Pharmacist Employee Choices: Hirschman’s Exit, Voice, and Loyalty (EVL)

Dr. Albert Hirschman wrote a pretty interesting book entitled Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States in 1970 to offer a model of how loyalty influences a customer or employee to exit or voice concerns.  I’d like to focus on this model from a staff pharmacist perspective for a large organization (ie: chain pharmacy or health system).  With the changing market for pharmacist labor over the past decade, I would argue that the increased supply of pharmacists has shifted employee decisions quite substantially (whether that shift is a good or bad thing is for you to decide).

Brief Background of EVL

Without going into a ton of detail on Hirschman’s model, it basically proposed that when an employee is unhappy with an organization, he may: 1) voice concerns and attempt to change the organization as an employee, 2) voice concerns while leaving the organization, 3) passively accept and be unhappy, or 4) quietly leave the organization.  Jill Graham and Michael Keeley summarized it very well in the Employee Responsibilities and Rights Journal in 1992 (see Figure 1).  As you can see, the model is pretty basic, but gives us an interesting construct.  Researchers have used this model to test things like “loyalty” to predict where employees will fall in this diagram.

Figure 1: Potential responses to organizational decline (Graham and Keeley 1992)

Figure 1: Potential responses to organizational decline (Graham and Keeley 1992)


Pharmacist Responses to Organizational Decline (Pharmacist Shortage)

When I first graduated pharmacy school in 2009, many of the retail pharmacists I worked with would have fallen in the top 2 quadrants, in other words they would “voiced” their concerns of corporate changes quite often.  Whether the pharmacists were unhappy with “Transfer Coupons” or “Wait Time Goals” set by their employer, you were likely to hear their dissatisfaction.  Just ask any District Manager from 2000-2010.  While the propensity to voice concerns sometimes came across as “whiny” pharmacists to upper management, it still was an avenue where professionals could attempt to change the organization.  Pharmacists concerned with the safety and care of their patients should voice concerns against promotional tools that only increase things like polypharmacy.  During this time, pharmacists were high in demand and companies had little leverage over their staff pharmacists.  Pharmacists felt secure about their employment and were not afraid to “rock the boat” with their dissent.

Pharmacist Responses to Organizational Decline (Pharmacist Surplus)

Fast forward to present day, where in most markets the supply of pharmacists adequately meets the demand.  The same health care professionals in large organizations face the same concerns in many cases (working conditions, transfer coupons, wait time expectations, lack of technician help, etc.), but with a different level of job security.  I believe it is safe to say that more pharmacists have shifted from “voicing” concerns to remaining silent (bottom 2 quadrants).  Pharmacists may be unhappy with their employer and will either passively accept the dissatisfaction or quietly search for a new job.  Pharmacists that are asked to verify more prescriptions with less help may have concerns, but what are their options with little leverage over their employer?

How does this impact patient care?

The real question that comes from this discussion, is how does pharmacist ability to express concern impact the quality of a pharmacy?  While I have my own thoughts and hypotheses, I welcome the readers to share opinions.  Maybe future research should be conducted in this area…

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Joey Mattingly, PharmD, MBA is an assistant professor at the University of Maryland School of Pharmacy located in Baltimore, Maryland. Joey has managed retail and long-term care pharmacy operations in Kentucky, Illinois and Indiana. Leading Over The Counter is a blog of Joey's views and opinions on the topics of pharmacy leadership and management and do not represent the University of Maryland, Baltimore. Joey can be followed on Twitter @joeymattingly.

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