Martine Kruijtbosch

206 Append i ces do justice to them all simultaneously. As a consequence health professionals may develop moral distress, a stress reaction in the form of feelings of guilt or fear that arises when one acts against one’s conscience and values, often accompanied by a feeling of lack of control. Community pharmacists need ethical competencies that enable them to deal with moral dilemmas. For example, in situations of moral dilemmas, pharmacists must reflect on the professional values and their meaning in the context of the values and perspectives of all parties involved. This ethical competency is termed ‘moral reflectivity’ in this thesis. There is still a lack of studies on community pharmacists’ moral dilemmas and the professional values that play a role therein. Also, the development of pharmacists’ ethical competencies required to deal with these dilemmas is hardly researched. To further develop Dutch community pharmacists’ competencies so that they can optimise their pharmaceutical care role in situations of moral dilemmas, we need more insight into the ethical competency of moral reflectivity. The objective of this thesis was to generate understanding of community pharmacists’ moral reflectivity in situations of moral dilemmas and how professional values play a role therein.We investigatedmoral reflectivity in the context of Rest’s Four Component Model of ethical decision-making. According to that model health professionals make use of four cognitive-affective processes when making an ethical decision in situations of moral dilemmas: (1) moral sensitivity (the individual’s ability to recognise moral dilemmas), (2) moral reasoning (the individual’s ability to reflect on the moral ideal course of action), (3) moral intention (the motivation that prioritises the moral ideal course of action) and (4) moral character or action (the ability to hold onto the morally ideal intended action). The last process was not investigated because that was practically not feasible. This thesis consists of five parts. Part 1 contains the general introduction. In Part 2 we investigated community pharmacists’ moral sensitivity for moral dilemmas and the professional values that play a role therein ( Chapters 2.1 and 2.2 ). The narratives of 220 dilemmas of early career Dutch pharmacists (pregraduate and postgraduate pharmacists working in community pharmacy) were used. The pharmacists had written these narratives shortly after they had experienced the dilemmas in practice. This method made it possible for them to directly reflect on their feelings during these encounters and vividly remember the frustrations and other emotions they experienced. In Chapter 2.1 we described the themes that emerged from 128 eligible moral dilemmas. We found22 themeswhichcouldbe furtherdivided into threecategories: themesofmoral dilemmas experienced within 1) the pharmacist-patient relationship, 2) the pharmacist-colleague relationship, and 3) a variety of relationships. The moral dilemmas and their themes revealed that pharmaceutical care and professional autonomy in decision-making by pharmacists was