanguage is missed. In audio recordings, language and paralanguage, the symbols and signals that participants exchange, can be captured. Dialogues can be analysed by their smallest discriminable speech segments, which are defined as utterances .
Pharmacy cognitive services
The introduction of new services at community pharmacies, such as extended cognitive services, has increased professionals’ responsibilities [9, 10]. These services support a closer relation with the customer, most times moving the interaction from the counter to a private setting. Portuguese community pharmacies are now required to have a consultation room for the management of extended customer services  such as diabetes, asthma, and hypertension medication reviews.
Blood pressure (BP) measurement is an established and regular service in Portuguese community pharmacies, allowing the follow-up of customers’ BP and to grant personal advice. The service is provided in a consultation room and follows a sequence similar to the medical interview. There are 5 main segments: opening, history, measurement, counselling, and closing (detailed in Methods). The classical opening and closing segments might not be present during the actual service, since greetings and social talk occur in a previous moment, at the counter, when customers ask for the service. As well as, final remarks and goodbyes take place out of the consultation room, when the customer leaves the pharmacy. The relevance of this service is confirmed knowing that hypertension is a prevalent risk factor for cardiovascular conditions [12–14]. Beyond BP clinical implications, this study has focused on a privileged moment of pharmacist–customer interaction to pilot interpersonal communication in the Portuguese community pharmacy context.
Aim of the study
The main objective of this study is to characterize the communication between pharmacists and customers during a BP measurement and counselling episode, in the community pharmacy setting. Specific objectives comprised of a demographic description of customers measuring their BP in the pharmacy; dialogue characteristics and qualities such as interview length, intensity of exchange and talk dominance, and distribution of utterances by either content or segment of the interview, as well as correlations with selected variables.
This pilot research followed an exploratory, observational cross-sectional design. Participants were selected through a convenience criterion. All pharmacy customers asking at the counter to measure his/hers BP were invited to participate. Before the actual measurement episode, participants were elucidated about the study purpose and method, as well as data confidentially assuring participants’ privacy at all research stages (e.g. name initials, one single coder). The study took place during 4 weeks (from 4th to 29th January 2009), in a community pharmacy in Almada, Portugal.
Two field researchers, both male employed pharmacists with a mean of 1.5 years of practice, took a number of BP measurements equivalent to the average number of hypertensive customers visiting the pharmacy during a 4 weeks period. This matched a sample size of 50 customers. The measurements were taken in a private setting, in the pharmacy consultation room. After the written informed consent by each participant, the BP measurement episode (BPME) data collection was obtained by audio recording. BP measurement was performed according to the recommendations listed in World Health Organization’s Guidelines, using a calibrated automatic device, with international validation (M4 (Omron)/HEM 722C1-E) . While audio data was digitally captured, basic demographics, BP values, heart rate and medication information was gathered through a written questionnaire. Both pharmacists received the same research training, used the same measurement procedures and interview structure.
The encounters’ verbal content was transcribed verbatim, utterances identified, time stamped, and classified according to a coding scheme of fifteen categories. This simpler scheme was developed from literature review [8, 15–18], although framed in Roter Interaction Analysis System (RIAS) method (www.rias.org/manual). The original RIAS frame was not used since it requires adequate training for coding reliability, while addressing interactional dimensions beyond the scope of the present study. The simplified coding scheme comprised of closed and open questions, as well as informative and advise codes related to medical, therapeutic, and lifestyle/psychosocial information. Four other categories were introduced to address emotions and directions/orders. This scheme was pretested in a pilot sample of 6 customers (approx. 10% of the sample), to confirm its usefulness and adjusting some of the classifying categories. For instance, ‘personal dialogue’ here corresponds to pharmacist–customer greetings, which does not correspond to tight socio-emotional categories considered in the medical setting  or, oppositely, to a passer-by simple salutation . The simpler coding scheme became stable and consistent after the third transcript was coded.
Coding scheme with fifteen categories driven from literature and transcription analysis
Questions that produce restricted answers with few words
3. Lifestyle (LS)/psychosocial (PS)
Questions that will solicit more than factual restricted information
Utterances related to all information stated in a non-interrogative form
Utterances that suggest or imply some resolution to be taken by the other
10. Medical and therapeutic
13. Personal dialogue
Negative emotional disclosures
Positive points of view
Speaker turn is defined as a continuous segment of uninterrupted utterances of a single speaker. The total number of speaker turns per interview can be interpreted as the rate of floor exchanges.
Dialogue interactivity is defined as the number of speaking turns per interview minute. For example, a 5 min interview with 30 turns will average 6 turns per minute.
Turn density is characterized as the average number of utterances within a turn by the speaker.
Turn duration represents the length of time in seconds spanning the block of uninterrupted speech by the speaker.
All interviews, including the pilot sample, where segmented in the five interactional phases earlier referred and identified by the content of the information exchanged. The opening segment was an extension of pharmacist and customer greetings and initial talk. In the history segment, the pharmacist gathers background and clinical information, e.g. medication adherence and lifestyle. The measurement segment corresponds to the use of validated procedures and equipment, and related orientation utterances. The counselling segment includes dyad’s interpretation and discussion of the observed BP results with specific information and counselling exchange. The interaction closes with final remarks and reminders.
All coded utterances, correspondent timestamps, interview segments, dialogue structures, as well as demographic and clinical data were statistically analyzed using the Statistical Package for Social Sciences (SPSS v17). Descriptive statistics were calculated for all variables, including Student t-test and bivariate Pearson correlation. The significance value for all statistics was set to a P-value less than 0.05.
Demographic and clinical data
A total of 56 pharmacy customers asked for a BP measurement during the study period. After being informed about the study and occasional doubts cleared, only 5 customers refused to participate, mentioning no available time (3) or privacy matters (2). All customers who agreed to participate remained in the study, corresponding to 51 participants.
Participants’ demographic and clinical data
Frequency (n = 51)
No formal education
BP categories (mmHg) 
Normal (<139; <89)
Grade 1 hypertension (140–159; 90–99)
Grade 2 hypertension (160–179; 100–109)
Grade 3 hypertension (>180; >110)
Isolated systolic hypertension (>140; <90)
Taking anti-hypertensive medication
No significant differences were observed between age groups or gender with all communication variables.
Communication variables mean values were not showing significant differences with the customers’ demographic or clinical variables, except for participants with systolic hypertension. In this case, the total number of closed questions asked by pharmacist and customer were, on average, significantly higher if compared to non-hypertensive customers (t = −2.027, P = 0.049). Speaker turns showed the same difference between these BP groups (t = −2.038, P = 0.048). Systolic hypertension was also significantly associated with an increased number of utterances at the counselling segment (t = −2.151, P = 0.037).
Interview duration (min:s)
5:35 (SD = 3:33)
Number of utterances
81.2 (SD = 47.2)
Number of speaker turns
38 (SD = 17.7)
Interactivity (total turns per min)
7 (SD = 2.3)
Turn taking characteristics
Pharmacist (n = 2)
Customer (n = 51)
36.3 (SD = 16.8)
44.9 (SD = 34.5)
Turn density (average utterances per turn)
2.1 (SD = 0.6)
2.4 (SD = 1.3)
Turn duration (in s)
7.0 (SD = 2.7)
8.0 (SD = 7.6)
Distribution of the identified utterances in the pharmacist–customer communication
Utterances on average (SD)
Pharmacist utterances (SD)
Customer utterances (SD)
10. Medical and therapeutic
13. Personal dialogue
The pharmacist asked a mean of 4.35 closed-questions per interview, while the customer asked 1.51. The most common theme was ‘medical’ for both, comprising 67.6% of all closed-questions. Regarding open questions, the pharmacist asked on averaged 2.75 per session, while the customer 0.47. The main theme was also a medical one, with 60.9% of all open questions. Utterances related to give information, presented an average of 12.69 for the pharmacist and 34.66 for customers. The informational exchange was essentially of medical content (71.4%).
Interview segments with utterances and questioning distribution
Closed % (n = 223)
Open % (n = 141)
Closed % (n = 77)
Open % (n = 24)
Relationships among selected variables by linear correlation (r)
Customer give information
Turn duration (customer)
Turn duration (pharmacist)
Turn density (customer)
Turn density (pharmacist)
Turn density (pharmacist)
Turn density (customer)
Turn duration (pharmacist)
Turn duration (customer)
Customer give information
Large correlations were found between turn density and duration, with Pearson correlation coefficients of 0.789 and 0.967 for pharmacist and customer, respectively. No significant correlation was found between pharmacist and customer turn duration (r = 0.229, P = 0.11). Systolic values were positively correlated with more speaker turns (r = 0.312, P < 0.05), as well as closed-questions (r = 0.386, P < 0.01).
All closed-questions and the information given by the customer had a higher correlation coefficient than the total number of open questions (r = 0.616, P < 0.01 vs. r = 0.371, P < 0.05, respectively).
The BPME was found to be an active exchange. Results showed an average of 14.5 utterances produced by the dyad per minute of interview, as well as 7 speaker turns independent from background variables. These and other findings are detailed and discussed next.
Demographic and clinical data
The study sample comprised of predominantly elderly females. This is in agreement with the population group that commonly uses community pharmacies [20–22]. The low literacy level is in accordance with the lack of education observed for the Portuguese elderly population (Portuguese census 2001). Demographics might explain why the BPME was more frequent in the mornings: old and retired women usually do their daily shopping at the local market, open in the morning and located near to the pharmacy where the study took place.
This was not a BP study. Nevertheless, findings point to an average BP that can be classified as borderline systolic hypertension. BP values were expected to be closer to normal as 88.2% of the participants were under anti-hypertensive therapy. This might show a lack of therapeutic effectiveness, while anxiety related with study participation also might have had some influence. The heart rate was considered normal [23, 24].
According to previous research, a counter interaction is an episode with variable length, from 1:54 min  to 74 s , according to study objectives and not accounting for practice and cultural differences. In a Portuguese context, the BPME took on average 5:35 min. This is shorter than the average length of hospital pharmacists’ interviews (approx. 7 min) , as well as shorter than the average European primary care consultation (approx. 11 min) . Differences in duration between counter and in-room interviews can result from privacy issues. Consultation rooms allow customers to declare or elaborate on their own problems and fears, since the interaction is more private. On the other hand, lack of confidentiality limits the pharmacist probing, particularly on the type of information that might be asked. Customer services occurring in a private setting favour a trustful environment, facilitating the customer’s disclosure of clinical and personal information, thus increasing the time spend with the health professional.
It is widely accepted that there is a relational dominance of practitioners over patients. In this specific setting, customers contributed more to the overall dialogue, presenting slight talk dominance. A less formal consultation climate and pharmacists’ questioning behaviour leads customers to perceive few response restrictions. Nevertheless, the dialogue in terms of verbal content seemed to be controlled by the pharmacist through closed questioning. This supports the pharmacists allowing for customer participation, but without truly facilitating customer narratives which would include spontaneous worries and doubts. Low customer questioning also suggests limited active information searching, using the pharmacist as a valuable and trusted source. The prevalent closed questioning format, for either pharmacists or customers, revealed a circumscribed information pursuit. More open questions would be preferable, so an improved usage of the informative potential of these encounters might be reached. This way, professionals could also create more opportunities for customers to expose their questions and qualms. It is a pharmacist’s responsibility to provide information and not to forget basic communication principles, such as probing the customer’s understanding of their condition and treatment. Asking simple questions such as ‘do you have any doubts?’ would encourage patients to adopt an active role beyond information giving.
The dialogue structures were a powerful analytical tool to describe and characterize dyad exchange. Although both pharmacist and customer speaker turns contributed to the length of the visit, only customer turn density and duration had significant and equivalent correlations with visit length. This suggests the number of utterances and its duration in the pharmacist’s turns are not related with the total length of the visit. It seems that customer participation in the dialogue had a greater influence in the BPME duration. This hypothesis is also corroborated by the smaller turns identified for the pharmacist, when the number of speaker turns increased. On the other hand, interactivity decreased as the customer turn density and duration became higher. This rate also decreased with the total number of customer utterances, namely give information ones. This supports the customer’s influence in the dialogue interactivity.
The absence of a significant relationship between the speaker turns and interactivity was not expected. This could be explained from greater number of turns followed by longer turn duration, thus diluting any increases in the total number of turns per minute, suggesting a stable interactivity rate through speaker turns.
Correlation results also indicated that an increment in the customers’ systolic pressure was associated with the number of speaker turns and information search (closed-questions). The floor of speech changed often and closed questioning might have confirmation purposes. This also supports the increased number of utterances in the counselling segment, where the dyad try to understand and explain the unexpected systolic pressure value.
Since no significant associations were found with diastolic pressure or heart rate, it might be said that either the pharmacist or the customer underestimated these two variables. However, it is possible that this absence of relationship with diastolic pressure could be related with the 88.3% of the participants that showed normal levels, presenting fewer problems to discuss. Further analysis is needed, since both diastolic pressure and heart rate are relevant cardiovascular risk factors , and should be addressed by pharmacist.
Non-significant relationships between demographics and communication variables suggested a stable pattern of interaction, independent from customer age and gender. This contradicts the general assumption of female elders as more talkative then other population groups.
To conclude, and contrasting with other findings [15, 28], the closed-questioning format produced more information exchange than open questioning. Sequences of closed and moderately closed questioning indicate an inquiry type of talk, displaying a pharmacist’s will to gain access to specific and relevant information. This, on the other hand, stimulates customer participation while exerting control over the dyad exchange.
As a pilot and exploratory study, some limitations were identified. Dialogues were analysed through verbatim transcriptions, placing difficulties on identifying the correct length of individual utterances, as well as losing tonal characteristics and emotional content. Nevertheless, due to a simpler coding scheme and the broad scope of the coding categories, in particular concern and optimism, losing tonal qualities of the dialogue had a reduced impact. Additionally, this discrepancy might have affected all utterances, being the final coding internally coherent.
Participants were not blinded to the exact nature of the research, thus some influence on the content of the dialogue might have occurred i.e. a possible Hawthorne effect. As well, an increase in anxiety among customers might have modified the information exchanged if compared with a non-recorded BPME. This potential bias was controlled in terms of interview length, since the average non-recorded BPME presents a similar duration (approx. 5 min).
Although selection and participation bias were controlled by low refusal rate, a previous relationship between the pharmacists and some participants can be seen as a source of information bias, as the pharmacist knew already the medical history of those customers (approx. 60%), somehow limiting information search. In addition, two field researchers might be seen as a limitation. Nonetheless, BP measurement was a routine service provided by equally trained pharmacists, who followed established guidelines .
BP measurement episodes have proven to be a useful opportunity to collect communication related data as well as demographic and clinical information.
This study revealed a balanced dialog between the interactional pair. Dyad exchange behaviour suggests the visit is under the professional’s control. However, to improve interaction quality and avoid misleading the customer, pharmacists should provide customers with more questioning opportunities, stimulating an active process of information searching. Pharmacists may control verbal exchange, but customers seemed to be responsible for interview duration as well as turn talk and interactivity. Although Portuguese pharmacists seem to adopt a conduct that reinforces a standardized care, specific hypertensive episodes induced a dissimilar information search.
This pilot study shed new light on the characterization of the communication ritual between pharmacists and customers during the common BP measurement episode. Although talk dominance is balanced, further analysis is required to better inform these findings, confirming the low interactivity and the reduced information-seeking behavior showed by the dyad.
The authors would like to thank the community pharmacy ‘Tovar Chaves’ for the collaboration with this study.
No external sources of funding for this work were obtained.
Conflict of interest
There are no conflicts of interest.