Martine Kruijtbosch

18 Chap t e r 1 developed and validated: the Professional Ethics in Pharmacy test (PEP test). 43 It measures three developmental levels of moral reasoning: a pre-conventional level (moral reasoning oriented towards business), a conventional level (moral reasoning oriented towards rules and regulations) and a post-conventional level (moral reasoning oriented towards professional ethics). The post-conventional level of moral reasoning in the PEP test is based on the professional ethics that exists in Australia. It seems, the PEP test has not been applied in other countries. Finally, research into training pharmacists in ethical competencies is still a mostly untrodden area. Few studies suggest that joint moral dilemma case discussions are successful, mainly for developing moral sensitivity and moral reasoning. 44-46 Moral case deliberation (MCD) among health professionals in secondary care proved to be successful in developing moral reflectivity in the context of moral dilemmas. 47-49 Only one study exists where one method of MCD (Utrecht method) was described for a moral dilemma case in pharmacy practice. 25 However, this study did not evaluate the deliberation itself and its effects on the participants’ abilities how to deal with the case. It remains thus unknown whether this and other methods are effective to develop pharmacists’ ethical decision-making competencies. Objective Community pharmacists increasingly experience moral dilemmas in a changing complex healthcare context. Therefore, it is important that community pharmacists are ethically competent in order to deal with these dilemmas professionally. Thus far, an overview of themes of moral dilemmas experienced by community pharmacists in daily practice is not available. Also a pharmacy-specific moral reasoning test is not validated for Dutch community pharmacists. Besides, it is unknown whether moral case deliberation supports community pharmacists in developing ethical decision-making competencies needed in moral dilemmas. Moreover, it has not been investigated to what extent community pharmacists are able to reflect on the professional values in the four cognitive-affective ethical processes of ethical decision-making in situations of moral dilemmas. Therefore, the objective of this thesis is to generate understanding of community pharmacists’ moral reflectivity in situations of moral dilemmas and how professional values play a role therein. The six studies presented in this thesis focus on the moral reflectivity of community pharmacists in three of the four cognitive-affective processes of Rest’s model (Figure 1): moral sensitivity, moral reasoning and moral intention. The process of moral character was practically not feasible to investigate and is therefore not addressed.