Abstract
This article builds upon literature on materialities of care and departs from a relational view of care and place. Using the concept of atmosphere, it investigates how care practices are situated spatially and temporally in pharmacies. In many countries, pharmacies are viewed as an important sector in formal healthcare systems. Rarely discussed in pharmacy literature is the affective and embodied aspect of care and care services. Drawing on an ethnographic study of Swedish pharmacies, I demonstrate that pharmaceutical care services are more than filling prescriptions and giving medical advice. Senses of care are partly accomplished through pharmacy staff's routinized and embodied engagement with the material environment. They also are performed through staff's tacit reading of customers. This article argues for an alternative understanding of care than an institutionally scripted one.
“Do you often visit pharmacies?” I asked Tania, 1 who agreed to be interviewed about her experiences of pharmacies.
“Quite often. I normally get medications for my children and my husband from the pharmacy”, she said.
“When was the last time you visited a pharmacy?” I followed up.
“Hmmm… some minutes ago, in fact, in the train station, while I was waiting for you.”
“Were you there to fill a prescription?”
“No. I was just looking, to see what they have on offer.”
This is a snapshot of my fieldnotes collected in the autumn of 2019. When Tania said she was there just looking, it seemed, at that particular moment, visiting a pharmacy was like spontaneous shopping in a high-street store. In this scenario, the pharmacy becomes a retail site where customers are allowed, and even encouraged, to stroll around and spend some enjoyable time. This sense of consuming a retail place (Dubuisson-Quellier, 2007; Geysmans et al., 2017; Steadman et al., 2020) echoes what Sanna, a pharmacist I met during the fieldwork, said: “People come here for experience. It must be for the experience.”
Policy makers in many countries, including Sweden where I conducted fieldwork, envision potentialities of better-utilizing pharmacists’ expertise to offer pharmaceutical services (Frisk et al., 2019). Across the extensive pharmacy literature, pharmacies are generally positioned as healthcare institutions. The retail side of pharmacies, however, tends either to slip away from this body of work or be framed as a tension for pharmacists to balance between selling products and providing care (Mossialos et al., 2015; Scahill et al., 2018). In connection, academic debates are centered on how to elevate the professional role of pharmacists in primary healthcare (Hughes et al., 2017; Westerlund and Marklund, 2020). Care, in this line of research, is largely characterized as being prescribed and institutionally scripted. Although this understanding of care offers practical implications on transforming pharmacies from retail settings to healthcare institutions, it does not fully capture the embodied and situated aspect of care services (Mol, 2008; Schillmeier, 2017). Empirically, it fails to account for Tania's “just looking” or Sanna's idea of shopping for experience.
Nonetheless, Tania's “just looking” provides a glimpse over a changing pharmacy market in Sweden. Forty years of centralized national drug supply was replaced by a reregulated pharmacy market in 2009 (Wisell et al., 2015). From a state monopoly to a market-based system, the change was considered drastic, with nearly no restrictions on ownership or establishment (Wisell, 2019). Since then, private and chain pharmacies have sprung up. A selection of medical products is allowed to be sold in nonpharmacy outlets (Lindberg, 2014). Partly as responses to market competition, pharmacies increasingly share many similarities with other conventional retail businesses (Westerlund and Marklund, 2020). This is illustrative in the large floor space occupied by a wide range of over-the-counter (OTC) medicines, health products and beauty products on the open shelves. It also is represented in pharmacies’ marketing strategies such as memberships, discounts and, not least, an effort in staging an aesthetically pleasing retailscape (Fuentes et al., 2017). In addition, the annual report published by the Swedish Pharmacy Association (2020) shows that the turnover of nonmedical products grows much faster than that of pharmaceutical products.
Building upon literature on materialities of care (Parkhurst and Carroll, 2019; Buse et al., 2018; Mol et al., 2010), and specifically answering the call to be place-sensitive in care studies (Martin et al., 2015), I address two questions in this article. First, can care services be provided in alternative forms, beyond institutionally scripted ones, that is, beyond standardized and measurable practices? Second, what makes pharmacies places of care? Empirical data were collected during ethnographic fieldwork in Swedish pharmacies between September 2019 and January 2020.
Care is a spatial-temporally configured practice (Mol, 2008). To study care is to understand how people and things are related in particular situations where care is enacted (Schillmeier, 2017). Rather than an inert backdrop, place is an active player in shaping everyday life (Gieryn, 2000). Producing a place of care, such as pharmacies, requires more than a biomedically inflected, placeless or emotionless understanding of care (Thompson and Bidwell, 2015). Instead, both affective and material dimensions of a place are essential elements to enact care practices and produce the feel of a caring space (Buse et al., 2018; Duff, 2011).
In line with this relational view of place and care, atmosphere emerges as an important analytical concept. In healthcare settings, especially in hospitals, the idea of atmosphere is used to unveil multilayered care practices. Sumartojo and colleagues (2020) study ward atmosphere in a psychiatric unit. They show that senses of care are constantly shaped through staff's anticipation and physical movement. Similarly, Stefansen (2017) examines the establishment of a child-friendly environment, where children with traumatized experiences are interviewed. Stefansen argues that a caring atmosphere involves both an aesthetic-spatial dimension and active participation from the staff. Another example comes from Nielsen and colleagues’ (2020) study in delivery rooms. They describe how midwives work with lighting technologies and deliver care in a way attentive to human bodies. Outside medical institutional settings, Duncan and colleagues (2020) highlight the role of atmosphere in risk control and harm reduction in drug consumption rooms. All these studies point to the affective and material aspects of place in the provision of care. Inspired by this body of work, I use the concept of atmosphere to investigate how care is expressed in pharmacy staff's routinized engagement with the store environment. This article contributes to the growing literature on materialities of care with an empirical study on the atmospheric and spatial aspects of care services. It also sheds light on an alternative understanding of care beyond institutionally scripted practices.
In the following, I sketch out the theoretical implications of using atmosphere to study care practices. I then present how atmospheres are empirically captured in pharmacies in southern Sweden. This is followed by an analysis of findings to demonstrate how care is manifested through pharmacy staff's embodied engagement with customers and products in the environment. In a concluding discussion, I address the issue of attending to both affective and material aspects of care services.
Atmosphere and care
Atmosphere is ontologically difficult to define and hard to locate. Schroer and Schmitt (2017) describe it as clouds in the sky, always forming and reforming. A shared perception among scholars is that this is a key concept to understand human life and the world we inhabit (Schroer and Schmitt, 2017; Ingold, 2012a; Böhme, 1993).
To grasp atmosphere, Böhme (1993, 2013) emphasizes the need to acknowledge the existence of a sentient body. This applies to all living things including human beings. In a sentient world, human beings are first of all bodies that are able to sense and feel the place and the environment. In relation, things within an environment are not inert materials, neither do they stand still (Hahn and Weiss, 2013). They acquire meanings and agency through constant movement and entanglement in what Ingold (2012b) refers to as the meshwork, where things and people are related and form part of the environment. Building upon the phenomenological understanding of bodies and things, Böhme (2013: 2) argues that atmosphere exists neither in the subjects nor the objects, but somewhere in-between as “a typical intermediate phenomenon.” Encounters and relations between humans and nonhumans are “enveloped” into an atmosphere (Ingold, 2012a). In other words, atmospheres can be vague and indeterminate, but they are contingent, simultaneously generating and generated through specific spatial and temporal arrangements (Sumartojo and Pink, 2019; Duncan et al., 2020). This understanding of atmosphere bridges the production and consumption of staged experiences (Böhme, 2013; Sumartojo and Pink, 2019). Hence, atmosphere provides an analytical pathway to understand how material surroundings and people's subjective feelings are related.
Being contingent on particular qualities of things and places, atmospheres are also spatially and temporally porous (Steadman et al., 2020; Bissell, 2010). How an atmosphere is perceived relates to people's memories, anticipations, bodily movements and negotiations of values and norms (Bille et al., 2015; Sumartojo et al., 2020). This means that atmospheres can be both subjectively experienced and collectively shared among a community (Bille, 2015). In addition, multiple atmospheres can be sensed on the same time-place dimension (Buser, 2016; Degen and Lewis, 2019). The fragmented nature of atmospheres reinforces that they are relational, performative and emergent.
Ingold (2012a, 2015) reminds us that atmosphere is the air that people breathe in and survive by. It is inseparable from materiality and bodily presence (Bille et al., 2015). The material grounding of atmospheres thus challenges a hierarchical order where the tangible and the concrete are privileged over the atmospheric in staging and experiencing a place (Brown et al., 2020). This has implications for how to understand care. Following Schillmeier (2017: 56), establishing a caring relation or cultivating a caring encounter is “a collective achievement of affective, embodied and material relations between humans as well as humans and non-humans.” It means care is always situated and configured by social relations and material settings. Mol (2008) convincingly shows that care is often not verbally expressed, but folded into emotions and physical movements. Conceptualizing atmospheres as both affective and material, therefore, makes it possible to account for different expressions of care.
Approaching atmospheres in pharmacies
Researching atmosphere remains an empirical challenge (Sumartojo and Pink, 2019). Bille and Simonsen (2019) argue that atmosphere is not only something we feel but something we do in the felt space. Articulating one's feelings or doings in verbal forms is not always easy, particularly in studying mundane and everyday activities in familiar settings (Pink et al., 2015; Bille, 2015). This study is informed by a methodological framework proposed by Sumartojo and Pink (2019) of knowing in, about and through atmosphere. Ethnography, as a research approach that has been proven capable in unveiling tacit and often taken-for-granted everyday activities (Ehn et al., 2016), appears as an appropriate method.
Most research material presented in this article was collected through ethnographic fieldwork in two pharmacies in southern Sweden. Both pharmacies belong to the same pharmacy chain, but differ in size. One is located on a high street in the downtown district of a traditionally industrial city. The other is in a hospital building in a harbour city, and much smaller in terms of floor space and the range of products on the open shelves. In total I visited these pharmacies nine times within four and a half months. Each visit varied between one and six hours, depending on my work schedules and pre-agreed arrangements with pharmacy managers. I attended morning staff meetings four times, joined some staff at tea breaks seven times and lunch breaks four times. This resulted in a total of 25 hours of ethnographic observation, materialized in 32 pages of fieldnotes. During those breaks and less busy hours, I made informal conversations with the staff and customers. Following the idea that atmosphere is an embodied experience (Sumartojo et al., 2020), and the fact that most activities in pharmacies happen on the move, I shadowed some staff, to observe how they engaged with material displays and worked on the store space. Given the fairly limited space for movement in pharmacies, shadowing customers appeared inappropriate, especially during peak hours. Therefore, I chose to stand at different positions in the shops. Sometimes I stood behind the dispensary counters, or next to check-out counters. At times, I stood in less visible corners in the retail area to observe customers’ movement and their engagement with the physical surroundings. Apart from observing people, I noted down the store layout, display of shelves, and the use of environmental stimuli such as lights, scent and sound, if there were any.
Such ethnographic immersions allowed me to capture atmospheres and to understand how different elements effected one another. I was aware that my task as an ethnographer was not to note down all atmospheres generated in the place, but to attend to the “atmospheric configurations” (Sumartojo and Pink, 2019: 39) that enabled my knowing in the places. Thus, my ethnographic engagement with the field is a useful resource. Most materials presented in the article can be traced back to my fieldnotes taken either during or shortly after my time in the field.
Reflecting on the idea of researching atmosphere from the inside and on a move, I became aware of my dual identities of being a researcher and an ordinary consumer. The overlap between the two identities evoked an image of ethnographic flaneur (Soukup, 2012). It suggests a mobile way of observing and interpreting social life, especially in researching everyday retail sites (Iqani, 2011). My ethnographic field was not limited to predefined sites, but extended to a much wider range of places, both physical and virtual (Burrell, 2009). Apart from the abovementioned pharmacies I visited as a researcher, I encountered a number of other pharmacies in my daily life. On these occasions, I did not disclose my identity as a researcher but merely observed the physical settings and noted my feelings about the place in that particular moment. During these informal visits and covert observations, I did not aim for representative accounts of atmospheres but rather to gain a sense of the mundane and fleeting aspect of consuming the pharmacy space as an ordinary customer. At those moments, I was invited to look, touch, smell and feel the retail environment. To a large extent, this experience is common to most pharmacy customers and possibly contemporary consumers (Bowlby, 1985; Mubi Brighenti and Kärrholm, 2018). In addition, I conducted six semi-structured interviews with pharmacy customers, including the one with Tania presented in the beginning of the article. My interviewees, two of international origin and four Swedish, were recruited initially through my personal contact and subsequently through snowballing. All interviews were conducted in English and lasted between 45 min and two hours. Audio recordings were transcribed verbatim. The interviewees shared their experiences of pharmacy services with me. These interviews were not aimed to construct demographic representation of pharmacy customers in southern Sweden. Rather, they were used to reflect on my observation data and to keep me alert to the affective aspect of the pharmacy space. Furthermore, I regularly checked on the social media accounts of major Swedish pharmacies and their official web pages, to situate pharmacies in a highly mediated consumption landscape (Soukup, 2012). Observation and reflections on digital platforms were documented in the form of fieldnotes and screenshots. Although the data generated outside the two prearranged pharmacies do not constitute the majority of the research material for this article, they provided different perspectives with which to examine the pharmacy space and prepared me with rich background information for each of my return visits to the field sites.
With these various ways of knowing in and about the field, I was able to attend to the mundane, ephemeral and processual aspects of atmospheres. Particular attention was paid to the doings that were tacit and even unnoticed. Collected research material was analyzed thematically (Braun and Clarke, 2006). Close reading of fieldnotes and interview transcriptions laid the ground for coding and subsequently sorting codes into themes. Far from being linear, this has been an ongoing process, requiring a constant shift among rereading material, recoding, analyzing and writing (Ehn et al., 2016). Gradually, the idea of care becomes graspable and even tangible in my close contact with both the field and the pharmacy staff. This chimes with Sumartojo and Pink's (2019) knowing through atmosphere to understand other things. Specifically, it conjures up a nuanced understanding of care provision beyond medical institutional settings.
Before proceeding to findings and analysis, I briefly reflect on the ethics of doing research on atmospheres. All methods of data collection, except the informal visits in my private time, were included in an ethics application to the Swedish Ethical Review Authority and approved. As mentioned earlier, ethnographic field sites can hardly be predefined. Ethnographic approaches assume an emergent and uncertain field where researchers are expected to encounter the unknown and the unpredictable (Ehn et al., 2016). This challenges the institutional regulation of ethics that seeks to secure predictable results before studies are initiated (Pink, 2017). Knowledge production requires reflexivity and sensitivity from the researchers’ side. This insight became particularly relevant for my study when the image of ethnographic flaneur was invoked. My encounters with pharmacies as an ordinary customer, either physically or digitally, perhaps are not qualified as doing research, but they partly inform and shape how I know and experience pharmacies. Such experiences inevitably affect the research process regarding, for example, the questions I posed to research participants, the field notes I took, and in general the ways I engaged with the field. Echoing Sumartojo and Pink's (2019: 39) argument, studying atmospheres “always involves an autoethnographic engagement with our own experience.” In the process of accounting for various atmospheric configurations, I was sensitive to the impact of my presence as a researcher on other people. For example, I was cautious about not eavesdropping on customers’ conversations with the staff. I was also mindful not to disturb customers or staff when they were in a rush or performing duties. With such constant reflections of ethics in the study of atmospheres, it becomes clear that the researcher is part of the atmospheric configurations.
Catching atmospheres of care in pharmacies
Through a thematic analysis, three prominent themes emerge. In the following, I discuss how the idea of care is materialized in present and absent things, practiced through people's interactions with ordinary objects, and embodied in pharmacy staff's tacit ways of sensing the place.
The bountiful and the absent
Pharmacies resemble retail stores at first sight. Digital signage is installed to advertise the latest sales and new campaigns. The concept of multichannel retail is implemented by offering click-and-collect to customers. Extensive use of spotlights brightens up the interior space and directs customers’ attention to rows of products packaged in different colors and sizes. In some pharmacies, soft lounge music is played. The volume is high enough to fill the entire store but low enough to not disturb any conversations. Entrances are not gated, creating a feeling of welcoming openness. Pharmacies by the streets mostly have automatic doors, sending out a sense of responsiveness. Somehow, the physical environment is turned into a sentient being, capable of responding to customers’ physical movement (Mubi Brighenti and Kärrholm, 2018).
During my observations, there was a rather identical arrangement of products in nearly all pharmacies. Beauty products and toiletries were placed closest to the entrance. Moving further toward the dispensary, which was often located in the inner part of the store, the shelves started to be filled with products more commonly categorized as pharmaceuticals, such as pain relievers and anti-inflammatory medicines. Apart from fixed shelves, freestanding tables were topped with less chunky packs such as tissues, cotton pads or beauty products in travel sizes. These stands were moved around regularly by the staff. They might be put right by the entrance to attract customers with the latest campaign products; they might also be found amid shelves of pharmaceuticals or close to the seating area for dispensary customers. Products on these stands were often ordered according to shapes, functions, or colors. Sometimes the staff arranged them exactly the same way as presented in the campaign posters. If any packs were displaced by the customers, the staff would put them back and line them neatly. In many ways, this is similar to Pettinger's (2006) observation in fashion retail shops. Alongside direct interaction with customers, retail workers routinely work on the products and the physical space. With these seemingly mundane activities, products are styled into attractive commodities such that shops are no longer just for transactions but transformed into sites of enticement (Pettinger, 2006). A pleasant and orderly store environment is, therefore, created and maintained. Following the winding paths created by these movable stands and wandering through aisles of products, retail products and pharmaceuticals are not spatially categorized, but encroach into one another. It easily stages a feeling of “the generous and bountiful in the profusion of stock”, as Rapport and colleagues (2009: 319) also observed in the UK pharmacies.
Surrounded by beauty products and pharmaceuticals, I realized that I could not catch any traces of smell. When I asked pharmacy customers and my interview participants to comment on the smell, nearly all of them confirmed my impression that pharmacies did not smell anything. To some extent, the lack of smell of medicines can be explained by the removal of laboratories from pharmacies. It can also be due to the fact that many pharmaceuticals are biomedical products rather than herbs which often diffuse a smell of bitterness. Regarding the beauty products, the staff explained that those sold in pharmacies were carefully selected with particular care for allergic ingredients. Many of them were therefore perfume-free. Still, considering the power of smell in affecting customers’ purchasing decisions (Spangenberg et al., 2005; Canniford et al., 2017), and the overwhelming scent in other cosmetics shops selling the same makeup brands and similar products, the absence of smell in pharmacies draws attention.
Smell is not tangible, sometimes undetectable, but it is material and omnipresent (Stenslund, 2015). Smells can be generative of certain meanings and memories; they may also serve as a component of certain identities (Synnott, 1991; Canniford et al., 2017). Carefully managed smells even constitute therapeutic encounters and communicate the ideas of health and well-being in certain places (Gorman, 2017). Increasingly, an absence of smell is associated with good hygiene and risk reduction. Many public places, including hospitals, strive to achieve olfactory neutrality (Howes and Classen, 2014). Thus, creating a deodorized environment is suggestive of a caring practice, signaling to people that they are in safe hands (Stenslund, 2015). Kraftl and Adey (2008: 226) argue that “there are always problems of intention, of what is (or seems) right”, no matter how flexible and open an environment may look. As institutional places where primary care is delivered, it would not seem or smell right for pharmacies to infuse the air with a strong scent. The absence of smell is, therefore, not a random result of selling organic products or purely due to the removal of laboratories. It indicates an effort made to neutralize the space and fill it with a sense of care. To some extent, care is in the air. Smell is atmospheric; it touches the mood and can be felt through the body (Stenslund, 2015; Canniford et al., 2017). Compared to visual sensations, the power of smell lies exactly in the unnoticeable (Synnott, 1991). Although people I talked to found it hard to associate pharmacies with any smell, after a short while, they often concluded that it smelled “fresh and clean.”
Presented in this section is the intertwinement of bountiful visual cues and absent smells in staging pharmacy stores as a sensory environment. In the intertwinement, the material settings between retail shops and healthcare institutions become blurred. Such an environment is partially produced in the design of the store layout, but it also is staged through staff's active participation in managing a pleasant atmosphere. In the bountiful visual cues care is paradoxically rendered less visible, but amplified in the presence of the absent, such as the smell.
The dispensary counters
In the pharmacies in which I did overt observation, pharmacists often commented on the “strange angle” of the dispensary counters. Those counters were lined up in a way that pharmacists had to turn their head back and forth between the computer and the customer. To avoid this physical discomfort, and for a better view of both the screen and customers, they usually chose to turn the screen slightly. This made a triangular position, with the staff, the customer and the computer taking each point. However, this adjustment led to another issue. Caroline, a pharmacist, told me: “You know what I don’t like the most? I don’t like it when customers try to peep into my screen. I don’t want them to point at my screen and pick medicines.”
In this situation, the material design appears prominent in suggesting a particular power dynamic and a preferred relationship (Dubuisson-Quellier, 2007). The counters facilitate a physical distance and form a boundary between the professional and the customers. To some extent, they help pharmacists to maintain their medical authority and claim control over the dispensing activity. Customers by the counters are not expected to behave as if they were in the retail area and take products freely off the open shelves. In that position, they become patients in need of pharmaceutical knowledge from the professionals on the other side of the counters. Whereas the retail area is staged to encourage self-service and free choice, the design of the dispensary counters seems to be guided by a similar understanding of care as that found in medical institutions. Thus, care by the counters is intended to be delivered through negotiations subjected to a power imbalance between care providers and care receivers.
Furthermore, the strange angle led to other concerns. Caroline gave me a scenario when teenagers were accompanied by their parents to fill the prescriptions. “In Sweden, even under 18, parents do not automatically have the rights to access their children's medical journals. But at the moment, it is very easy for those parents to peek.” At this point, the strange angle is not simply about the physical discomfort or the diminished authoritative status, as described earlier. It also concerns following work ethics as a medical professional. In another situation, Marie, a pharmacist, moved a freestanding trolley topped with tissues slightly away from the dispensary counters because “it was a bit too close to the counters, and those buying the tissues might overhear our conversation (with dispensary customers).” In these accounts, a multilayered caring attitude takes shape, turning ordinary objects into emotionally contested spaces.
Around the dispensary counters, I have seen worrisome looks when customers were told their medicines were out of stock. I could also feel and even see the anxiety gradually spreading in the air when a long queue started to form. During these moments, pharmacists did not simply dispense medicines but also managed the atmosphere. This is exemplified in the following fieldnote: A customer rushed to the counter with a long list of medicines. While Sanna was collecting them, the customer told me she was so worried when she realized her medicines were running out this morning. “Thank god they have it.” She repeated this several times, feeling relieved. When Sanna was back with at least 6 boxes in different sizes, the customer was told one of the medicines had only one pack left. “But at least you got one and it should last for a month, right?.” Sanna suggested the customer come back tomorrow to collect the rest “But I can’t. I’m going to a cooking course”, said the customer. “That's fine. You just come whenever suits you.” Then Sanna changed the subject of their conversation. Now it seemed the customer was very relaxed. She even shared some fun stories about cooking. While they were chatting, Sanna scanned all those packages, printed out the labels, stuck them onto the packages, got the payment system ready and prepared an updated medicine list She made eye contact with the customer from time to time, but her hands never stopped moving, not even for a second. When all the preparation was done, she said: “Ok, now let's pack!” (fieldnotes, November 2019)
Captured in this fieldnote is Sanna's efficiency and familiarity with her working space. She was well aware of her primary role as a pharmacist to dispense medicines, yet she also sought to create a relaxing and friendly atmosphere. In this case, she did so by picking up a subject of the customer's interest, which was the cooking course. The actual conversation did not take more than two minutes, but it smoothed the waiting time, and somehow even entertained the customer.
The dispensary counters are emotional sites, where pharmacists claim their professional authorities and customers approach with a mixture of feelings. Various atmospheres are made present around these objects. The events presented above suggest the atmospheric work (Duncan et al., 2020; Martin, 2016) staff undertake in addition to their professional duties. Adjusting the angle of computer screens in order to talk to customers face to face, and keeping small talk going with customers while preparing medicines, these acts are trivial, and often unnoticed. However, they are essential elements in configurating senses of care and facilitating a caring encounter. To some extent, such practices are concrete translations of the discoursal shift from product-centered to patient-centered care. Sanna once commented on the changes from working for the state monopoly to now working in a retail setting: “Before, we only talked to the bottle, but now, we talk to the people.” After pausing for a second, she added: “More accurately, now we talk to the bottle and to the people.”
Sensing the place
Some empty rows on the shelves close to the dispensary caught my attention. When I asked Marie, she did not seem to understand my curiosity immediately: “Oh, it is (name of a brand). That's why we don’t put them here.” “What do you mean?.” She reacted to my confusing look, and started to explain: “(Name of the brand) is for diarrhoea, you know, to slow down the bowel movement. They can be misused, by people, like those taking narcotics. But this is not really the drug's problem, I mean, it is not intentionally produced for people using narcotics. So, they are still OTC, but we have the responsibility to monitor if someone buys a lot of these, then there might be a problem.”
I followed by asking how customers in need could get these medicines. She pointed to a sticker hanging on the shelf and said: “You see here is a sign. They can ask us and we bring it out for them. Actually, many drugs can be easily misused, even paracetamol. Like, if a patient was sent to emergency in the hospital, and they realized it was due to misuse of large amount of paracetamol and then they would ask the patient where you got so many (paracetamol). Then they (the patients) say from here, our pharmacy, then we would be in trouble because we should be responsible for customers’ safety.”
In Marie's account, it becomes rather clear that stocking shelves involve more than just filling them with correct products and enough packs, or lining them neatly. It requires professional judgement to decide what not to put on the shelves. Certainly, part of the judgement comes from an awareness of not getting their business into trouble, but it also implies a sense of professional pride as drug experts utilizing their knowledge to ensure safe drug use. “What if people don’t buy a lot at once, and just come and buy a couple for one day and then come back and buy some the next day….” I wondered how this kind of surveillance was done in practice. Marie started to laugh and said affirmatively: “Yes that is possible! But then I will recognize that person.” She twisted her brows and continued: “Hmmm… he is here today, tomorrow and the day after. Then I start to wonder what he is doing here.”
In these words, the empty rows suddenly become an area tightly controlled and closely monitored. It produces a contrast, visually and affectively, to the bountifulness and enchantment experienced in other parts of the retail area. On the one hand, this is connected to the power imbalance between pharmacy staff and customers, as presented previously. On the other hand, these empty rows carve out a gray zone in that they are located in the self-service retail area but still subjected to the vigilance of pharmacists as medical gatekeepers. This is comparable to Martin's (2016) account of Maggie's patient center. Although Maggie's is designed to accommodate an informal and relaxing atmosphere for patients, a certain level of vigilance is deemed necessary from the healthcare professionals’ side. Similarly, in Duncan and colleagues’ (2020) study, vigilance is identified as an indispensable element to maintain desired atmospheres in drug consumption rooms. In retail sites, surveillance is often achieved by using cameras, security guards or written warning signs, to keep out unwanted consumers and to regulate consumers’ access to products (Iqani, 2013; Fredriksson, 1997). In this pharmacy, surveillance partly functions in a similar way regarding medicine access. However, surveillance, as an expression of care, is practiced to perform professional duty and to ensure safe medicine use (cf. Martin 2016; Duncan et al. 2020).
Apart from an intentional decision to leave the shelves empty, surveillance largely relies on pharmacy staff's familiarity with the place and constant reading of customers. In other words, it requires the staff to sense the situation. To further illustrate, I bring in another excerpt from my fieldnotes. The store was still rather empty. A woman came in and went straight to Kate. She talked in a very low voice. Kate (a pharmacy technician) replied in an equally low voice and walked to a shelf, picked a product and handed to the customer. When the customer was ready to pay, Kate resumed her regular pitch and read out the price. After the transaction, Kate lowered her voice again and gave out some advice on how to use that product. Later I traced their steps and realized it was a pregnancy test kit. (fieldnotes, September 2019)
Without overhearing any verbal exchanges, I could read from the pitch that the customer wanted to keep a low profile and needed some immediate help. Kate reacted in a very responsive way. When she helped the customer select a product and gave advice, she instinctively lowered her voice which possibly saved the customer from unnecessary attention. In dealing with the payment, she resumed to her normal pitch as she used to talk to all customers. By switching between a low and a regular pitch, Kate managed the situation sensitively. In addition to the product, the customer was provided with a safe and secure environment. This was one of the many fleeting moments during my stay in the field, but for this customer it might be a particular one, received with sensitivity and a caring voice.
In comparison to bodily movement, which is notable and noticeable in many retail sites, talking appears a mundane act, naturally required by the service work. However, it is equally skilled, situated and embodied, requiring a spatial-temporal awareness. During customer encounters, staff know when to talk or stop, when to do small talk or keep it business only, when to approach customers and offer help or advertise upcoming sales, and not least, when to talk in a higher pitch or lower the voice, as Kate did. By sensing the situation and reading customers’ physical and emotional conditions, talking forms a part of the choreography of care practices (Anderson and Jorgenson, 2018). In this respect, care is situated in the mundane, but affective, act of talking. Talking can be exhausting, physically and mentally. Kate told me when she got home from work, she did not want to talk anymore. She would prefer sitting in her garden for a while if the weather was nice: “And suddenly I hear some birds singing. Oh, how beautiful! I really need to recharge in the evening.”
Care in the air?
I have drawn on the concept of atmosphere to study how care takes place in pharmacies. It is undeniable that care services in pharmacies share similarities with that in doctor–patient encounters. This is particularly exemplified in the way dispensary counters are designed and used by pharmacists. Nonetheless, by examining care spatially, my analysis demonstrates that care services are weaved into a series of seemingly contradictory ideas. Expressions of care reside in visible objects such as the counters and the shelves. They also are materialized in invisible, but embodied, elements, such as the air one breathes in and the sounds one hears. In addition, care is provided in both enabling and vigilant manners, such as staging the store with an attractive appearance but intentionally leaving some shelves empty.
Care does not speak for itself through the display of health products or pharmaceuticals. Likewise, selling pharmaceuticals alone does not make pharmacies a place of care. In agreement with the argument about care as a situated way of doing (Schillmeier, 2017), this study highlights that care practices are performative and emplaced. They are bodily and affective gestures that require both professional expertise and responsive awareness of constantly changing atmospheres. In other words, care is about being attentive, adaptive and attuned to both the material and the immaterial (Mol, 2010; Duckworth, 2019). Linking back to the nature of atmosphere as emergent, ephemeral and contingent, pharmacies become sociomaterially assembled places where senses of care are enabled and enacted (Duff, 2011).
With a nod to the material grounding of atmosphere, it is necessary to note the societal context where these pharmacies are situated. Along with a structural change in Swedish pharmacy market, as introduced earlier, and political endorsement of individual responsibility (Liu and Lundin, 2020), a majority of pharmacies have become private-owned; people visiting pharmacies are commonly addressed as customers rather than patients. Positioned as healthcare institutions, pharmacies are legally required to offer high-quality pharmaceutical care services. Meanwhile, they face increased market competition. This connects to existing pharmacy literature that conceptualizes pharmacy work as a tension between being profit-driven and serving public goods. Much of the work done by pharmacy staff does not seem to differ substantially from conventional retail services. Nevertheless, my analysis shows that care can be delivered in other ways than institutionally scripted ones. Senses of care are often enacted tacitly and affectively in a nonverbal manner. Pharmacy staff participate in a form of atmospheric labor (Duncan et al., 2020), whose mundane engagement with the place fills the pharmacy stores with feelings of care. This study provides an account that shakes the dichotomized understanding of profit-oriented retail services and supposedly nonprofit-oriented institutional health care. Selling health products and offering care services do not necessarily generate tensions or intensify conflicts of interests. Rather, they are interlaced acts. Heavily involved in these acts is the need to stage and maintain desirable atmospheres. Providing care services in pharmacies is therefore more than filling prescriptions and giving medical advice. It also is practiced by attending to the spatial and temporal dimensions of the place, so as to make conditions for caring encounters. Thus, pharmacies become, and sustain as, places of care.
Although this study examines atmospheres of pharmacies in the Swedish context, it offers implications to understand care services in general. In line with previous studies on emplacement of care (e.g. Stefansen, 2017; Sumartojo et al., 2020), this study argues that care is not fixed in the material design, nor is it automatically instilled through political discourses. Rather, it is mediated through material surroundings and tacit doings that are folded in an atmosphere in particular time-space dimensions. Connecting to a broader scope where many types of public care services are increasingly administered beyond medical institutional settings, in Sweden and elsewhere, what is needed is a multiple understanding of care and care services. This requires a reflection on what constitutes good care and how it can be cultivated to keep up with the shifting landscapes of healthcare services. These issues demand close attention to the situatedness of care, particularly in settings where the line between the commercial and the institutional is blurred.
Footnotes
Acknowledgements
I thank Amelie Persson and Cecilia Lenander for their generous help in connecting me to the empirical research sites, and Cecilia Andersson for checking the language. I am also grateful to my research participants for their involvement and for making this study possible. Lastly, my thanks goes to Cecilia Fredriksson, Henrik Loodin, Susanne Lundin and three anonymous reviewers for their illuminating comments on previous versions of the text.
Author’s note
This study was approved by the Swedish Ethical Review Authority (case number: 2019-02226).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
