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International Journal of Clinical Pharmacy (2019) 41:1085–1098 https://doi.org/10.1007/s11096-019-00815-5

RESEARCH ARTICLE

Pharmacy ethical reasoning: a comparison of Australian pharmacists and interns

H. Laetitia Hattingh1,2  · Michelle A. King1,2,3  · Denise L. Hope1,2,3  · Elizabeth George1

Received: 8 November 2018 / Accepted: 22 March 2019 / Published online: 15 May 2019 © Springer Nature Switzerland AG 2019

Abstract Background Ethical reasoning informs decision making and professional judgement, is guided by codes of ethics and con- duct, and requires navigation through a regulatory framework. Ethical reasoning should evolve throughout the pharmacy internship year and prepare interns for independent practice. Objective To explore the ethical reasoning and processes of Australian pharmacists and pharmacy interns. Setting Queensland community pharmacists and interns. Method A survey to determine use of resources to guide ethical decisions, management of ethical dilemmas, and exposure to potential practice privacy breaches. Participants were recruited at pharmacy intern training events, a pharmacist education session and through telephone contact of randomised community pharmacies. Main outcome measure Comparison between pharmacist and intern responses using 5-point Likert scales, listings and prioritising. Results In total 218 completed surveys were analysed: 121 pharmacy interns and 97 pharmacists. The Code of Ethics was identified as the resource most frequently consulted when faced with ethical dilemmas. Interns were more likely to consult legislation and regulatory authorities whereas pharmacists with colleagues. Responses to ethical vignette scenarios and exposure to privacy breaches varied between interns and phar- macists, with some scenarios revealing significant differences. Most participants had been exposed to a variety of potential privacy breaches in practice. Conclusion Interns focussed on legislation and guidelines when presented with hypothetical ethical dilemmas. In contrast to this positivist approach, pharmacists reported using a social constructionist approach with peers as a reference. Pharmacists avoided ethical scenario options that required complex management. Interns reported more exposure to potential practice privacy breaches.

Keywords Australia · Decision making · Ethics · Interns · Moral development · Pharmacists

Impacts on practice

• Interns are less likely to consult with more experienced pharmacists when presented with dilemmas which would potentially stimulate local conversation and reduce pro- fessional isolation.

• Financial pressures on the profession impact on pharma- cists’ management of complex scenarios and highlight the need for ongoing development of ethical reasoning skills.

• Pharmacists in Australia need to accept independent pro- fessional responsibility as a culture of subordination to doctors may impact on patient care.

• In Australia, there seems to be an ongoing need to upskill pharmacy staff members in privacy requirements.

* H. Laetitia Hattingh [email protected]

Michelle A. King [email protected]

Denise L. Hope [email protected]

1 School of Pharmacy and Pharmacology, Griffith University, Clinical Sciences 2, G16_3.26, Gold Coast Campus, Gold Coast, QLD 4215, Australia

2 Quality Use of Medicines Network, Griffith University, Gold Coast Campus, Gold Coast, QLD 4215, Australia

3 Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Gold Coast, QLD 4215, Australia

1086 International Journal of Clinical Pharmacy (2019) 41:1085–1098

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Introduction

Over recent decades pharmacy practice broadened from mainly medicines provision to pharmacists having more clinical and patient-centred healthcare relationships [1]. Community pharmacists are accessible health professionals, providing a range of primary and public health services and are often confronted with challenging scenarios that require professional judgement [2]. In addition to clinical knowl- edge, it is recognised that the ability to apply moral and ethical reasoning is a critical factor that affects pharmacists’ decision making when making professional judgements [2, 3]. Moral reasoning involves forming judgments about what one ought, morally, to do. This can be a practical question, a certain way of asking about what to do, and hence moral reasoning is also referred to as practical reasoning [4].

With regard to the development of ethical reasoning for health professionals, moral reasoning philosophy has over recent years been used to explain and facilitate the devel- opment of professional ethical reasoning processes [5–8]. Theories of moral reasoning argued that moral reasoning involves a cognitive decision-making process that is based on cognitive moral decision-making capabilities [9, 10]. One such theory was Kohlberg’s Cognitive Moral Devel- opment model that involved six stages of cognitive moral development [11, 12]. Kohlberg’s model had been applied to pharmacy scenarios to illustrate how these stages could be mapped to pharmacists’ chosen actions when confronted with a practice scenario that requires professional judgement [13, 14]. According to this model a pharmacist’s actions involve decision-making processes that rely on the pharma- cist’s cognitive moral development, which in turn impacts on the pharmacist’s ethical reasoning processes.

The integrity and standing of the profession are contin- gent on a strong basis of ethical reasoning to facilitate good patient care. However, research in pharmacy ethics is scarce [15, 16], especially when compared to other health profes- sional groups such as medicine and nursing [17]. Profes- sional ethics are commonly described in codes of ethics and conduct for various health professionals, which reflect public expectations of the profession. In Australia, the Pharmacy Board of Australia Code of Conduct [18] and the Pharma- ceutical Society of Australia (PSA) Code of Ethics for Phar- macists [19] provide guidance for acceptable behaviours and the foundation for Australian pharmacists’ ethical conduct. Pharmacy practice is highly regulated with complex legisla- tive requirements [20]. To facilitate practice provision the profession has developed a guiding framework of regulatory requirements, standards and other documents to enhance and maintain standards of professionalism, supplementing the legislative requirements.

Pharmacists need to understand how to navigate the regu- latory framework to support their professional decision mak- ing. This requires practice as decision making could involve conflicts between legal and ethical reasoning. It is hence not surprising that some pharmacists have difficulty distin- guishing between ethical and legal issues, lack confidence in making decisions, avoid their responsibilities by passing the decision to other health professionals, or indeed do nothing at all [21]. There is evidence indicating that pharmacists may not always adhere to best practice standards, have difficulty with ethical decision-making and overlook aspects of the law [22, 23].

Ethical reasoning and professionalism skills are embed- ded in pharmacists’ competency standards [24] and are mandatory skills to be developed throughout the pharmacy curriculum, as specified by the Australian Pharmacy Council [25]. Although the foundation of ethical reasoning is estab- lished during university studies and student placements [21, 26], this skill needs to be continuously practised and devel- oped. Research highlighted that medical students’ ethical behaviour is influenced by internal factors such as university teaching as well as external factors including work-related role models or family values [27], although the evidence for this in pharmacy students is limited. While it is possible to teach pharmacy students about the conflicts between legal and ethical reasoning, dilemmas can be more complex in real practice [28]. Ethical reasoning should thus evolve through- out the internship year that follows graduation as interns gain practice experience that involves exposure to challeng- ing scenarios, whilst working under supervision [29–31].

Community pharmacy service provision has increased in complexity with a myriad of factors to consider includ- ing ethics and law, standards and procedures, and financial pressures. It is important to identify how the relationship of these factors influences ethical reasoning and the ability to provide the best possible patient-care. There is, however, a scarcity of research into contemporary pharmacy ethics with a lack of research comparing the ethical reasoning processes and resources used by pharmacy interns and pharmacists.

Aim of the study

The aim of this study was to compare ethical reasoning between Australian pharmacists and interns.

Ethics approval

Ethics approval was obtained from the Griffith University Human Research Ethics Committee (2017/640).

1087International Journal of Clinical Pharmacy (2019) 41:1085–1098

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Method

This quantitative comparative study involved surveying Australian community pharmacists and intern pharmacists to explore their reasoning and the processes they apply to inform their decisions and actions when confronted with ethical dilemmas. Specific objectives were to explore:

• Their use of resources to guide ethical decisions, • Options they choose when presented with ethical

dilemmas, and • How frequently they experience potential privacy

breaches in practice.

Survey development

A survey was developed based upon focus group discus- sions [32], pharmacy ethics literature, experience with use of vignettes for ethical reasoning research [33–35], evidence supporting advantages of using of vignettes in research to simulate practice [36–40], the Australian community phar- macy context and the authors’ extensive teaching, research and practice experience. The survey provided participants with an overview of the study that included definitions of ethics and ethical dilemmas and consisted of four sections:

• Section A—general demographic information such as age, gender, current pharmacy roles and qualifications. It also requested listing of up to five resources used when presented with an ethical dilemma in practice;

• Section B—two ethical dispensing scenario vignettes with five Likert-scale ratings (strongly agree, agree, neu- tral, disagree and strongly disagree) to indicate the level of agreement with hypothetical options. Scenario 1 listed seven hypothetical options whilst scenario 2 was divided into two sub-scenarios: the first had seven hypothetical options and the second had five hypothetical options. Participants were also given the opportunity to list alter- native options they would consider in practice;

• Section C—17 short pharmacy privacy scenarios with five ranked timeframes namely daily, weekly, fort- nightly, monthly and less often to indicate how often participants were exposed to the scenarios; and.

• Section D—numerical prioritising of 12 resources used to inform ethical decision making with 1 as the most and 12 as the least relevant.

The survey was face and content validated by four aca- demic pharmacists and four pharmacist practitioners with advanced expertise in pharmacy law and ethics. Feedback was discussed and incorporated following consensus.

Participant recruitment

The target population was Queensland intern pharmacists and pharmacists who worked in community pharmacies. Participants were offered a gift card as an appreciation of their contribution.

The three Queensland intern training providers, namely the Pharmacy Guild of Australia (the Guild), PSA and National Alliance for Pharmacy Education (NAPE), were approached and all three agreed to distribute the sur- veys at face-to-face intern training sessions. Members of the research team attended five workshops in Brisbane throughout August to November 2017 during which a PowerPoint slide was used to explain the study; participant information sheets and surveys were then distributed. A total of 203 interns were invited to participate in the sur- vey and completion of the survey was regarded as consent.

Two approaches were followed to recruit pharmacists. The first was to invite participation from pharmacists attending an annual PSA Queensland education seminar during October 2017. The second was to randomly select Queensland community pharmacies from a list of 740 pharmacies that provided needle and syringe services, using a randomisation calculator [41]. Randomly selected pharmacies were telephoned by a team member (EG) who explained the project to a pharmacist at the pharmacy. If the pharmacist agreed to participate and provided their email address the information sheet with a link to an online version of the survey was emailed through.

Data analysis

All hardcopy responses were entered by a trained com- puter data entry clerk into SPSS, Version 22 (IBM USA, 2013). The online survey automatically populated into an Excel spreadsheet. Duplicates were removed, and the data transferred to the SPSS file. Sources identified as those most likely to be consulted to inform decision making were coded either during the data entry process or before transfer to SPSS. All data entries were independently audited and corrected where necessary.

Descriptive statistics were used to summarise demo- graphic information and questionnaire responses. For the listed resources in Section A: comparisons between phar- macists and interns using the Chi squared test were based on counts of the ten most frequently identified resources. For Sections B, C, and D: the pharmacists’ and interns’ rankings of scenarios and the resources were compared using the Mann–Whitney U test. A p value < 0.05 indi- cated a statistically significant association.

1088 International Journal of Clinical Pharmacy (2019) 41:1085–1098

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Results

Of the 203 interns attending the intern training sessions 117 (57.6%) returned surveys. The education seminar was attended by approximately 110 pharmacists and interns; approximately 30 pharmacists were approached about the

project with 16 returning surveys. The online survey was emailed to 250 community pharmacists with 92 responses received. Seven were identified as duplicates and excluded. Of the remaining 85, four identified as interns and were grouped with the intern data. Hence, 81 online pharmacist surveys were included in the analysis. Overall there were

Table 1 Summary of participants’ demographic data

Intern n = 121

Pharmacist n = 97

n (%) n (%)

Gender  Male 46 (38.0) 35 (36.1)  Female 75 (62.0) 62 (63.9)

Age  21–30 106 (87.6) 44 (45.4)  31–40 14 (11.6) 30 (30.9)  41–50 1 (0.8) 11 (11.3)  51–60 0 (0.0) 11 (11.3)

> 61 0 (0.0) 1 (1.0) Primary role  Interns n = 121   Community pharmacy intern 87 (71.9)   Hospital pharmacy intern 33 (27.3)   Academic intern 1 (0.8)

 Pharmacists n = 94   Pharmacy owner 17 (17.5)   Community pharmacy manager 29 (29.9)   Community pharmacy dispensary manager 9 (9.3)   Community pharmacist 35 (36.1)   Hospital pharmacist 2 (2.1)   Academic pharmacist 1 (1.0)   Locum pharmacist 1 (1.0)

Table 2 Resources most likely to be consulted when presented with an ethical dilemma (top ten by overall frequency)

PBA/AHPRA Pharmacy Board of Australia/Australian Health Practitioner Registration Agency, SUSMP Standard for the Uniform Scheduling of Medicines and Poisons (The Poisons Standard) Bold represents the statistically significant association (p value < 0.05)

Resource Total Intern Pharmacist p value

n (%) n (%) n (%)

Code of Ethics 92 (42.2) 63 (52.1) 29 (29.9) 0.001 Professional indemnity insurer 84 (38.5) 49 (40.5) 35 (36.1) 0.506 PBA/AHPRA 78 (35.8) 56 (46.3) 22 (22.7) < 0.001 SUSMP/poisons legislation 59 (27.1) 28 (23.1) 31 (32.0) 0.145 Pharmaceutical Society of Australia 56 (25.7) 27 (22.3) 29 (29.9) 0.932 Colleague 55 (25.2) 18 (14.9) 37 (38.1) < 0.001 Legislation 48 (22.0) 43 (35.5) 5 (5.2) < 0.001 Clinical resources 41 (18.8) 23 (19.0) 18 (18.6) 0.203 Supervisor/preceptor 21 (9.6) 16 (13.2) 5 (5.2) 0.045 Practice Standards 19 (8.7) 3 (2.5) 16 (16.5) < 0.001

1089International Journal of Clinical Pharmacy (2019) 41:1085–1098

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121 completed intern surveys (117 + 4) and 97 completed pharmacist surveys (16 + 81); 218 participants in total.

Most interns and pharmacists were female (62.0% and 63.9%) and, as expected, most interns were less than 30 years old (106/121, 87.6%) while 45.4% (44/97) of the pharmacists were aged 21–30 years and 30.9% (30/97) were between 31 and 40  years old. Most pharmacists (58.5%; 55/94) were in a managerial or ownership role. Table 1 provides a summary of the participants’ demo- graphic data.

Ethics resources

Sections A and D requested information about resources used when presented with an ethical dilemma in practice: in section A participants had to list resources and in sec- tion D they had to prioritise 12 named resources.

The ten resources most frequently listed ranged from leg- islation, to professional guidance to personal communica- tion. Overall, the Code of Ethics was the most frequently identified resource (Table 2). Table 3 summarises the prior- itisation of resources. Interns were approximately twice as likely to identify the Code of Ethics and the Pharmacy Board of Australia (PBA)/Australian Health Practitioner Registra- tion Agency (AHPRA) as resources and almost seven times more likely to identify legislation as a resource to consult. In contrast, pharmacists were far more likely to identify col- leagues and the practice standards as resources.

Dispensing scenario ratings

Some Section B vignette scenarios were responded to differently by interns when compared with pharmacists (Table 4). There were statistically significant differences between two of the responses to the scenario 1 options.

• 85.2% of interns disagreed or strongly disagreed that they would ‘… dispense the drug without saying anything to the patient because you accept the doc- tor’s explanation of the adverse reaction being all in the patient’s mind’ whereas a much lower 75.0% of pharmacists disagreed or strongly disagreed with this option (p = 0.017), and.

• 79.3% of interns strongly agreed or agreed that they would ‘… inform the patient that both medications are similar and therefore he may experience the same response as previously’ compared to 71.5% of pharma- cists who strongly agreed or agreed with this option (p = 0.031).

Three of the scenario 2 options resulted in statisti- cally significantly different responses between interns and pharmacists:Ta

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1091International Journal of Clinical Pharmacy (2019) 41:1085–1098

1 3

Ta bl

e 4

(c on

tin ue

d)

Yo u

di sp

en se

D RU

G

ZX :

[n =

in te

rn ; p

ha rm

ac ist

]

In te

rn s

Ph ar

m ac

ist s

p va

lu e

St ro

ng ly

ag

re e

A gr

ee N

eu tra

l D

is ag

re e

St ro

ng ly

di

sa gr

ee St

ro ng

ly

ag re

e A

gr ee

N eu

tra l

D is

ag re

e St

ro ng

ly d

is ag

re e

n %

n %

n %

n %

n %

n %

n %

n %

n %

n %

e. …

a nd

in fo

rm th

e pa

tie nt

th at

b ot

h m

ed ic

at io

ns a

re si

m ila

r an

d th

er ef

or e

he m

ay

ex pe

rie nc

e th

e sa

m e

re sp

on se

a s p

re vi

ou sly

. [n

= 11

6; 9

5]

35 (3

0. 2)

57 (4

9. 1)

15 (1

2. 9)

7 (6

.0 )

2 (1

.7 )

16 (1

6. 8)

52 (5

4. 7)

17 (1

7. 9)

9 (9

.5 )

1 (1

.1 )

0. 03 1

f. …

a nd

y ou

in fo

rm

th e

pa tie

nt th

at th

e m

ed ic

at io

ns a

re n

ot

si m

ila r a

nd th

er ef

or e

it is

u nl

ik el

y fo

r h im

to

ex pe

rie nc

e th

e sa

m e

re sp

on se

a s p

re vi

ou sly

. [n

= 11

4; 9

5]

1 (0

.9 )

5 (4

.4 )

17 (1

4. 9)

39 (3

4. 2)

52 (4

5. 6)

0 1

(1 .1

) 7

(7 .4

) 37

(3 8.

9) 50

(5 2.

6) 0.

09 6

g. …

a nd

y ou

in fo

rm th

e pa

tie nt

th at

b ot

h m

ed i-

ca tio

ns a

re si

m ila

r b ut

th

ey a

re sl

ig ht

ly d

if- fe

re nt

a nd

h e

m ay

n ot

ex

pe rie

nc e

th e

sa m

e re

sp on

se . [

n = 11

4; 9

7]

40 (3

5. 1)

47 (4

1. 2)

21 (1

8. 4)

5 (4

.4 )

1 (0

.9 )

42 (4

3. 3)

44 (4

5. 4)

9 (9

.3 )

1 (1

.0 )

1 (1

.0 )

0. 05

3

Sc en

ar io

2

Yo u

ar e

th e

on ly

p ha

rm ac

ist w

or ki

ng in

a ru

ra l t

ow n

an d

re ce

iv e

a ne

w p

re sc

rip tio

n fo

r D ru

g E.

T he

p at

ie nt

h as

a c

on ce

ss io

n ca

rd .

Th e

pr es

cr ip

tio n

is fo

r a m

al e

pa tie

nt w

ith a

n on

-li fe

-th re

at en

in g

co nd

iti on

th at

is c

au si

ng c

on si

de ra

bl e

di sc

om fo

rt. Y

ou a

re u

nd er

in cr

ea si

ng p

re ss

ur e,

fr om

th e

ow ne

r, to

d is

pe ns

e ge

ne ric

br

an ds

. T he

p ha

rm ac

y as

si st

an t h

as e

st ab

lis he

d th

at th

e pa

tie nt

a gr

ee d

to re

ce iv

e a

ge ne

ric b

ra nd

. T he

p re

sc rib

er a

gr ee

d to

su bs

tit ut

io n.

H ow

ev er

, w he

n yo

u ch

ec k

th e

pa tie

nt ’s

d is

pe ns

ed h

ist or

y on

y ou

r s of

tw ar

e yo

u no

tic e

th at

th e

pa tie

nt h

ad p

re vi

ou sly

re po

rte d

an a

dv er

se e

ffe ct

, c la

ss ifi

ed a

s s ev

er e

di ar

rh oe

a, fr

om th

e ge

ne ric

br

an d

sto ck

ed b

y th

e ph

ar m

ac y.

T he

p at

ie nt

w as

su bs

eq ue

nt ly

d is

pe ns

ed th

e or

ig in

at or

b ra

nd , w

hi ch

h as

a b

ra nd

p re

m iu

m (a

dd iti

on al

fe e

ch ar

ge d

fo r a

sp ec

ifi c

br an

d) a

t a no

th er

p ha

rm ac

y w

ith n

o ad

ve rs

e co

ns eq

ue nc

es .

Yo ur

p ha

rm ac

y sto

ck s t

he o

rig in

at or

b ra

nd a

nd o

ne g

en er

ic b

ra nd

o f D

ru g

E, w

hi ch

is th

e br

an d

th e

pa tie

nt p

re vi

ou sly

re ce

iv ed

.

1092 International Journal of Clinical Pharmacy (2019) 41:1085–1098

1 3

Ta bl

e 4

(c on

tin ue

d)

Le ve

l o f a

gr ee

m en

t w ith

hy

po th

et ic

al o

pt io

ns [n

= in

te rn

; p ha

rm ac

ist ]

In te

rn s

Ph ar

m ac

ist s

St ro

ng ly

ag

re e

A gr

ee N

eu tra

l D

is ag

re e

St ro

ng ly

di

sa gr

ee St

ro ng

ly

ag re

e A

gr ee

N eu

tra l

D is

ag re

e St

ro ng

ly

di sa

gr ee

p va

lu e

n %

n %

n %

n %

n %

n %

n %

n %

n %

n %

a. D

is pe

ns e

th e

ge ne

ric

br an

d in

st oc

k an

d ex

pl ai

n to

th e

pa tie

nt

th at

th er

e is

a p

os si

bi lit

y of

h im

a ga

in d

ev el

op -

in g

th e

se ve

re d

ia rr

ho ea

. [n

= 11

7; 9

5]

9 (7

.7 )

28 (2

3. 9)

16 (1

3. 7)

32 (2

7. 4)

32 (2

7. 4)

4 (4

.2 )

23 (2

4. 2)

14 (1

4. 7)

20 (2

1. 1)

34 (3

5. 8)

0. 31

4

b. In

fo rm

th e

pa tie

nt th

at

yo u

ca n

or de

r a d

iff er

en t

ge ne

ric b

ut it

c ou

ld ta

ke

24  h

to a

rr iv

e. [n

= 11

6;

95 ]

25 (2

1. 6)

45 (3

8. 8)

27 (2

3. 3)

11 (9

.5 )

8 (6

.9 )

14 (1

4. 7)

46 (4

8. 4)

13 (1

3. 7)

11 (1

1. 6)

11 (1

1. 6)

0. 48

2

c. In

fo rm

th e

pa tie

nt th

at

yo u

ca n

or ga

ni se

fo r

th e

ne ar

es t p

ha rm

ac y

(a pp

ro x.

5 0 

km aw

ay ) t

o su

pp ly

h im

w ith

a n

al te

r- na

tiv e

ge ne

ric b

ra nd

. T he

pa

tie nt

h as

to o

rg an

is e

tra ns

po rt.

[n =

11 8;

9 5]

6 (5

.1 )

30 (2

5. 4)

26 (2

2. 0)

35 (2

9. 7)

21 (1

7. 8)

2 (2

.1 )

11 (1

1. 3)

16 (1

6. 5)

34 (3

5. 8)

32 (3

3. 7)

<  0 .0 01

d. In

fo rm

th e

pa tie

nt th

at

yo u

ca n

or ga

ni se

fo r

th e

ne ar

es t p

ha rm

ac y

(a pp

ro x.

5 0 

km aw

ay )

to su

pp ly

h im

w ith

a n

al te

rn at

iv e

ge ne

ric b

ra nd

. Yo

u off

er to

o rg

an is

e tra

ns po

rt. [n

= 11

5; 9

5]

6 (5

.2 )

35 (3

0. 4)

25 (2

1. 7)

31 (2

7. 0)

18 (1

4. 9)

3 (3

.2 )

10 (1

0. 5)

18 (1

8. 9)

38 (4

0. 0)

26 (2

7. 4)

<  0 .0 01

e. E

xp la

in to

th e

pa tie

nt

th at

y ou

n ee

d to

d is

pe ns

e th

e or

ig in

at or

b ra

nd

an d

he w

ill n

ee d

to p

ay

th e

br an

d pr

em iu

m su

r- ch

ar ge

. [ n =

11 7;

9 5]

15 (1

2. 8)

39 (3

3. 3)

38 (3

2. 5)

20 (1

7. 1)

5 (4

.3 )

11 (1

1. 6)

41 (4

3. 2)

25 (2

6. 3)

13 (1

3. 7)

5 (5

.3 )

0. 42

8

1093International Journal of Clinical Pharmacy (2019) 41:1085–1098

1 3

Ta bl

e 4

(c on

tin ue

d)

Le ve

l o f a

gr ee

m en

t w ith

hy

po th

et ic

al o

pt io

ns [n

= in

te rn

; p ha

rm ac

ist ]

In te

rn s

Ph ar

m ac

ist s

St ro

ng ly

ag

re e

A gr

ee N

eu tra

l D

is ag

re e

St ro

ng ly

di

sa gr

ee St

ro ng

ly

ag re

e A

gr ee

N eu

tra l

D is

ag re

e St

ro ng

ly

di sa

gr ee

p va

lu e

n %

n %

n %

n %

n %

n %

n %

n %

n %

n %

f. Ex

pl ai

n to

th e

pa tie

nt

th at

y ou

n ee

d to

d is

pe ns

e th

e or

ig in

at or

b ra

nd b

ut

on ly

if h

e is

w ill

in g

to

pa y

th e

br an

d pr

em iu

m

su rc

ha rg

e. [n

= 11

8; 9

6]

28 (2

3. 7)

57 (4

8. 3)

23 (1

9. 5)

6 (5

.1 )

4 (3

.4 )

31 (3

2. 3)

37 (3

8. 5)

21 (2

1. 9)

5 (5

.2 )

2 (2

.1 )

0. 44

2

Yo u

ar e

un de

r i nc

re as

in g

pr es

su re

, f ro

m th

e ow

ne r,

to m

ak e

co m

pa ni

on sa

le s w

ith D

ru g

E. T

he c

om pa

ni on

p ro

du ct

h as

li m

ite d

ev id

en ce

.

Le ve

l o f a

gr ee

m en

t w ith

h yp

o- th

et ic

al o

pt io

ns [n

= in

te rn

; p ha

rm ac

ist ]

In te

rn s

Ph ar

m ac

ist s

St ro

ng ly

ag

re e

A gr

ee N

eu tra

l D

is ag

re e

St ro

ng ly

di

sa gr

ee St

ro ng

ly

ag re

e A

gr ee

N eu

tra l

D is

ag re

e St

ro ng

ly

di sa

gr ee

p va

lu e

n %

n %

n %

n %

n %

n %

n %

n %

n %

n %

a. O

ffe r t

he c

om pa

ni on

p ro

du ct

to

m ee

t t he

q uo

ta se

t b y

th e

ow ne

r. [n

= 11

7; 9

4]

2 (1

.7 )

20 (1

7. 1)

37 (3

1. 6)

39 (3

3. 3)

19 (1

6. 2)

2 (2

.1 )

18 (1

9. 1)

25 (2

6. 6)

24 (2

5. 5)

25 (2

6. 6)

0. 47

7

b. O

ffe r t

he c

om pa

ni on

p ro

d- uc

t, at

a re

du ce

d co

st to

th e

pa tie

nt (p

at ie

nt h

as c

on ce

s- si

on c

ar d)

, t o

m ee

t t he

q uo

ta

se t b

y th

e ow

ne r.

[n =

11 7;

94

]

2 (1

.7 )

10 (8

.5 )

32 (2

7. 4)

47 (4

0. 2)

26 (2

2. 2)

0 4

(4 .3

) 16

(1 7.

0) 43

(4 5.

7) 31

(3 3.

0) 0. 00 8

c. O

ffe r t

he c

om pa

ni on

p ro

du ct

to

th e

pa tie

nt a

nd e

xp la

in th

e lim

ite d

ev id

en ce

. [ n =

11 9;

95

]

23 (1

9. 3)

64 (5

3. 8)

15 (1

2. 6)

11 (9

.2 )

6 (5

.0 )

14 (1

4. 7)

45 (4

7. 4)

24 (2

5. 3)

8 (8

.4 )

4 (4

.2 )

0. 16

7

d. D

o no

t o ffe

r t he

c om

pa ni

on

pr od

uc t t

o th

e pa

tie nt

a s

th e

pa tie

nt p

ro ba

bl y

ca nn

ot

aff or

d it.

[n =

11 7;

9 4]

5 (4

.3 )

15 (1

2. 8)

40 (3

4. 2)

44 (3

7. 6)

13 (1

1. 1)

1 (1

.1 )

7 (7

.4 )

27 (2

8. 7)

51 (5

4. 3)

8 (8

.5 )

0. 07

4

e. D

o no

t o ffe

r t he

c om

pa ni

on

pr od

uc t t

o th

e pa

tie nt

a s t

he re

is

li m

ite d

ev id

en ce

. [ n =

11 5;

95

]

12 (1

0. 4)

30 (2

6. 1)

44 (3

8. 3)

23 (2

0. 0)

6 (5

.2 )

10 (1

0. 5)

21 (2

2. 1)

38 (4

0. 0)

22 (2

3. 2)

4 (4

.2 )

0. 65

1

B ol

d re

pr es

en ts

th e

st at

ist ic

al ly

si gn

ifi ca

nt a

ss oc

ia tio

n (p

v al

ue <

0 .0

5)

1094 International Journal of Clinical Pharmacy (2019) 41:1085–1098

1 3

Ta bl

e 5

C om

pa ris

on o

f e xp

os ur

e to

p ot

en tia

l p riv

ac y

br ea

ch es

H ow

o fte

n ex

po se

d to

th e

fo llo

w in

g sc

en ar

io s i

n re

gu la

r pr

ac tic

e [n

= in

te rn

; p ha

rm ac

ist ]

In te

rn s

Ph ar

m ac

ist s

D ai

ly W

ee kl

y Fo

rt- ni

gh tly

M on

th ly

Le ss

o fte

n D

ai ly

W ee

kl y

Fo rt-

ni gh

tly M

on th

ly Le

ss o

fte n

p va

lu e

n %

n %

n %

n %

n %

n %

n %

n %

n %

n %

a. T

he p

ha rm

ac y

re ce

iv es

a fa

x fro

m a

h ea

lth p

ro fe

ss io

na l

in te

nd ed

fo r a

no th

er re

ce iv

er . T

he fa

x co

nt ai

ns p

at ie

nt

id en

tifi er

s/ in

fo rm

at io

n. [n

= 12

1; 9

7]

16 (1

3. 2)

12 (9

.9 )

4 (3

.3 )

8 (6

.6 )

81 (6

6. 9)

3 (3

.1 )

10 (1

0. 3)

6 (6

.2 )

13 (1

3. 4)

65 (6

7. 0)

0. 50

8

b. A

st aff

m em

be r r

el at

es m

ed ic

in es

in fo

rm at

io n

to a

c on

- su

m er

a nd

th en

re al

is es

th at

h e/

sh e

m ay

n ot

b e

en tit

le d

to

th at

in fo

rm at

io n.

[n =

12 0;

9 6]

6 (5

.0 )

18 (1

5. 0)

10 (8

.3 )

20 (1

6. 7)

66 (5

5. 0)

2 (2

.1 )

3 (3

.1 )

2 (2

.1 )

9 (9

.4 )

80 (8

3. 3)

<  0 .0 01

c. A

st aff

m em

be r s

ho w

s o ne

m em

be r o

f a fa

m ily

o th

er

fa m

ily m

em be

rs ’ r

ep ea

t p re

sc rip

tio ns

w ith

ou t o

bt ai

ni ng

co

ns en

t f ro

m th

em . [

n = 11

9; 9

7] .

36 (3

0. 3)

19 (1

6. 0)

12 (1

0. 1)

12 (1

0. 1)

40 (3

3. 6)

12 (1

2. 4)

25 (2

5. 8)

7 (7

.2 )

15 (1

5. 5

38 (3

9. 2)

0. 04 9

d. A

st aff

m em

be r d

is cu

ss es

c on

fid en

tia l d

e- id

en tifi

ed

in fo

rm at

io n

ab ou

t a c

on su

m er

o ut

si de

o f t

he p

ha rm

ac y

at

a no

n- pr

of es

si on

al se

tti ng

. [ n =

11 8;

9 6]

11 (9

.3 )

13 (1

1. 0)

9 (7

.6 )

24 (2

0. 3)

61 (5

1. 7)

3 (3

.1 )

10 (1

0. 4)

6 (6

.3 )

10 (1

0. 4)

67 (6

9. 8)

0. 01 1

e. A

st aff

m em

be r d

is cl

os es

c on

fid en

tia l i

de nt

ifi ab

le in

fo r-

m at

io n

ab ou

t a c

on su

m er

(s ) o

ut si

de o

f t he

p ha

rm ac

y.

[n =

12 0;

9 6]

6 (5

.0 )

5 (4

.2 )

9 (7

.5 )

19 (1

5. 8)

81 (6

7. 5)

1 (1

.0 )

2 (2

.1 )

4 (4

.2 )

4 (4

.2 )

85 (8

8. 5)

<  0 .0 01

f. A

st aff

m em

be r d

is cl

os es

re al

p ra

ct ic

e sc

en ar

io s o

n a

so ci

al m

ed ia

p la

tfo rm

su ch

a s F

ac eb

oo k.

[n =

12 1;

9 6]

4 (3

.3 )

4 (3

.3 )

3 (2

.5 )

4 (3

.3 )

10 6

(8 7.

6) 2

(2 .1

) 1

(1 .0

) 2

(2 .1

) 4

(4 .2

) 87

(9 0.

6) 0.

45 0

g. O

ne m

em be

r o f a

fa m

ily re

ce iv

es a

P R

F pr

in to

ut , t

ax

pr in

to ut

o r d

is pe

ns in

g su

m m

ar y

co nt

ai ni

ng id

en tifi

ab le

m

ed ic

in es

in fo

rm at

io n

of o

th er

a du

lt fa

m ily

m em

be rs

. [n

= 11

9; 9

6]

12 (1

0. 1)

26 (2

1. 8)

17 (1

4. 3)

20 (1

6. 8)

44 (3

7. 0)

3 (3

.1 )

17 (1

7. 7)

8 (8

.3 )

18 (1

8. 8)

50 (5

2. 1)

0. 00 9

h. A

st aff

m em

be r s

or ts

th ro

ug h

pr es

cr ip

tio ns

o n

a fro

nt /

di sp

en sa

ry c

ou nt

er in

v ie

w o

f o th

er c

on su

m er

s. [n

= 12

0;

96 ]

35 (2

9. 2)

27 (2

2. 5)

11 (9

.2 )

12 (1

0. 0)

35 (2

9. 2)

15 (1

5. 6)

14 (1

4. 6)

12 (1

2. 5)

15 (1

5. 6)

40 (4

1. 7)

0. 00 4

i. A

st aff

m em

be r c

ou ns

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0. 03 5

1095International Journal of Clinical Pharmacy (2019) 41:1085–1098

1 3

• 13.4% of pharmacists agreed or strongly agreed to ‘… inform the patient that you can organise for the nearest pharmacy (approx. 50 km away) to supply him with an alternative generic brand. The patient has to organise transport’ compared to 30.5% of interns (p < 0.001),

• 13.7% of pharmacists agreed or strongly agreed to ‘… inform the patient that you can organise for the nearest pharmacy (approx. 50 km away) to supply him with an alternative generic brand. You offer to organise trans- port’ compared to 35.6% of interns (p < 0.001), and.

• 4.3% of pharmacists agreed or strongly agreed to ‘… offer the companion product, at a reduced cost to the patient (patient has concession card), to meet the quota set by the owner’ compared to 10.2% of interns (p = 0.008).

Privacy scenario exposure

Participants had been exposed to a variety of potential privacy breaches in practice (Table 5). Daily exposure to ‘A staff member discloses real practice scenarios on a social media platform such as Facebook’ and ‘Medi- cines awaiting collection have dispensing labels visible to other consumers’ were reported by few respondents. In contrast daily exposure to ‘Consumer names are called out when the medications are ready to be collected’ and ‘Collected medicines are visible to other consumers (e.g. when taking to front counter)’ was identified by almost half of respondents.

Of interest was that there were statistically significant dif- ferences between interns and pharmacists in nine of the 17 scenarios with interns identifying being exposed to the sce- narios more often than pharmacists. The following scenarios showed the greatest statistical difference:

• A staff member relates medicines information to a con- sumer and then realises that he/she may not be entitled to that information (p < 0.001),

• A staff member discusses confidential de-identified infor- mation about a consumer outside of the pharmacy at a non-professional setting (p = 0.011),

• A staff member discloses confidential identifiable infor- mation about a consumer(s) outside of the pharmacy (p < 0.001),

• One member of a family receives a patient record form (PRF) printout, tax printout or dispensing summary con- taining identifiable medicines information of other adult family members (p = 0.009),

• A staff member sorts through prescriptions on a front/dis- pensary counter in view of other consumers (p = 0.004), and.

Ta bl

e 5

(c on

tin ue

d)

H ow

o fte

n ex

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d to

th e

fo llo

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en ar

io s i

n re

gu la

r pr

ac tic

e [n

= in

te rn

; p ha

rm ac

ist ]

In te

rn s

Ph ar

m ac

ist s

D ai

ly W

ee kl

y Fo

rt- ni

gh tly

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th ly

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o fte

n D

ai ly

W ee

kl y

Fo rt-

ni gh

tly M

on th

ly Le

ss o

fte n

p va

lu e

n %

n %

n %

n %

n %

n %

n %

n %

n %

n %

n. M

ed ic

in es

aw ai

tin g

co lle

ct io

n ha

ve d

is pe

ns in

g la

be ls

vi

si bl

e to

o th

er c

on su

m er

s. [n

= 12

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(2 .5

) 16

(1 3.

2) 8

(6 .6

) 6

(5 .0

) 88

(7 2.

7) 4

(4 .2

) 2

(2 .1

) 4

(4 .2

) 6

(6 .3

) 79

(8 3.

2) 0.

05 7

o. C

om pu

te r d

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g hi

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is -

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sh op

st aff

. [ n =

12 1;

9 5]

25 (2

0. 7)

9 (7

.4 )

7 (5

.8 )

9 (7

.4 )

71 (5

8. 7)

17 (1

7. 7)

4 (4

.2 )

7 (7

.3 9

(9 .4

) 59

(6 1.

5) 0.

55 5

p. C

on su

m er

n am

es a

re c

al le

d ou

t w he

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at io

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re ad

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91 (7

5. 2)

8 (6

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1 (0

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2 (1

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19 (1

5. 7)

74 (7

7. 1)

8 (8

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2 (2

.1 ))

2 (2

.1 )

10 (1

0. 4)

0. 63

1

q. C

ol le

ct ed

m ed

ic in

es a

re v

is ib

le to

o th

er c

on su

m er

s ( e.

g.

w he

n ta

ki ng

to fr

on t c

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[n =

12 0;

9 6]

57 (4

7. 5)

9 (7

.5 )

8 (6

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6 (5

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40 (3

3. 3)

47 (4

9. 0)

10 (1

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1 (1

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4 (4

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34 (3

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0. 94

8

PR F

Pa tie

nt R

ec or

d Fo

rm , N

at RU

M N

at io

na l R

et ur

n of

U nw

an te

d M

ed ic

in es

B ol

d re

pr es

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th e

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ss oc

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n (p

v al

ue <

0 .0

5)

1096 International Journal of Clinical Pharmacy (2019) 41:1085–1098

1 3

• A staff member counsels a patient about the use of a medicine, or management of a condition, that is of a sen- sitive nature in front of other consumers (p < 0.001).

Discussion

There were some differences in the resources used by interns and pharmacists when confronted with an ethical dilemma. The choices on the management of the two ethical scenarios were mostly similar between the interns and pharmacists, although pharmacists avoided choices that required complex management. Interestingly, interns’ responses showed that they were more often exposed to potential practice privacy breaches compared to pharmacists.

There were statistically significant differences in the rel- evance of the Code of Ethics and PBA/AHPRA resources with interns relying on them more than pharmacists. A potential explanation for this is that these resources form the basis of ethics teaching with interns being familiar with them. In contrast, pharmacists showed a higher preference for consultation with co-workers. This finding is similar to United Kingdom (UK) qualitative research with 23 purpo- sively selected community pharmacists that showed some pharmacists were of the opinion that codes of practice and university-based training were unhelpful. They instead relied on their experience and common sense to respond to chal- lenging ethical scenarios [42].

Practice standards should provide a framework to assist with ethical decision-making [43, 44] and both interns and pharmacists indeed rated practice standards as useful. This differed from a qualitative study conducted in England and Wales that reported pharmacists perceived standards to be unhelpful and contribute to procedure overload [45]. The difference in outcomes between Australia and the UK study could be due to Australian community pharmacists’ famili- arity with quality care accreditation requirements with inte- grated practice standards into processes [46]. Many Austral- ian community pharmacists are therefore already conversant with the standards. However, questions still remain as to the relevance and usefulness of practice standards [23].

The pharmacy intern year facilitates the transition from being a pharmacy student to a registered pharmacist through practising in a supervised environment. However, the interns in our study did not select to consult with colleagues, such as mentors or preceptors (supervisors), but rather focussed on the resources they were familiar with through university teachings. Although this is a positive finding in that it seems interns consult relevant resources, this could indicate a more positivist approach to ethical dilemmas rather than an appre- ciation of the nuances of complex situations and that if their actions are brought into question, they will be judged against their peers. Pharmacists, on the other hand, refer to their

peers to inform their decision making (social constructiv- ism). Alternatively, it could indicate a lack of trust interns have in colleagues’ ethical reasoning competence, or low confidence in asking colleagues for assistance and awareness of the support provided by professional indemnity organisa- tions. Australian pharmacy intern preceptors do not undergo a credentialing process. Our study shows that there may be benefit in preceptor training and assessment to ensure pre- ceptors act as mentors for interns as personal accounts of ethical dilemmas have shown to be of value in appreciating and understanding ethical reasoning [5]. Consulting with more experienced pharmacists when presented with dilem- mas to stimulate conversation reduces professional isolation, which is a risk in community pharmacy practice [47].

The responses in the management of the second sce- nario that required organising transport to the nearest pharmacy showed statistically significant differences with interns being more willing to facilitate provision of patient-care. This finding could show that pharmacists have more pressure to balance patient-care with financial aspects compared to interns or are more time poor. More research on this is needed in the Australian community pharmacy context as international studies have shown that patient-care activities often clash with profitability and time management. With the corporatisation of community pharmacy, owners may be more interested in pharmacists achieving financial targets compared to professional per- formance with professional autonomy influenced by busi- ness settings [45], causing conflict between business tar- gets and patient-care [48, 49]. It is therefore particularly important for pharmacists to have ethical reasoning skills to guide their decision making when providing profes- sional services [50].

Another interesting finding was that the pharmacists’ responses in the first scenario showed higher preference to accept the doctor’s explanation of the adverse reaction ‘being all in the patient’s mind’ compared to the interns. Therefore, interns were less likely to withhold informa- tion from the patient and more inclined to support patient autonomy. This finding suggests that some pharmacists did not want to challenge the doctor’s decision. This shows that there is still a degree of subordination to doctors, even though the pharmacy profession has evolved towards the provision of patient-care. This finding is similar to the UK study finding that showed a culture of subordination to doc- tors in community pharmacy practice [47]. However, as health professionals, pharmacists need to accept independent professional responsibility for patients. The need for inde- pendent professional responsibility in the interest of patients was highlighted in a recent Australian inquest that followed the death of a patient due to a medication overdose [51]. The Coroner stressed that pharmacists should not underestimate their importance in the delivery of healthcare and that regard

1097International Journal of Clinical Pharmacy (2019) 41:1085–1098

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for the doctor–patient relationship should not prevail against their own duty of care.

The interns indicated that potential privacy breaches occurred more frequently with nine of the 17 scenarios showing statistically significant differences to pharmacists’ responses. Although reasons for these differences are unknown one potential explanation could be that pharmacists become more complacent with privacy issues. It could also be that managers and owners may be less aware of activities in the front area of pharmacies. More research is needed to explore these differences and the possible upskilling of pharmacy staff members in privacy requirements. Australian research highlighted the challenges community pharmacies have in safeguarding privacy and confidentiality and the need for all pharmacy staff members to be familiar with privacy require- ments [52, 53]. Ensuring adherence to privacy in pharmacy practice is particularly important considering developments with the national rollout of the online personal medical record system [54].

Limitations

This study involved a quantitative survey of interns and phar- macists. Additional insights would have been obtained if the survey incorporated explanations of responses however the authors decided to limit the survey to quantitative responses. The sample represented approximately 41.7% (121/290) of all Queensland interns and 1.7% of all Queensland pharma- cists (97/5648) [55].The number of interns that participated could therefore be regarded as representative but the number of pharmacists was small and there is a possibility of bias as pharmacies were selected from a list of pharmacies provid- ing needle and syringe services. This study was also limited to one state of Australia and, due to potential jurisdictional variation in legislation and practice requirements, may not be representative of all Australian interns and pharmacists. There are limitations of self-reported data in terms of the privacy questions, especially as some of the respondents could have considered information as business sensitive. The responses to the vignettes were hypothetical and may not reflect actual practices.

Conclusion

There are differences between interns and pharmacists in which resources they prefer most when presented with ethical vignette dilemmas and their preferred actions, and also in their perceptions of how often they are exposed to potential privacy breaches. The results of this study will be used to inform fur- ther research into preparation of the pharmacy profession in ethical reasoning skills.

Acknowledgements The authors acknowledge the support of the intern providers who facilitated access to the interns at the training workshops and the PSA (Qld branch) for facilitating access to pharmacists at the seminar. We also acknowledge the pharmacists and interns that par- ticipated in the study.

Funding This study was supported by funding provided by the Quality Use of Medicines Network, School of Pharmacy and Pharmacology, Griffith University and the School of Pharmacy, Curtin University, Western Australia.

Conflicts of interest The authors declare that they have no conflict of interest with regard to the study or the manuscript.

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