Martine Kruijtbosch

184 Chap t e r 5 role. Factors that were mentioned were: entrepreneurship in pharmacy practice, the culture of subordination to physicians, the culture within larger pharmacy chains, the challenges with remuneration of pharmaceutical care activities, and the strict regulation with potential consequences for their own business. 18,19,46,47,64,72-74 Although our study showed that in situations of drug shortages Dutch pharmacists’ predominantly have a professional ethics (patient-centred) MRP (Chapter 3.2), they are also challenged by contextual factors. For example, being a managing pharmacist was negatively associated with a dominant professional ethics MRP in situation of drug shortages (Chapter 3.3). This indicates that pharmacists who are responsible for the viability of the community pharmacy, may be more sensitive for financial factors in their moral reasoning than locum pharmacists. Another example can be found within the theme ‘Public health and third- party payer regulations’ in the moral dilemma narratives (Chapter 2.1). The reflections of pharmacists in these dilemmas suggest that pharmacists are hampered in their professional autonomous decision-making by health insurance companies. Payers expect pharmacists to dispense a selection of generic drugs only and provide standard contracts without appropriate remuneration for patient care, while society and patients expect patient-centred care that takes into account patient preferences. 75 A last example indicates the culture of subordination to physicians. Within the theme ‘Pharmacist and physician have a different opinion about appropriate pharmacotherapy’ physicians overruled pharmacist’ proposals without discussing these professionally (Chapter 2.1). Taking into account the above contextual factors one can imagine that the professional ethics MRP of Dutch pharmacists is challenged, which may result in suboptimal pharmaceutical care for patients. Dutch community pharmacists, as individuals and common practice, need support to deal with these challenges. The professional association of pharmacists should come up with an implementation strategy for the Dutch Charter of Professionalism, including a strategy to realise the preconditions for a patient-centred care role. 8,21 As part of this strategy individual pharmacists should be educated on the Dutch Charter and on moral reasoning to identify all contextual factors. Improving moral reasoning skills of community pharmacists will increase the acceptance of their social role by others. And better moral reasoning skills may be evenmore important than expanding patient-centred services. 76 Strategies for other preconditions should also be developed. For example, for the precondition that physicians share necessary medication-related patient information with community pharmacists in order to reduce prescribing and dispensing errors. 77-79 But also