Dana P. Hammer, PhD, a
Bruce A. Berger, PhD, b
Robert S. Beardsley, PhD, c
and Michelle R. Easton, PharmDd
aSchool of Pharmacy, University of Washington bHarrison School of Pharmacy, Auburn University cSchool of Pharmacy, University of Maryland at Baltimore dSchool of Pharmacy, Hampton University
The purpose of this paper is to provoke thought in the pharmacy academy about the critical and
comprehensive need to address professionalism. Several forces are driving the need for this conversation:
the movement toward pharmaceutical care as the practice standard requires a higher level of professionalism
from practitioners; critical issues with regard to current practice that address patient safety, workload, and
shortages in our profession; and the sentiment that there has been a decline in the professionalism of our
students over the last several years as well as within society in general. This paper will comprehensively
review the concept of professionalism, its value to pharmacy practice, challenges to its development, factors
necessary to support it, and recommendations to foster it in the academy and in practice. We hope this paper
serves as a call to action for administrators, faculty, practitioners, and students to think and discuss critically
professionalism in pharmacy education, as well as to stimulate additional work in this important area.
Schools of pharmacy exist to develop professionally mature pharmacy practitioners who can render
pharmaceutical care. As such, our schools’ primary reason for being is to develop students into practitioners
who can serve patients and their drug therapy needs…to do as much as possible to ensure that patients’
drug therapy is necessary and appropriate for them and their conditions, and does no unnecessary harm.
That is our first obligation. Preparation to accomplish this requires both the acquisition of a great deal of knowledge by our students and the development of the necessary
professional attitudes and behaviors. Do schools of pharmacy foster those attitudes and behaviors that protect
patients and promote patient care? Have we made technical competence our mission, or have we attempted
to “frame ‘technical competence’ and ‘academic excellence’ as subsets of professionalism, not as ‘stand alone’
values or goals, and most surely not as the principle goal of the educational enterprise”?1 If all we are interested in is technical competence, then we have become a trade school. If technical
competence exists but not the necessary attitudes, values, and behaviors of the professional, then our graduates
may “wear the trappings of that profession, but would no longer be a representative of the profession.”2
Is there evidence to suggest that perhaps we have not fostered the professional attitudes and behaviors
that we desire in health care professionals? Consider the following frequently occurring community practice
scenario: a patient or caregiver is asked to sign his or her name to a document in order to receive a
prescription. Often disclosure of intent is not provided. Most patients assume they are acknowledging
receipt for insurance purposes; however, in actuality, many are declining counseling services. Unfortunately,
this is not an isolated event. Why this occurs really does not matter. What matters is that pharmacists are
avoiding their professional responsibility of educating patients and by doing so are putting patients at risk.
How did we get to this point? This is especially distressing since there is supposedly a severe shortage of
pharmacists. Being in short supply should allow pharmacists to demand more of what they want professionally.
What happened to pharmacists’ sense of ethical obligation to the patient? If a corporation did impose this
standard, where is the pharmacist’s moral courage to stand up and say, “I will not practice this way”? Why do
pharmacists who do not practice this way, yet know about these practices, permit this to continue? Should
they not report this behavior, and if they do, should not boards of pharmacy respond appropriately? Do we,
in pharmacy education, share any responsibility for what happened here? Do graduates leave our schools of
pharmacy with a sufficient sense of professional identity that they will not “sell out” and permit or foster
such unethical behavior? Do they understand and internalize the attitudes and behaviors necessary for
professional conduct?
Figure 1 portrays the delivery of pharmaceutical education that seeks as its outcome to develop a professionally
mature pharmacist who can render pharmaceutical care. In this diagram, the umbrella represents the overall goal of pharmacy curriculum, to develop student professionalism. The student is represented by the central pole of the umbrella. Through the curriculum, the schools’ culture, faculty, staff, practitioners, and
administrative interactions, various subsets of knowledge, skill sets, instruction, and experiences assist in
shaping and developing the student’s professionalism. Examples of these various subsets, not an inclusive list, are represented by hinged ribs radiating from the central pole: empathy, communication, instruction and guidance
(faculty/practitioner), personal values, extracurricular activities, school culture and environment, mentoring
and modeling, and professional competence (knowledge). This figure may help to elucidate the relationships
of professionalism and some of its attributes in pharmacy education.
Another way to conceptualize professionalism is to think of a bicycle wheel. The center of individual
professionalism is a set of core values that includes altruism/service, caring, honor, integrity, duty, and others.
The spokes radiating from the hub are behaviors demonstrated by the individual: respect, accountability,
empathy, compassion, and others. The tire itself is what some could consider ‘icing on the cake’ – dressing
professionally, punctuality, acting courteously, exhibiting good grooming habits, and so on. It is important to
keep in mind that the heart of what we are talking about is one’s values. We often tend to focus our efforts on the tire, or more superficial aspects of professionalism, which
are also important, but may not address underlying values supporting the behaviors. Acting professionally is not the same as being a professional.
In her courageous talk at the 1999 ASHP meeting, Kathleen Marie Dixon called upon pharmacists to take
up the torch of virtue theory and ethics. She reminded us of what the ethicist Philippa Foot said, “For
sometimes one man succeeds where another fails not because there is some specific difference in their
previous conduct but because his heart lies in a different place; and the disposition of the heart is part of
virtue.”3 She went on to say that virtue theory helps us to reengage our hearts in both our work and ourselves.
“Underneath those layers is a spark of passion, perhaps not for the discipline as it is practiced today, but for
what it can be. That perception of excellence, that insight into virtue grounds this paradigm. That spark can pass
quickly between human beings creating interest in and desire for personal development, revealing new patterns
of thought and experience. This in turn becomes the engine that drives professional change.”3
We hope that this manuscript becomes the spark that drives the engine for professional change in
pharmacy education. In this paper, we provide ideas about why professionalism has become a current focus,
present some historical and literary perspective, and discuss current emphases in some of our national
organizations. We also analyze current trends in pharmacy education, the value of professionalism within the
context of pharmaceutical care, and challenges to its development. Finally, we discuss factors necessary to
support development of professionalism and provide recommendations as such. It is our goal that this paper
will serve as a call to action for administrators, faculty, practitioners, and students to think and discuss critically
professionalism in pharmacy education.
This section describes rationale for discussing professionalism in the pharmacy academy, provides a
brief historical perspective of professionalism, presents definitions of professionalism, and explores related
constructs.
Why Talk About Professionalism?
Current evidence reveals an erosion of values and ethics within society at large. Incivility on the
roadways and well-publicized ethics violations in corporate America are just two examples of this deterioration.
Since pharmacy is a microcosm of society, this erosion influences its practitioners, faculty, and students. Many
are concerned with the emphasis on self in today’s society. People will do whatever is best for them; they are
thinking more about themselves than about others. Certain “professionals” have different standards of
conduct than in the past that reflect changes in ethics and values. These changes have impacted how society
views certain “professions.” For example, society views the legal profession differently than it did 20 years
ago. In the past, the general public trusted lawyers’ intentions and respected their actions, but now it
questions their ethics and decision making. Accountants and clergymen were once some of the most
respected professionals. However, due to recent ethic and legal violations, the public views members of
these professions in a different light.
Whether unethical behavior is more rampant now than in the past or whether the recent generations
of students are any worse than earlier cohorts can be debated. Many people feel that societal values have
been gradually weakening over the past 40 years, while others state that the values have always been
relatively weak, but now people are more aware of unethical behavior in today’s culture. Rather than
getting involved in a debate about the extent of the deterioration or about which generation is worse, it is
best to focus on societal values that are less than optimal and on society’s need to do several things to
enhance its values structure. By the same token, pharmacy needs to proactively enhance its level of
professionalism or it runs the risk of losing societal prestige as seen in the legal and accounting professions.
The key is that professionalism must become part of the soul of pharmacy students, faculty, and
practitioners.
There is evidence that other health care professions are concerned about the professional conduct
of their practitioners and students. Physicians and nurses, as well as others, have also written about the
need to enhance professionalism in their professions and their works are cited throughout this paper. The
premise of these works is similar to concerns discussed earlier: the erosion of values in today’s society
influences the values within a profession. Some practitioners even advocate that aspects of their
professionalism are “under attack” from elements of society. One example being that insurance companies
are dictating professional behavior and instructing practitioners about the type of care that can be delivered
to patients and the amount of time practitioners can spend with them. Pharmacy must learn from the
experiences of these other health care providers.
Historical Perspective
Health care disciplines have been concerned about professionalism since the time of Hippocrates.
There were many historical period s during which health care providers studied and wrote about the
importance of professionalism. They were concerned about their relationships with patients and their
status as viewed by the public. The origin of professions and consequently professionals was initially given
to those who professed their faith in God and who committed their existence to contemplative living such
as the monks.4 By definition today, a profession is a group of persons who “profess” or “proclaim” its
beliefs to others. Furthermore, a profession is a group of persons who provide a significantly recognized
service (eg, education, healthcare, religion) that is central to human values.5 The service provided by the profession must be adapted to individual needs and require knowledge,
training, and skills that the typical user (lay person) does not possess.6
Professions, identified as such by society, receive benefits, special recognition, and greater autonomy
than non-professional groups or organizations. For example, society allows recognized professions to
determine how their members will be selected, educated, licensed, monitored, awarded, and punished. A
profession’s standards of practice are also self-developed. The following factors/characteristics are
recognizable traits of a profession:7
Provides socially necessary and important functions
Encompasses a body of specialized knowledge and skills requiring advanced theoretical training
Renders an individualized, unstandardized service directly to clients/patients
Provides autonomy for the definition, organization, and performance of work
Internally controls the behavior of its practitioners
Has formal organizations, code of ethics, and licensure requirements
As a result of the autonomy and special recognition bestowed upon professions, there is higher trust,
expectations and standards for the profession and its members. Societal expectations include: discretionary
use of professional ability to assist those without knowledge and expertise; use of professional judgment; and
volunteerism/altruism (eg, boards, missionary work, health screenings).8
Professionals are the persons who practice within the profession and have met the stringent and
coordinated requirements set forth by the profession. Professionals utilize tangible (obvious) and intangible
(non-obvious) measures to produce the activities of the profession. Examples of obvious measures would
include materials, products, and objects, whereas non-obvious measures are knowledge, skill, and critical
thinking/problem-solving skills. Being a professional is not an achievement attained upon graduation or with
the conferring of a degree. Rather, being a professional is a life-long commitment to the journey that must
be traveled irrespective of the environment of the professional.
From the definitions, characteristics, and traits mentioned previously, there is no question that
pharmacy is a profession. However, this status was vigorously debated in the past. Some authors have
argued that pharmacy is not a “true” profession because it lacks full status of some of the characteristics
described above such as complete autonomy.9-12 Denzin and Mettlin described pharmacy as a “quasi-profession” that has achieved “incomplete
professionalization” because it has yet to attain all the necessary characteristics to become a profession.9 Montague reviewed four studies that investigated the profession of pharmacy versus the business
of pharmacy and concluded that pharmacy suffered from the “structural strain” between professional and
business orientations of pharmacists and pharmacies.10 Ladinsky described professional problems in pharmacy as having yet to establish exclusive professional
control over its field of work in such a way as to be recognized and respected for its contributions to
consumers and by other health professionals, as well as having a tarnished service image.13
Although many of these decades-old arguments are applicable to current pharmacy practice, in fact,
pharmacy is one of the oldest health-related professions and it most certainly does provide services that are
of fundamental value to society.14 The specialized body of knowledge that pharmacists must attain as it relates to medicines and their
uses, along with the mission to assure the safe and effective use of them in patients, embodies the definition
and requirements of a profession. Although the roles and emphasis of pharmacy have evolved and continue
to do so in the United States, vigilance with respect to meeting professional characteristics, traits, and
responsibilities must occur. An example of this is provided by Wolfgang, in his efforts to continually challenge
students to critically review pharmacy’s status as a profession.15
Present day pharmacy practice is challenged with moving toward a patient-centered, pharmaceutical
care practice versus the traditional product-oriented, fiscally focused practice. Providing drug therapy for
the purpose of achieving positive health outcomes (pharmaceutical care) versus focusing on the manufacture,
compounding, and distribution of the drug product requires re-examination of professional values and services
provided.
Challenges in Defining Professionalism
Before schools can begin to develop and measure professionalism in their programs, they must first
define it. Ask 100 individuals how they would define professionalism and it is likely that you will receive 100
different responses. Professionalism is defined in numerous ways in both professional and lay literature.
Literally, professionalism is the extent to which an occupation or a member of that occupation exhibits
the characteristics of a profession. Merriam-Webster’s defines professionalism as “the conduct, aims or
qualities that characterize or mark a profession or professional person.”16 The White Paper on Pharmacy Student Professionalism defined it as “the active demonstration
of the traits of a professional” and in their previous deliberations, those authors had described it as
“displaying values, beliefs and attitudes that put the needs of another above your personal needs.”17,18 The Medical Professionalism Project describes it as “the basis of medicine's contract with
society. It demands placing the interests of patients above those of the physician, setting and maintaining
standards of competence and integrity, and providing expert advice to society on matters of health.”19 These definitions are rather broad and are not very useful until they are further explored and
refined.
When sociologists first began studying the differences between occupations and professions in the
1950s and 1960s, they described professionalism based on professions and members of those professions
possessing degrees of ‘structural’ and ‘attitudinal’ attributes that set them apart from occupations and
members of those occupations.20-25 Classic, true professions at the time were considered to be theology, law, and medicine, although
this ‘true’ status today could be debated. The professions and members of those professions were
considered more ‘professional’ if they exhibited, to a great extent, these structural and attitudinal
characteristics. Structural attributes include those described earlier in this paper as well as social
prestige and unique socialization of student members. Attitudinal attributes of professionals were
described as:
use of the professional organization as a major reference, ie, using professional colleagues as
the major source of professional ideas and judgments in practice
belief in service to the public, ie, one’s professional practice is indispensable to society
and benefits the public
belief in self-regulation, ie, one’s peers are the best qualified to judge one’s work
sense of calling to the field, ie, dedication to the profession regardless of extrinsic rewards
autonomy, ie, one can make professional decisions without external pressures from clients,
non-professionals, and employers.
Structural and attitudinal characteristics are the ‘original’ attributes of professions and professionals.
However, professionalism is most often described in terms of behavioral attributes in the professional and lay
literature.
“Professionalism is displayed in the way pharmacists conduct themselves in professional
situations. This definition implies a demeanor that is created through a combination of behaviors,
including courtesy and politeness when dealing with patients, peers, and other health care
professionals. Pharmacists should consistently display respect for others and maintain appropriate
boundaries of privacy and discretion. Whether dealing with patients or interacting with others
on a health care team, it is important to possess--and display--an empathetic manner.”26
The term ‘behavioral professionalism,’ behaving in a manner to potentially achieve optimal outcomes in
professional tasks and interactions, was developed to establish the relationship between professional behaviors
and the structural and attitudinal attributes of professionalism.27 Behavioral professionalism includes attributes such as reliability and dependability, confidence, active
learning, communicating respectfully and articulately, accepting and applying constructive criticism, behaving
ethically, demonstrating a desire to exceed expectations, putting others’ needs above one’s own, and other
professional behaviors. It is these professional attributes upon which pharmacy academia has been most
focused recently.
Academic medicine and the medical profession have been grappling with similar challenges and issues
and have made great strides in helping to define the meaning of professionalism for its constituents. The
American Board of Internal Medicine’s (ABIM) Project Professionalism, which served as part of the foundation
of the Medical Professionalism Project, described three commitments as necessary elements of
professionalism:28
A commitment to the highest standards of excellence in the practice of medicine and in the
generation and dissemination of knowledge.
A commitment to sustain the interests and welfare of patients.
A commitment to be responsive to the health needs of society.
These elements are just as applicable to pharmacy and other health care professions as they are
medicine. ABIM further elucidated these commitments into six tenets: altruism, accountability, excellence,
duty, honor and integrity, and respect for others. These tenets, as defined by ABIM but adapted
specifically for pharmacists, read:
Altruism is the cornerstone of professionalism. Pharmacists must serve the best interest of
patients above their own or above that of employers. This means that care is not
compromised or reduced in quality because of a patient’s inability to pay.
Accountability is required at many levels -- individual patients, society and the profession. Pharmacists
are accountable for fulfilling the implied covenant that they have with their patients. They are
also accountable to society for addressing the health needs of the public and to their profession
for adhering to pharmacy’s code of ethical conduct.
Excellence requires a commitment to lifelong learning and knowledge acquisition or retrieval to
serve patients.
Duty requires that pharmacists be committed to serving patients even when it is inconvenient
to the pharmacist. The pharmacist is an advocate for the appropriate care of the patient even
if payment cannot be made.
Honor and integrity means being fair, being truthful, keeping one's word, meeting commitments, and being
straightforward. They also require recognition of the possibility of conflict of interest and
avoidance of relationships that allow personal gain to supersede the best interest of the
patient.
Respect for others, including other pharmacists, health professionals, patients and their families. This is the
essence of humanism, and humanism is both central to professionalism, and fundamental to
enhancing collegiality among pharmacists.
In addition to the commitments and tenets, ABIM has also embarked on revising curricula, accreditation
standards, and certification procedures to allow for inclusion and enforcement of these elements.
Professionalism is a complex composite of structural, attitudinal and behavioral attributes. A broader
definition of professionalism that attempts to encompass all of the aforementioned characteristics is “the
possession and/or demonstration of structural, attitudinal and behavioral attributes of a profession and its
members.”29 Regardless of which definition one chooses to use, what is important is that the attributes of
professionalism are specifically defined so that schools can strategically plan and evaluate activities designed
to promote professionalism in their programs. It would be nice if the profession could develop a consensus
definition of professionalism – then schools should determine which behaviors to address and develop
strategies to enhance them by asking questions such as: what does it mean to “put another’s needs above
one’s own”? What do “competence” and “integrity” look like? What does it mean to “demonstrate respect”
to others? Often it is much easier to describe those behaviors that illustrate unprofessional behavior versus
those that demonstrate professional behavior. Some schools have taken this approach in an attempt to
ascertain student, faculty and practitioner views about professionalism.30,31 This may not be a bad approach, as long as care is taken to describe the converse of those
unprofessional behaviors. If professionalism is defined only in terms of what is it not, then students may not intuitively know which behaviors are considered appropriate.
Related Constructs
There are many constructs related to the concept of professionalism. Many of these ideas overlap
with professionalism and might even be considered part of the broader concept. Some of these constructs
include: professional ethics, professional commitment, professional responsibility, professional attitude,
professional behavior, professional competence, professional values, professional identity/image, moral
reasoning, work ethic, empathy, caring, advocacy, and covenantal relationships. A discussion of some of
these constructs in the context of pharmacy professionalism follows; a full exploration of all of them,
however, is beyond the scope of this paper.
Professional attitudes and behaviors. Some of the definitions previously noted described
professionalism as a set of attitudes and behaviors. Many researchers have studied students’, faculty
members’, and practitioners’ attitudes toward particular referents. Attitudes are often described and
measured because they supposedly serve as a proxy for one’s behavior. Psychological literature of the
1970’s purported a “theory of reasoned action” which, in simplified terms, states that beliefs shape
attitudes which in turn can predict behavior toward which the belief and attitude are directed.32 Fishbein defined beliefs as “hypotheses concerning the nature of an object or class,” attitudes
as “learned predispositions to respond to an object or class of objects,” and behaviors as “actions in
response to an object or class of objects.”33 To contrast these definitions to those from a dictionary, a belief is defined as “a state of
mind or habit in which trust or confidence is placed in some person or thing,” an attitude is defined
as “a mental position, feeling or emotion with regard to a fact or state,” and behavior is defined as
“the manner of conducting oneself.”16(p75,103-4)
It is important to illustrate the relationship between professional attitudes and behaviors to
professionalism because the more clearly these concepts are defined and understood, the easier it should
be for programs to determine which aspects they should develop and measure. An example of this might
be found on an evaluation form of a student’s performance during a clerkship rotation. There may be a
line item that asks the preceptor to rate the student’s “professional attitude.” While this might seem to
be easily and consistently interpreted, there are actually many different ways this could be interpreted,
and probably have been, by different preceptors. Attitude toward whom/what? Does this item refer to
behaviors, such as punctuality or follow-through, or does it refer more to communication styles and
interpersonal interactions? Additionally, although attitudes are usually easily measured using survey
instruments or interviews, how predictive are they of actual behavior? Could a student demonstrate a
‘bad attitude’ on a survey but perform professionally on a rotation, and vice-versa? There are many
examples of attitudinal research in the pharmacy academic literature from which to draw, but fewer
that describe empirical observations and evaluation of behavior.
Professional competence. Epstein and Hundert put forth a definition of this construct in a recent
article in Journal of the American Medical Association: “the habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the
benefit of the individual and community being served.”34 They wrote that “Current assessment formats for physicians and trainees reliably test core
knowledge and basic skills. However, they may underemphasize some important domains of professional
medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core
knowledge into clinical practice.” They conducted an extensive review of the literature to find
information about assessment activities, and proposed recommendations and strategies of how medical
schools and licensing bodies can better assess candidates’ professional competence. The ideas in their
paper are very applicable to pharmacy and other health professions.
Advocacy, caring, and covenants. Advocacy. Professionals must assume an advocacy role in which
they provide sufficient information for patients to make good decisions. But, it does not stop with simply
the provision of information. There is an advocacy role here…one of patient empowerment. Patient
advocacy needs to be more than giving patients information in order to satisfy informed consent or
autonomy. It certainly needs to be more than simply giving patients what they wish. Giving patients
information without assessing the patient's understanding of that information is simply another form of
paternalism in which the health care provider decides what constitutes enough. Moreover, patients
should not be left alone in their decisions about managing their health because pharmacists believe that
they have "done their job" by giving patients information. Pharmacists cannot act as if it is up to the
patient to sort through this maze of information and decide what is best. This simply will not work and
it is neither true advocacy, nor does it promote empowerment. Lastly, pharmacists cannot defer this
advocacy for others to provide to patients simply because they ‘don’t have time’ to serve as a patient
advocate in this manner.
So what is true advocacy? Advocacy can be further understood by analyzing Gadow's concept of
‘existential advocacy.’ Existential advocacy involves “participation with the patient in determining the
unique meaning which the experience of health, illness, suffering, or dying is to have for that
individual. . . . a way of reaching decisions which are truly one's own - decisions that express all that
one believes important about oneself and the world, the entire complexity of one's values.”35 To do this, patients must not only be informed about their illnesses and treatment options, but
they must also be given ample opportunity to express their understanding, beliefs, and values about the
illness and treatment options. They must be given the time and encouragement to ask questions, raise
concerns, and express feelings about what is happening to them -- they are not left in isolation by
pharmacists to decide on their own. Pharmacists can willingly help with the decision by expressing
what they think is advisable. Ultimately, though, all decisions must be up to the patient. This kind of
advocacy values the patient's right to self-determination above all other human rights. Without the kind
of advocacy described above, patient empowerment cannot truly occur.
Caring. Central to altruism and professional behavior is caring. What is caring? According to Galt
and Markert, basing their work on Leininger, caring is “. . . the direct (or indirect) nurturant and skillful
activities, processes and decisions related to assisting people in such a manner that reflects behavioral
attributes which are empathetic, supportive, compassionate, protective, helpful, educational, and others,
dependent upon the needs, problems, values, and goals of the individual or group being assisted.”36 They go on to say that “caring is expressing attitudes and actions of concern for patients in order
to support their well-being, alleviate undue discomforts, and meet obvious or anticipated needs.” At the
most basic level, caring means to attend to the needs of others…to make the concern for others paramount
in importance. Can caring be developed in a professional curriculum? Galt and Markert’s research
demonstrates that pharmacy students can demonstrate development of caring behaviors, at least on a
standardized instrument. Unfortunately, however, there is also evidence that clinical training actually
teaches students to emotionally detach from patients in order to remain objective toward them and
their problems.37
Covenants. In 1994 the profession of pharmacy, spearheaded by the then American Pharmaceutical
Association (now American Pharmacists’ Association) and encouraged by the Joint Commission of Pharmacy
Practitioners, put forth a new and dramatically different Code of Ethics for the profession of pharmacy.
The full text of the code may be found at: www.aphanet.org/pharmcare/ethics.html. The code is based on the concept of pharmaceutical care as developed by Hepler and Strand.38 About the revised code of ethics, Vottero commented: “Pharmacists who respond to this
additional level of professional practice and autonomy, [and] embrace the unique caring expectations
of this new practice mode, will be further challenged to demonstrate group and personal behavior
that may be far beyond the present expectations of society.”39
Pharmaceutical care requires that pharmacists develop a covenantal relationship with patients.
It requires that they care and provide care. The first line of the APhA Code of Ethics states, “A
pharmacist respects the covenantal relationship between the patient and pharmacist.” What does
this mean? A covenant is a promise. It is a gift. It is something owed. What do pharmacists owe
patients? They owe them their expertise. They owe them sufficient time and energy to allow them
to understand their illness and its treatment and to ask questions about those things and choices they
do not understand or are unclear about. They owe them current information and the highest quality
standards they can provide. They owe them the privilege of maintaining the confidentiality of all
information shared. These thoughts embody covenantal relationships.
This section discusses the professional socialization process in pharmacy education and describes
the current national focus on professionalism in pharmacy. Specific examples of individual efforts will be
highlighted in the Factors section of this paper.
Professional Socialization
Merton defined socialization as a “process by which people selectively
acquire the values and attitudes, the interests, skills and knowledge--in short, the culture--current in the groups of which they are, or seek to become a member.”40 He applied his definition to the field of medicine, and used the term professional socialization to describe the transformation of medical students into physicians. Professional socialization
involves transformation . . .the transformation of individuals from students to professionals who understand the values,
attitudes, and behaviors of the profession deep in their soul. It is an active process that must be nurtured
throughout the professional’s/student’s development. In pharmacy the socialization process begins the
moment a student (or potential student) observes or interacts with pharmacists, evaluates what they do,
or actively seeks information about the profession. Beliefs, attitudes, and behaviors begin to develop with
regard to pharmacists’ roles.
Professional socialization literature reports that the factors that influence students’ attitudes and
behaviors are: the values and behaviors that students bring into professional programs, role models in the
professional and academic environments, and the environments themselves.41-47 Although professionalism can be considered a product of the professional socialization process,
it is important to remember that students can be “negatively” socialized just as easily as they can be
“positively” socialized. If students come into a program with values incompatible with those of the
profession and the academic program, have negative role models, and learn to practice in an
unprofessional environment, there is a high probability that students will neither develop nor
exhibit a high level of professionalism until some of those factors are modified. The converse is also true.
The professional socialization process in pharmacy occurs both in and outside pharmacy school
walls. Responsibility for professional socialization rests with students entering the profession, the faculties
of schools of pharmacy, and the practitioners with whom these students interact. Staff and other
‘non-professionals’ with whom students interact, such as school secretaries and pharmacy technicians,
also share responsibility in helping to shape students as professionals. Students must accept that, as
professionals, what is expected of them may be more than the expectations of average university students
or curriculum. On the other hand, faculty, practitioners and others must act as role models to display or
demonstrate the kinds of attitudes, values, and behaviors expected of students, and must take the lead
in guiding and facilitating the professional socialization process.
Role of professional schools. It was stated in the Introduction of this paper that the reason schools of pharmacy exist is to
“develop professionally mature pharmacy practitioners who can render pharmaceutical
care.” This purpose implies three obligations. Pharmacy schools are obligated to society to prepare
competent individuals to practice pharmacy in order to optimize patient care and prevent harm – to serve
society in it’s best interest related to healthcare. Pharmacy schools are obligated to the profession of pharmacy to produce competent individuals who will uphold the profession’s standards and continue to
advance the profession. Lastly, pharmacy schools are obligated to students to provide them with the best
education they can in order to achieve the first two obligations. It has been said that the true model of
education should be analogous to coaching: learning and developing foundational skills, practicing, training,
mentoring, and modeling, all the while progressing through a continuum of activities to achieve a goal and
receiving constructive, developmental feedback along the way. Pharmacy faculty, administrators and
practitioners should consider themselves, and behave accordingly, as coaches of future pharmacists.
Role of practitioners. The practice component in the training of a pharmacist is essential and follows
the mantra ‘learn by doing.’ Practicing the ‘art of pharmacy’ under the supervision of a competent
pharmacist is one of the main vehicles to producing a modern day pharmacist. Consequently, schools of
pharmacy have developed elaborate training opportunities for students to learn the art of practicing
pharmacy. Modern practice components within pharmacy curricula are commonly termed experiential education where experiences are key to exposing students to the rich traditions of the profession and
contemporary pharmacy practice.
The role of practitioners in the professional socialization of pharmacy students is enormous and
substantial. Practitioners are often the ones who ‘are doing’ or have achieved that which students strive
to become. Because of this, students consider practitioners credible well before students rotate, interact,
or are supervised by practitioners. The role of the practitioner should be one of mentor, teacher,
motivator, and keeper of the flame as it relates to the standards of the profession. Having said this, it is
imperative that schools of pharmacy appropriately train and sensitize practitioners to the power of their
influence, to their role in the development of student professional identity, and to provide assistance in
structuring how they can maximize their professional traits and guidance in student interactions.
Nonaffiliated training opportunities. Many students enter pharmacy school with a wealth of practical
knowledge received under the mentorship of licensed pharmacists as they were gainfully employed as
technicians. Many students continue to work as pharmacy interns while carrying full course loads in
pharmacy school These circumstances allow students to learn more about the health care system, practice
of pharmacy and about specific medications, while enabling them to earn money for tuition and living
expenses.
In most technician and internship experiences, the practitioner’s influence on the student is outside
of the purview of the school. Hopefully, these experiences truly enhance students’ professional development
toward practicing pharmaceutical care. However, it is troublesome if the practice habits, ethics, and morals
of the practitioner and environment are not congruent with the teachings of the school and profession.48 A disconnect between didactic instruction and the students’ work environment often develops that
may lead to inconsistent socialization and professional disillusionment.49,50 Ideally, didactic and experiential instruction complements, stimulates, and motivates the additional
quest for knowledge in pharmacy students.
Instances where inexperienced pharmacy students challenge practitioners can also affect the
positive professional socialization of the student. Although it is natural for these students to want to
cling and believe information and examples presented by didactic instructors, the role of the practitioner
should be to acknowledge and assist the student in framing didactic knowledge and providing appropriate
relevance as it relates to actual practice. Moreover, practitioners often unknowingly negatively socialize
pharmacy students by trivializing the knowledge and skills learned in pharmacy school. These situations
put students in the position where they must choose what information they feel is correct and can alter
student receptiveness to information in the future. Didactic instruction should balance theoretical
information with practical experiences, whether similar, contrary or dissimilar, to facilitate student
comprehension and contextual application.
Introductory Practice Experiences (IPEs). Although at this time schools may not have much
influence over student technician or internship training, they do have purview over the variety of
experiential programs offered. AACP’s Center for the Advancement of Pharmaceutical Education (CAPE)
Outcomes and American Council on Pharmaceutical Education (ACPE) Accreditation Standards both
advocate for the inclusion of IPEs into pharmacy curricula. IPEs are designed to provide students
with baseline experiences in relationship and confidence building, empathy, concern, and caring for
patients. They are meant to positively socialize students into health care professions and often include
service-learning experiences, shadowing programs, and interactions with other health care agencies,
health care providers, and their students. IPEs can set the tone for professionalism in a program and
can truly serve as the arena where students practice the tenets of professionalism of which they are
learning. The role of the preceptors in these experiences is critical to positive socialization of students
in their future roles as care providers.
Advanced Practice Experiences (APEs). The Advanced Practice Experiences (APEs) serve as capstones
to student academic understanding and performance with respect to the overall teachings of the pharmacy
curriculum. APEs provide the venue for students to demonstrate their mastery of didactic information
through application of information in a manner that is reflective of the professional expectations, and in a
health care environment that provides direct patient care or other services. APEs are positioned at the end
of curricular training and should expose and prepare the student to become effective and efficient in the
delivery of pharmaceutical care that optimizes positive health outcomes.
The role of practitioners in APEs is to stimulate student growth and development, challenge student
understanding and practice of medication review, and provide the opportunity for students to hone their
abilities to demonstrate caring, empathy, and compassion to patients served. It is during this period in
students’ training that students most notably develop and accept the life-long commitment to the
responsibilities to patients, pharmacy colleagues, the profession, and society as a whole. Preceptors
should provide not only the environment but also the appropriate attitudes and behaviors that invite
students to explore their health care belief systems and emulate the positive behavior that is modeled by
the practitioner and required by the profession.
Guided, purposeful practice experiences like IPEs and APEs are invaluable to the training and
development of future pharmacists. However, there are several challenges that schools face when
maintaining the high quality of these experiences. There are much greater demands on pharmacists
and pharmacy sites with staffing shortages, increased pharmacy school enrollments and the opening
of additional pharmacy schools. Experiential coordinators, practitioners, and pharmacy faculty will
need to be creative with their efforts to ensure that the quality and quantity of these experiences
does not diminish.
Role of students. One cannot underestimate the power of students to socialize each other, most notably the
influence of upperclassmen on lower classmen. What is the ‘student culture’
within a school’s program – the culture that most faculty members are usually
unaware? Is it considered taboo to ‘rat’ on a fellow student who was cheating
on an exam? Is it ‘uncool’ to join pharmacy student organizations? Are the
‘geeks’ the only ones who study hard and perform well academically? Of course
the converse can also be true – students may uphold high standards for themselves and their
colleagues and may strive to achieve beyond most faculty members’ expectations of them.
Most often, the student culture tends to mimic the school’s culture and is also a reflection of the level of involvement of the faculty with students. Faculty who
highly engage students and serve as mentors and role models for them will most often promote a professional
culture.
Students must be actively involved with this professionalization process, both their own and that of
others; they cannot idly stand by and expect professionalism to wash over them during their pharmacy
education. Wrestling with professional issues that arise in the classroom, laboratory or experiential site
takes work. As discussed in other sections of this paper, student organizations and involvement in school-wide
committees are essential in this professional socialization process.
Professionalism: A National Focus
Some authors have suggested that if the mission of the profession of pharmacy is for practitioners
to provide pharmaceutical care, then the socialization process of students becoming professionals needs
to be significantly improved.17,26,51 Currently, many schools and colleges of pharmacy are struggling with the challenges of how to
improve and strengthen this professional socialization process. Several examples of recent pharmacy-related
initiatives are briefly described below. Only a sample of the wide-range efforts put forth by faculty,
practitioners and students are listed. Many other programs exist to promote professionalism but could not
be mentioned due to space constraints. The efforts of individual schools and colleges of pharmacy are
mentioned in the Factors section of this paper. Readers are also encouraged to review the referenced
literature to learn more about these exciting new initiatives.
Task Force on Professionalism. In 1993, the Council of Deans of AACP and the Academy of Students
of Pharmacy of the American Pharmaceutical Association (APhA-ASP) established the Task Force on Professionalism to study and promote pharmacy student professionalism within pharmacy education and
practice. The Task Force met over a 5-year period and issued a final report that included several
recommendations for both pharmacy practice and education.17 Its report stimulated significant activity within schools and colleges of pharmacy and as well as
within practice organizations. The Task Force developed a Pledge of Professionalism that is typically administered to entering students as they enter the professional curriculum.
The Task Force also revised the Oath of a Pharmacist and developed an accompanying Commentary to the Oath of a Pharmacist. Both organizations’ Board of Directors eventually adopted the
Pledge and the revised Oath. In early 2003, a new AACP/APhA Ad Hoc Committee on Student
Professionalism was created to assess what has happened since the work of the initial Task Force
and to focus on additional practice issues. The new committee hopes to collaborate with several
of the professional organizations within pharmacy to promote professionalism within students, faculty,
and practitioners.
APhA-ASP initiatives. Exploring elements of professionalism is an important priority for the current
leadership within ASP. In addition to re-establishing the previously mentioned Ad Hoc Committee on
Student Professionalism, ASP is planning programming at future annual meetings and upcoming regional
Mid-year Regional Meetings (MRMs). The September/October 2002 issue of ASP’s Pharmacy Student magazine was devoted specifically to professionalism.52 ASP is also working on developing a professionalism ‘tool kit’ to help member chapters create
professionalism initiatives in their respective programs.
SNPhA initiatives. The student chapters of the National Pharmaceutical Association (SNPhA) have
also been active in developing professionalism amongst pharmacy students. The Bridging the Gap program
is one successful initiative that encourages student-practitioner relationships.53 In this program, practicing pharmacists serve as mentors and role models to students. The program
also stimulates students to become involved in professional organizations and to become advocates for the
profession.
AACP initiatives. AACP and its members have provided additional leadership in the study of
professionalism. The depth and breath of programming and the type of articles being published in
its journal provide evidence of this leadership. A review of the topic index of the American Journal of Pharmaceutical Education reveals that several manuscripts deal directly or indirectly with
professionalism. In fact, three recent papers that were winners of the AACP Lyman Award dealt with professionalism, including the paper by Hammer and her colleagues, that focused on defining
and measuring ‘behavioral professionalism’ of pharmacy students.27 In 2001 Brown and colleagues integrated student-centered learning with cognitive/didactic
teachings (related to pharmacy practice) to develop affective skills, which directly influence professional
development.54 The most recent Lyman Award winning paper, received by Ried and his colleagues, examined
student perception of their professional development and included items such as ability to provide
professional, ethical, and compassionate care; demonstrate appropriate interpersonal skills; and assume
leadership positions.55 Additionally, many of the AACP Innovations in Teaching award winners have developed curricula
and processes that help to develop certain aspects of professionalism in students through didactic and
experiential training.
Recent AACP programs have explored this important topic in a variety of venues. The Teachers’ Seminar at the annual 2000 meeting in San Diego involved several presentations on professionalism and
civility.29,56-58 The sessions were well attended and generated significant discussion and interest by members of
the academy. A Special Forum on Professionalism was conducted at the annual AACP meeting in Kansas
City in 2002. Over 50 AACP members and guests attended the session. Discussion centered around
defining and assessing professionalism and as well as teaching the concepts of professionalism throughout
the curriculum in both the didactic and experiential components. Attendees shared their experiences,
both positive and challenging. Programming at the 2003 Annual Meeting in Minneapolis included a
discussion of this paper, as well as a joint special session and Curriculum SIG program about professionalism
in pharmacy education.
The Association has also addressed professionalism in its important CAPE Outcomes document. The
CAPE Advisory Panel on Educational Outcomes originally developed a list of professional practice-based
outcomes in 1994. These outcomes were further revised in 1998. Many outcomes relate indirectly to
professionalism and Section I-G mentions professionalism specifically.59
“Display the attitudes, habits, and values required to render pharmaceutical care.
1. Provide pharmaceutical care ethically and compassionately.
a. Give the well being of the
patient highest consideration in provision of pharmaceutical care.
b. Exhibit empathy and a
caring attitude when dealing with patients.
c. Facilitate the resolution
of ethical dilemmas in the provision of optimal pharmaceutical care.
d. Respect the dignity
and autonomy of individual patients.
2. Provide pharmaceutical care in a professional manner.
a. Dress and speak
in ways that convey a professional image.
b. Maintain personal
self-control and professional decorum.”
In addition, the CAPE Outcomes document lists several “General Ability-Based Outcomes” that
identify specific behaviors and abilities needed by pharmacy graduates. Several of these ability-based
outcomes involve elements of professionalism, such as Communication, Value and Ethical Decision
Making, Social and Contextual Awareness, Social Responsibility, Social Interaction, and Self-learning.
Other initiatives/examples of professionalism focus. In addition to the numerous references
and initiatives previously discussed, articles about professionalism or particular aspects of it can be
found in pharmacy lay literature as well as in academic/professional literature. One need only do a
search on professionalism and related terms in the appropriate databases to bring up these references,
which are too numerous to list here. This again reflects the importance of professionalism to education
as well as practice. At the agency level, the National Association of Boards of Pharmacy (NABP) has
also been concerned with professional development of pharmacy students as evidenced by informal
discussions at some of their district meetings, and ACPE Accreditation Standards also contain language
about professional attitudes and behaviors for students as well as faculty.60 Other health care professions are also interested in professionalism and have developed programs
to address it in the context of their practice and educational process. These initiatives are seen in
movements like the Medical Professionalism Project.19 Additionally, the June 2002 issue of Academic Medicine was devoted entirely to professionalism in medical education and practice.61
Harry S. Truman once commented "There is nothing new in the world except the history you
do not know." It will be interesting to see what future initiatives develop, what impact they will have
on future patients, students and practitioners, and how history will judge our efforts.
Historically, pharmacists have moved toward a higher level of professionalism as the profession
has evolved from those who compounded medications to those who know more at about medication
than most prescribers. Education changed from brief apprenticeships to several years of formal university
education; policies were defined to ensure continuing education; and professional associations and
self-governing bodies were established and continue to grow. Although pharmacy has grown as a
profession since its inception, many consider that it still has a long way to go to achieve its potential.
Others purport that pharmacy’s professionalism has declined in recent years due to heavy regulation
and a ‘business’ versus ‘patient’ orientation. This section briefly describes the relationship of
professionalism to the profession’s mission of pharmaceutical care as well as to direct patient care.
Relationship of Professionalism to Pharmaceutical Care
Most often, the current state of pharmacy practice does not fully demonstrate the model of
pharmaceutical care. The American Pharmacists’ Association states that in order to practice
pharmaceutical care, five things must occur:62
A professional relationship must be established and maintained,
Patient-specific medical information must be collected, organized, recorded, and maintained,
Patient-specific medical information must be evaluated and a drug therapy plan developed
mutually with the patient,
The pharmacist assures that the patient has all supplies, information and knowledge necessary
to carry out the drug therapy plan,
The pharmacist reviews, monitors, and modifies the therapeutic plan as necessary and
appropriate, in concert with the patient and healthcare team.
Most pharmacists do not perform all of these activities. Patients are ‘customers,’ medications are
‘drugs,’ and pharmacies are ‘drug stores,’ if they are a stand-alone business. Most pharmacists are involved
in the technical preparation and dispensing medication orders and trying to facilitate payment for these
orders via on-line adjudication of claims. If this latter type of practice is truly the norm for the profession
of pharmacy, then it is no surprise that other health care providers, patients, insurance executives, and
policy makers do not understand that pharmacists can provide a much higher level of service to patients.
If pharmaceutical care was the norm for the practice of pharmacy, then theory would dictate that
the profession and its members have achieved greater status of the structural and attitudinal attributes
of professionalism described earlier in this paper. Pharmacists would be performing more autonomously
and rendering more patient-specific services; they may have a higher level of education such as a PharmD
versus a Bachelor’s degree, and possibly post-graduate education; they would have more authority for the
“definition, organization and performance of work,” instead of their work being determined by others
outside the profession. They may feel more of a “sense of calling” to the profession if they are truly able
to make a difference in a patient’s life versus simply providing a product.
Behaviorally, if all of the above structural and attitudinal factors were in place, the practice of
pharmaceutical care should inspire more pride in the profession and more frequent demonstrations of
integrity, ethics, caring, empathy, responsibility, and putting patients’ needs above one’s own.
Pharmacy professionals would engage in life-long learning behaviors and maintain a high level of
competency in order to better serve patients. They may demonstrate more courtesy and respect
toward others because that is what is expected of them. The movement toward pharmaceutical care should, in theory, invoke a greater professionalism for the profession of pharmacy.
Relationship of Professionalism to Direct Patient Care
Professionalism, or lack thereof, can greatly affect patient care in number of ways. Patient satisfaction with health care services increases when patients feel like they are being cared for, receiving
individualized attention and a high level of service. Patient adherence to therapeutic regimens is also enhanced when pharmacists are able to be a part of the therapy
decision-making process, take the time to help educate patients about the therapies, and monitor
patients’ progress. Medication errors are reduced when pharmacists are able to aid in prescribing decisions as well as practice in environments
that allow for thoughtful, high levels of care as opposed to chaotic dispensing of medications. Workloads can be modified to allow for higher levels of care if pharmacists are in positions to make autonomous
decisions regarding practice environment and workflow. Additionally, pharmacists exhibiting higher levels
of professionalism could be expected to demonstrate higher levels of respect, ethical behavior, empathy,
and competence toward patients; these behaviors support greater quality in patient care.
This section describes some of the challenges to development of student professionalism, some
of which have already been mentioned. Areas to be explored include lack of desire to confront peers,
the effects of learning and practice environments and the role models within them, patient/societal
expectations, and the lack of clear definitions and best practices.
Peer Pressure
Difficulty in making a long-lasting impact on student professionalism can also be attributed to the
lack of various members of the profession accepting and participating in their role of self-regulation of
professional expectations and requirements. Unfortunately the limited peer pressure among practitioners,
faculty, and students alike makes it hard to develop professionalism among pharmacy students. Although
one of the hallmarks of professions is that they are self-regulated and self-governing, it is difficult for people
to consciously ‘rat’ on or confront a colleague on the grounds of unprofessional behavior, even if pharmacy
law requires it. Human nature dictates that people do not want to be identified as ‘tattle-tales’ or
‘goody-two-shoes,’ and that it is very difficult to try to diplomatically and respectfully confront a peer.
Traditionally, pharmacy practitioners are not very good at “policing” one another and participating in
professional citizenship. Instead, practitioners tend to prefer having a consumer, patient, or administrator
identify, initiate, and bring forth allegations of unprofessional actions and respond to them reactively
versus proactively (eg, completion of a customer comment card to report an infraction of professional
expectations).
It is equally as difficult for faculty members and students to confront unprofessional peer behavior.
When faculty members are aware of colleagues who are not appropriately modeling professional expectations
in their relationships with each other or in interactions with students it is rare and often with great
hesitation that they take action on these feelings. Students are no different. Diligent and more attentive
students may approach faculty members to take action against disruptive students, eg, those chattering
during lecture or arriving late to class. When students witness peers cheating on an exam or assignment
the likelihood of confrontation or reporting the incident to an authority is low. Honor codes and
professional conduct committees, designed to enforce and maintain appropriate professional decorum,
have not always lessened the negative connotations associated with the self-regulation process. The
difficulty in addressing and affecting peer pressure presents an important challenge to the development
of student professionalism.
Environmental Effects
Environmental surroundings influence socialization. Academic institutions and practice environments
can have the greatest impact on pharmacy student socialization. The impact that these “training grounds”
have on the impressionable and developing minds and practices of pharmacy students is easy to
underestimate.
Academic institutions. Within academic institutions there are a number of factors that can contribute
to the detriment of student professionalism. Inconsistent policies, unprofessional behavior by faculty, staff,
and administrators, and no visible method to discipline inappropriate and/or award appropriate professional
behavior can be an arduous challenge in the development of professionally aware students and practitioners.
If the academic environment does not support professionalism in both its academic and non-academic
activities then the ability to foster and develop professionalism in pharmacy students is greatly hindered.
For example, the environment of the school should embrace respect for all departments and individual
contributions and demonstrate and acknowledge appropriately those members of the institution who abide
by and enhance the professional culture of the academic institution. Likewise, the institution should also
equally identify and reprimand those departments, faculty, staff, and administrators whose behavior, attitude,
and/or policies are not in keeping with professional expectations. Unfortunately, the traditional incentives
of accreditation processes, promotion and tenure criteria do not necessitate strict adherence to policies
to enhance professionalism in school programs.
There may also exist other sorts of ‘environmental’ factors that challenge the development of
professionalism.29 Are the educational processes through which students must navigate well organized and efficient?
How does the school communicate with its students? Processes such as course registration,
purchase/retrieval of texts and course materials, and receipt of grades all reflect on the professionalism
of the school.
The physical environment of the school also reflects on its professionalism. Is the learning
environment professional? Are classrooms, equipment and materials updated and reflect professional
practice? In general, does the environment of the school encourage students to achieve their full
professional potential? Although resources are not always plentiful it is important that schools present
a professional image to help foster professionalism in its students and personnel.
Practice environments. Community pharmacy practice is perpetually displayed to society and
reinforced by pharmacists and pharmacy support personnel in their frequent interactions with the
public. Unfortunately, there are several examples of obvious challenges in this pharmacy environment
that are in direct conflict with the basic tenets of professionalism. A number of factors can either
enhance or detract from a pharmacy’s professional image, and thus may have the same effects on
pharmacy students working/learning in that site.63 Many of these factors also apply to other sorts of pharmacy environments, such as hospitals.
Some questions to ask to identify these factors are: where is the physical pharmacy located – in a
grocery store, mini-mart, warehouse, basement or website? Does it have a drive-through window like fast
food restaurants and espresso stands? When people walk into a pharmacy, what do they see? Are the
shelves clean, neat and organized? What kind of inventory does the store carry? Are there items that
are not necessarily health-care related or worse yet, may be detrimental to one’s health? What about
staff? Are they easily identifiable? Are they dressed in a manner to earn patients’ respect? Is their
demeanor such that they are helpful and respectful toward patients? Is there a clean and comfortable
waiting area? Are there educational materials available for patients to peruse while they wait? Are there
private areas for consultations or other services with the pharmacists? How do patients move through
the workflow in the pharmacy (ie, intake, output): do they stand in one line? take a number? make an
appointment? How about the workflow in the pharmacy itself? Are pharmacists, technicians and clerks
tripping over one another? Are shelves neat, clean, organized? Is there a logical, organized workflow
pattern? Does each employee adhere to his/her specific tasks? Does each employee even have specific tasks to adhere to? Are tasks assigned in such a way to make the best use of
pharmacists,’ technicians’ and clerks’ education, training,
skills, and expertise? Are pharmacists able to engage in clinical activities other than the filling
of prescriptions and online adjudication of insurance claims? Do pharmacists and other pharmacy
staff members demonstrate a positive and professional attitude about their practice?
This list of questions could seemingly be endless and perhaps is endless when all of the factors that
affect people’s image of a person or environment are delineated.
The marketplace desire to acquiesce to the convenience factor of consumers has led to and
encourages the belief and support of convenient pharmacy services that focuses on providing the
product (commodity) quickly at the expense of quality and value-added education, counseling and
other professional services that pharmacy professionals offer. From a student’s perspective, being
trained in today’s marketplace places a greater value on revenue and not on the delivery of
professional service. The fiercely competitive business of pharmacy uses the immediate dollar in
hand as the measure of success instead of the increased respect and enhanced relationship that
occurs when pharmacists make a connection with their patients that fosters more stable and
long-lasting financial impacts. Many pharmacists estimate their ‘professional worth’ by the number
of prescriptions they have filled versus the number of patients for which they have cared. The
resulting focus of students trained and exposed in this marketplace is not on the patient and
positive health outcomes, but on the customer and the positive revenue stream for the pharmacy’s
bottom line.
Patient Behaviors and Societal Expectations
One of the greatest challenges that has been overlooked to a certain extent is the pressure to
increase professionalism, or lack of pressure, from patients and the public. This issue can be discussed
in two ways. First, because of the current state of pharmacy practice and how pharmacy is portrayed
in the media, the general public may not have high expectations for pharmacists. Sure, patients want
their prescriptions filled correctly and quickly, but they may not expect to be educated by their
pharmacists, nor care if the pharmacist wears a white coat and dresses professionally. They may not
care to have their pharmacists get to know them or become more involved in their health care. These
perceptions can be further compounded if the practice environment itself is not very professional.
Second, patients may not even want their pharmacists to provide services other than filling prescriptions
quickly and accurately. Even if pharmacists try to counsel their patients, many patients are in a hurry
and do not want to stay and listen. This can be discouraging to pharmacists so they might ask
themselves, “why bother?”
Related to these behaviors is the lack of respect sometimes demonstrated by patients and other
health care professionals in their interactions with pharmacists. If patients are rude and difficult with
pharmacists, if pharmacists are yelled at by physicians or nurses over the phone, these events can also
be discouraging and make it even more difficult for pharmacists to continue to act in a manner of polite
service to these parties. The more often pharmacists are treated this way the more difficult it is to try
to maintain respect and professional behaviors towards patients and others.
Lack of Definition and Focus
Definitions of professionalism and its different aspects and attributes were discussed in a previous
section. Part of the reason why it is difficult to develop professionalism in students is that a consensus
definition of professionalism does not exist. Many faculty members and preceptors may interpret
professionalism in different ways, thus making its’ development potentially inconsistent and erratic.
This is based on the assumption that they are even trying to instill professionalism in students, which is
another challenge in and of itself. Although it may be difficult to agree on exactly what professionalism
is, it is still important that groups engage in this dialogue and be very specific about the attributes they
want to develop in students in order to begin to strategically plan how to instill professionalism.
Lack of Evidence
An even greater challenge is the lack of solid evidence as to what works. It is extremely difficult
to conduct a randomized, double blind, placebo-controlled study to see which ‘treatments’ best develop
professionalism in students. In addition to measurement challenges, there are not a lot of grant resources
devoted to trying to conduct professionalism studies. Most of the evidence described in the literature,
such as the references in this paper, is anecdotal and based on theoretical recommendations. This is not to say that this evidence is not valuable, it is just not as ‘objective’ as some
would like in order to help them make rational decisions about their programs. Some schools are currently
undertaking measures to analyze differences in students’ levels of professionalism and trying to
ascertain if there are any independent correlates to those outcomes. These endeavors may provide the
academy with possible reasons why some students develop professionally to a greater extent than others.
Based on the challenges described above, it is evident that many factors need to support the
development of professionalism in schools of pharmacy. This section describes the necessary steps to
take to build the foundation for professionalism in schools of pharmacy as well as approaches to improve
schools’ cultures in a variety of programmatic aspects. These approaches affect students as well as faculty,
staff, and administrators.
Educate the Educators
In order to support student achievement of professional curricular outcomes the culture within
the school of pharmacy must exude professional expectations and excellence. This culture requires a
“top down” and “bottom up” commitment and appreciation for all aspects of professionalism. The
first and most important step to creating the culture of professional expectations and excellence is
to ensure that upper administration (deans, department chairs and other administrators) believes and
whole-heartedly supports professional excellence. They must encourage, support, and perhaps require efforts to enhance professionalism in all aspects of their programs, including professional behaviors
of faculty and staff. From the “bottom,” students must embrace the development of professionalism
as required of them to become professionals and participate sincerely in efforts designed to enhance
their professional socialization. Faculty, preceptors, other practitioners, and staff, the middle of the
‘academic sandwich,’ must also work to emulate professionalism and support the efforts undertaken
to improve it in all aspects of academic and professional training. Efforts to enhance professionalism
in an academic program will not succeed to their potential if one or more of these parties is
uncooperative.
“It only takes a spark. . .” One or two people, believing in professionalism, can take the lead to
improve it in their schools. Students can set up programs, faculty can serve as role models and infuse
professionalism into their courses, and administrators can create policies and promote professionalism
as part of faculty development. However, the most successful efforts will be those that involve people
with the power and authority to make decisions about school programs, committees, and policies (ie,
deans). For example, the dean at one school of pharmacy appointed a committee of administrators,
faculty, practitioners, and students to analyze the professional development of its students and faculty
and make recommendations as to how to enhance professionalism in all aspects of the program.64 The work of this committee has served as the foundation of cultural change at that institution.
Changes made in the program based on the committee’s recommendations are being internalized as the
norm instead of the exception. Although not everyone involved in the school’s program may
wholeheartedly support the changes, the majority of administrators, faculty, preceptors and students
are working together to make the program better. This process of ‘buy-in’ included education, training,
and discussion of all parties involved. There was also significant brainstorming, planning and implementation
of different ideas by many different people, thus strengthening the ‘professionalism threads’ that are
being ‘woven into the fabric’ of the school.
If the mission of schools of pharmacy is to develop practitioners of pharmaceutical care, then
professional development must be the priority for the school. Technical competence is only a subset of professional development. All areas of the school must support, reinforce and affirm a culture of
professionalism. This requires a substantial commitment from the school’s leadership. The school’s
programs and personnel and affiliate personnel must support and engage in this mission. Once the
administration of the school embraces the mission and the resulting culture of the institution to
reflect a commitment to professional development, it becomes much easier to realize the goal of
professional development. All objectives, goals, and measurable outcomes from the school should
directly reflect facilitation of professional development. In addition, all programs and initiatives that
are supported by the school’s administration should embody professional development. For example,
orientation sessions for new faculty as well as new students could focus on how the school operates
to facilitate student and faculty professional development. These kinds of programs assist in driving
home the point that professional development is important and the reason for the school’s existence.
The majority of schools are evaluated academically (and assess themselves) on the ability of their
students to demonstrate pharmacy expertise via technical skills or knowledge. This is further reinforced
by the licensure process that uses a standardized, knowledge-based examination versus a performance-based
system. If a school embraces the concept that the demonstration of professional development is the gold
standard for pharmacy student training, then emphasis on internal performance-based abilities must be
present and paramount. This change in thinking, feeling, and evaluating school performance and success
would not come quickly nor easily particularly since it is contrary to what is presently accepted and
practiced across the country. It will require great courage, belief, and endurance to see the change in
thinking embraced by all parties involved: students, faculty, administration, staff, and preceptors. Once
there is consistency and continuity in the culture and sub-cultures, professional development can grow
and flourish. Additional activities can be implemented and the fruits of the labor will become evident.
Changing the Culture
Professional socialization is a process that must engage the entire organization for it to be optimally
effective.65 While most pharmacy curricula focus on technical competence (even though they may include
subject matter such as ethics and professionalism) a 360-degree, holistic approach to professional
socialization is essential if students and faculty are to become immersed in a culture that promotes the
transformation. The introduction to this section discussed the need to get buy-in and support from
members of all parties involved and affected by change, especially those in leadership positions.
The following two sections discuss some specific ideas related to culture change where ‘grassroots’
improvements can be made to affect students as well as faculty, staff, administrators and preceptors.
Specific areas in schools’ programs that directly affect the professionalism of students. This section describes areas of schools’ programs where significant improvements
can be made in the positive professional socialization of students: recruitment, admissions, environment,
orientation, curriculum, experiential program, extracurricular activities, awards, academic progression,
and role modeling/mentoring.
Recruitment. Professional development begins with exposing potential students and faculty to the
values that are important to the profession and the school. Schools can hire professional recruiters to
help them with these efforts or work on them with their own staffs. Efforts should be made to more actively
market the profession and the school and to expose students in junior colleges, four-year institutions,
and K-12 programs to the profession in general, and to the school’s program, depending on the audience.
Emphasis should be placed on the caring aspects of practice, contribution to society, the pharmacist
shortage, and opportunities. Pre-pharmacy student clubs should be visited by
faculty, practitioners, and pharmacy students who make presentations on professionalism, the school’s
programs and curricula, pre-pharmacy coursework, the interview process for admissions, and the school’s
experiential programs. The school’s website should also reflect these emphases.
In order to recruit applicants with “exceptional professional potential,” the White Paper on Pharmacy Student Professionalism recommended emphasizing the professional roles of students and
pharmacists during open houses and other recruitment events, incorporating professional codes into
recruitment literature (such as the Oath of a Pharmacist, Code of Ethics and Pledge of Professionalism),
informing “feeder” programs of the qualities desired in pharmacists and pharmacy students, and
encouraging potential applicants to get involved in student professional organizations, if possible.17 Some examples of this include a school having a working relationship with its feeder schools so
that qualified students earn Bachelor’s and Pharm.D. degrees concurrently, which serves as a powerful
recruiting tool.66 Another school works with local retail pharmacy corporations to enroll high school students into
a didactic and experiential ‘institute’ that aims to help them eventually matriculate into the school’s
professional program.67 A third school reports that implementation of some of the recommendations described has resulted
in a significantly increased (nearly doubled) applicant pool along with a much greater percentage of
students with previous degrees.64
Admissions. The admissions process is another opportunity to inculcate professional attitudes
and values in students, help them understand what is important to the school, and assess the student’s
initial attitudes and values. Many schools have looked beyond traditional admissions criteria such as
grade point average and Pharmacy College Admissions Test (PCAT) scores as the best measures of
applicant’s potential and appropriateness for admission to a professional program. Numerous schools
have incorporated personal interviews, group interaction activities, impromptu essays, various
inventories, and external recommendations as features of the applications and admissions processes.
Others have included demonstration of involvement in extracurricular activities, previous pharmacy
experience, and/or community service as criteria for application and admission. One school actually
implemented a program that requires applicants to complete an 80-hour shadowing component prior
to admission to the school.68
The movement to collect more qualitative data in addition to traditional, quantitative data may
be partially facilitated by the revised ACPE Accreditation Standards.60 Guideline 16.3 reads:
“Admissions criteria, policies, and procedures should give consideration not only
to scholastic accomplishments, but also to other factors such as motivation, industry, and communication
capabilities that show the student's potential to become a life-long learner and an effective professional.
Efforts should be made in the selection of students to foster diversity.”
The White Paper on Pharmacy Student Professionalism echoes this recommendation by elucidating several recommendations:17
Adopt admissions criteria based on professional outcomes desired upon graduation
Assess admissions screening processes for their ability to select students with a high level
of professionalism
Evaluate candidates’ humanistic qualities that will be predictors of success in . . . patient
care activities
Utilize instruments such as interviews and essays that assess professional qualities
Involve current professional students and practitioners in the admissions process.
The PharmCAS centralized application service sponsored by AACP also includes language about
professional behavior: “Pharmacy applicants are expected to act professionally in all of their dealings
with PharmCAS and all colleges and schools of pharmacy. Applicants are expected to follow instructions
properly and meet deadlines. Responsible behavior, respect for others, good judgment, and cooperation
are qualities valued by the pharmacy profession. Applicants should demonstrate these qualities beginning
with the application process."69
It is important that schools evaluate incoming student data against outcomes data to help refine
and revise the admissions process. For example, one school performing a preliminary data analysis has
found that applicants’ interviews scores were the greatest predictor of honors grades in clerkships,
thus lending credibility to the interview process.70
School environment. Although the personnel and students in the school are the keys to creating
a professional culture, there are environmental factors that can promote professionalism. As mentioned
in the Challenges section, educational processes such as course registration, purchase/retrieval of texts
and course materials, and receipt of grades should be well organized and efficient. The school’s physical
facilities should be neat, clean, and up-to-date, as well as equipment and materials. Websites should be
continually maintained and updated. Supporting a professional physical environment can go a long way
in enhancing professionalism of students and school staff.
Orientation. Orientation programs should allow new students to begin to understand and
experience the culture of the school of pharmacy as well as the profession. During these introductory
programs, many schools discuss the roles and responsibilities of pharmacists including the Oath of a Pharmacist and Code of Ethics for Pharmacists. Several schools also have students recite the Pledge of Professionalism for pharmacy students or have students create their own pledge. Other programs
have students create their own personal SOAP note71 or mission statement.64 Many schools’ orientation programs culminate in a “white coat ceremony” where students
receive their white lab coats from a high-level school administrator or pharmacy organization leader
as friends and family look on. Some schools’ programs also include a number of workshops designed
to introduce students to the curricula, faculty, and upperclassmen, and to help them begin to develop
skills necessary for success in the program and the profession.72-74
Curriculum. For professionalism to be considered seriously, it must be taught in the curriculum.75 It must be clear how coursework fits with and fosters professional development; classroom theory
and content need to address real-life experiences of students so that formal training is relevant and comes
alive for the student.65 Otherwise, these types of experiences may actually cause students to become disengaged or
cynical.76
There are multiple opportunities to infuse professionalism ‘training and education’ into didactic
portions of curricula. This can be done via content and process. Students should learn about the
concepts of professionalism and professional socialization early in their academic careers so that they
understand and appreciate the goals which they are trying to achieve and that pharmacy education is
not just about learning knowledge. It is important to help students understand what constitutes these
broad concepts and how they apply to them as professional pharmacy students and future practitioners.
Care should be taken to let students discuss their perceptions of professionalism and professional
socialization with the guidance of faculty members and practitioners who can help to elucidate broader
historical, literary, and practical perspectives. Traditional courses in ethics are examples of this sort of
content. Another example is a pediatric medical residency program at the University of Washington
that holds a five-day professionalism retreat for its residents. Workshops include team building,
ethics, interpersonal communication skills as well as other topics.77 The liberal and humanistic aspects of pharmacy curricula should also be developed or more
heavily emphasized since these courses more overtly develop attributes of professionalism and students’
abilities.
While including content about professionalism and professional socialization into a curriculum
is important, this is not enough for students to begin to internalize and demonstrate the professional
behaviors desired of a professional student and future practicing pharmacist. Care must be taken to
actively facilitate the process of professional socialization into a school’s program. This can be done
didactically by integrating professionalism-type activities into existing courses and laboratories.
Examples include establishing a dress code for certain courses or for the entire program; incorporating
demonstration of professional behaviors as part of the course grade/requirements; having students
prepare and be accountable for individual professional development plans; evaluate and provide
feedback on students’ professional behaviors; initiating speaker’s or seminar series on topics related
to professionalism/professional development; encouraging/requiring student involvement in community
service and professional organization activities; fostering active participation of role-model practitioners
and helpful patients; and the list goes on. Assignments that require students to research information
outside of class notes or texts, group exams and projects, and rescheduling of exams during
professional organization meetings are additional examples of helping to develop and foster
professional behaviors in students.
A number of pharmacy schools have been successful at integrating professional socialization
activities and courses throughout the entire PharmD curriculum.64,78-82 One school (and probably others) even uses common language for professional behavior and
related policies in all course syllabi.83 Additionally, smaller class size and active learning (eg, laboratory courses) promote greater
faculty interaction with students and socialization. Efforts should be made to increase these activities
throughout the didactic curriculum.
Experiential programs. As a reflection of the revised ACPE accreditation standards and other
recommendations, most schools have incorporated IPEs into their didactic curricula and have maintained
or enhanced the APEs, or clerkship component. Both sets of experiential programs provide invaluable
opportunities to help students learn about what it means to be a professional. IPEs involve a range of
activities, from shadowing programs to service learning activities to following real patients for the
duration of students’ academic careers. To ensure the maximum benefit to students through experiential
programs, several things should occur:29
Professional role models: Preceptors, residents and others with whom the students interact should demonstrate the
desired professional behaviors.
Professional practice environments: Practice environments should present a professional image and facilitate healthy patient
and practitioner behavior, not detract from it.
Preceptor discussion with students regarding professional behavior: Perhaps most effective in helping students to understand professional behavior are
preceptors’ individual discussions with students about behavioral issues. Are preceptors willing
and able to address a student’s behavioral strengths and weaknesses with that student? Is there
a systematic process in place for preceptors to do this?
Clear expectations and evaluation methods: Related to the above, expectations for student behavior and the method(s) in which they
are evaluated or assessed need to be made explicit to them.
Consistency in Evaluations: Those who complete student evaluations need to use the evaluation instruments correctly.
For example, a particular evaluation instrument includes a criterion about “professional attire” and
utilizes a rating scale of “below expectations,” “meets expectations,” or “exceeds expectations.”
Are all preceptors in agreement as to what each of the ratings mean with regard to that criterion?
One method to help achieve better inter-rater reliability is to have preceptors create the evaluation
tools together, or at minimum, discuss the appropriate use of the school’s evaluation tools.
Weight of behavioral evaluation: Does evaluation of student professional behavior have sufficient weighting in the overall
evaluation process so that students and preceptors take it seriously?
Early identification: Is there any form of behavioral assessment prior to the end of the rotation so that strengths
and weaknesses can be identified earlier? Better yet, are there behavioral evaluations associated
with early practice experiences in the curriculum? Many times experiential program administrators
receive calls from preceptors expressing concern about a student’s behavior. Chances are that
the student’s behavior has not been previously identified by the school as being problematic, or
if it was, possibly no intervention occurred. As more schools implement practice experiences
earlier in their curricula, identification of students’ strengths and weaknesses with regard to
professional behavior can occur earlier in our programs and perhaps in a more systematic fashion.
In addition to these suggestions, the White Paper on Pharmacy Student Professionalism recommended specific activities to enhance the professional socialization of students during the
experiential components of the curriculum:17
Involve preceptors in the formation of professional development outcomes and methods
to achieve [and measure] those outcomes,
Implement preceptor training programs that reflect professional issues,
Require preceptor adherence to professional standards,
Encourage preceptors to maintain a professional portfolio,
Solicit student feedback on the professionalism of preceptors, and
Give preceptor awards and site development grants to recognize professionalism
in practice.
Extracurricular activities. An obvious component of student professional development is
involvement in pharmacy organizations. Some schools automatically enroll students into pharmacy
student organizations upon admission to the school – the membership dues are part of the students’
professional fees.84,85 Others highly promote student involvement in a variety of extracurricular activities and try to
arrange curricular schedules to foster this participation. The ACPE Accreditation Standard that describes
student/faculty relationships, Guideline 22.1, states:60
“Faculty should actively encourage student involvement in various professional
organizations, serves as role models, and support student attendance at national, state, and local
meetings. Organized efforts should exist to broaden the horizons of students, including scientific
inquiry, scholarly concern for the profession, and post-graduate education and training, through
such means as guest lecturers, and participation in curricular and extracurricular activities.”
Student organization leadership must select activities that foster professionalism and similarly
discourage those which may erode professionalism.
Examples of other programs designed to foster professional beliefs, attitudes and behaviors
include:
School-wide seminars and programs with nationally recognized leaders in the profession
and other prominent speakers.83,79,86-88
Pharmacy leadership courses – one program is designed to enhance students’ leadership skills
by exposing them to, and/or having them participate in, corporate management, civic government,
and community service projects64; another incorporates leadership training and completion of group projects for students at
two universities89;
Involvement with school-wide committees: most schools encourage student representation
on a wide-variety of their standing committees90; one school even requires students in a communications practicum to serve on a university,
college or program committee86;
These are just a few examples of how students’ professional attitudes and behaviors may be
developed and fostered in extracurricular programs. Ideas also exist on how to get professional
associations and the pharmaceutical industry to aid in these efforts.91
Awards. APhA-ASP sponsors a Mortar and Pestle Professionalism award (supported by McNeil
Pharmaceuticals) to be given to a graduating student at each school of pharmacy, as well as recognizes
one student nationally.92 Winners from each school are eligible to compete in a professionalism essay contest for a
continuing education scholarship. In order to further encourage the development and demonstration
of professional behaviors, schools should establish awards and scholarships to honor those students
who serve as exemplars for others. These awards can be as simple as “student of the month” for each
academic class to more extensive, senior-level awards given at graduation.
Academic progression. If schools of pharmacy are going to treat the development of professional
attitudes and behaviors as the principle goal of the educational enterprise then they must think differently
about what constitutes “passing” the curriculum. In other words, are schools willing to make students
eligible for academic dismissal for unprofessional behaviors even if students have passing grades in all
coursework? Are schools ready to move toward documenting behaviors and attitudes that are not
appropriate and either remediate students or dismiss them if problems of unprofessional conduct
persist?
Several medical schools have adopted protocols for identifying and remediating unprofessional
behaviors. For example, University of New Mexico medical faculty and residents used a pocket-sized card,
the Noncognitive Skills Evaluation Form, to identify students who may be having difficulties in any of
these seven behavioral dimensions: reliability and responsibility, maturity, critique, communication
skills, honesty and integrity, respect for patients, and chemical dependency/mood disorder.93 Students who were identified as having difficulties in any of those areas were followed up for
intervention. The University of California at San Francisco School of Medicine has developed a program for
the early detection of deficiencies in professionalism in their students. “The goals of the system have been
to identify medical students who demonstrate unprofessional behaviors in order to remediate their
deficiencies and to give the school an administrative structure to deal with such behaviors.”75 A Physicianship Evaluation Form is used to identify problem attitudes or behaviors so that a
faculty member and student can engage in a discussion of the problem behavior and what needs to
be done. The goal of this process is to assist students in understanding why the behavior or attitude
is unprofessional so that the student can be helped to improve. If a problem is noted (eg, rude or
disrespectful conduct, student does not take appropriate responsibility in group assignments), a faculty
member or the associate dean meets with the student and discusses the problem. The student is asked
to sign the form, acknowledging that he/she had been contacted about the problem. The student is
given an opportunity to provide information that would allow the Form to be withdrawn by the faculty
member if this is deemed appropriate. If a student receives two or more of these forms during the first
two years of school and then receives another in clerkships, this indicates a serious problem that could
result in academic probation or dismissal.
The important point to the above discussion is that if professional socialization is to be taken
seriously and internalized, it must be evaluated and assessed as seriously as technical competency.
Adequate grade point averages simply are not enough to assure the development of a mature
professional. Most schools already have a system in place in which behaviors such as cheating and
plagiarism are identified and handled. But what happens if a student violates an affective professional
behavior? For example, if a student is observed blatantly disrespecting a fellow student or faculty
member, is that student’s case brought before an honor board or committee to pass judgment
and determine a course of action? Is there language in the school’s academic progression policies
that relate to passing behavioral as well as grade requirements? Inculcation of professionalism into
a school’s program must include discussion about these issues.
Role modeling and mentoring. The idea of role models and mentorship has been alluded to
several times in this paper thus far. It cannot be emphasized enough how important this is to the
process of professional socialization. The most significant predictor of students’ socialization
reported in some literature is students’ role models – both positive and negative.41-47 The importance of mentoring in professional development is also well documented in the
literature.94 The American Society of Health-Systems Pharmacists conducted a series of programs on
mentor-protégé relationships at its 2001 Annual Meeting, and AACP published a brochure on mentoring
in its Academic Life series.95
Mentors are needed to coach, guide, and stretch, or challenge, the student. The mentor-mentee
relationship requires a balance between the mentor helping the mentee obtain self-confidence
and independence and providing enough direction and support to allow confidence to grow. This
is the balance between how much the mentee is stretched and how much the mentee is
supported. Lack of support and stretching produces problems because there is no direction
and no encouragement. Too much support without enough stretching (the mentor spoon feeds
the student) does not develop self-confidence because students never really learn if they can do
what needs to be done independently. Lack of support with high stretching (the mentor does
not provide or assess foundational information and skills) produces too much fear and withdrawal
as a result. Therefore a combination of stretching (challenges within the students abilities) and
support (encouragement, help where needed) is needed to achieve independence and self-confidence.96
This takes time and committed effort on the part of faculty and students. Encouragement is
needed by faculty along with providing a safety net as students learn and mature. That is, students
should be given ample time to practice new skills and concepts. Students, on the other hand, must
be willing to take risks and to try new things in order to learn and stretch. This requires a safe
relationship in which the risks of “failure” are not formidable; and encouragement, understanding
and compassion are part of the process. Of course, maturity and responsibility on the part of students
are also essential.
Most students learn about professional behavior by observing others and thus, they will notice
what individuals do within an environment. If members of a school state that they value professionalism,
but then do not display it in their day-to-day relationships with others, students will clearly see the
hypocrisy and will discount the school’s efforts to promote professionalism. The school’s administration
is especially visible to students since many students hold high expectations for the school’s leaders.
These administrators need to model professionalism in their professional and personal lives. They
must handle situations involving their staffs, faculty, and students in a professional manner. Once
again, if students observe hypocrisy, they will not learn appropriate behavior and may justify inappropriate
behavior by stating that others can get away with it, so why not them?
Faculty must also model appropriate behavior in their actions with students, staff and colleagues.
Faculty members expect a certain level of professional behavior by students in the classroom, but many
unfortunately do not return appropriate behavior to students. Students also observe how faculty
members interact with graduate students, research assistants and other staff members. Inconsistent
messages from faculty promote inappropriate behavior by students.
Preceptor behavior is especially important for the reasons stated in a previous section of this paper.
Students model preceptor behavior once they enter the experiential learning components of their
educational program, as well as in their internships. In fact, preceptors are probably more influential
than faculty since students envision themselves being more like preceptors once they graduate. In the
later stages of the curriculum, students may value preceptor attitudes and behaviors more than faculty’s.
If faculty members stress the need for professional behavior, but practitioners do not display these
behaviors, students will discount the faculty’s message as being academic rhetoric.
Many schools have recognized the need for role modeling and mentorship to facilitate students’
socialization. Schools often utilize individual faculty advisors for a number of purposes such as mentorship
for a student research project, academic and career advising, and seminar development. Two schools
have developed virtual/on-line mentoring programs for their students involving practitioners or faculty.97,98 APhA-ASP and ASHP have also initiated virtual mentor programs for students.99,100 Additionally, schools utilize student networks for mentorship opportunities; senior students
may serve as tutors and mentors to junior students. Regardless of how mentoring programs are
established, it is important that they exist on a number of different levels to help facilitate positive
professional socialization of students.
Specific areas in schools’ programs that directly affect the professionalism of faculty, staff,
preceptors and administrators. Based on the importance of role modeling and mentoring for student
development, it is imperative that schools work to develop appropriate role models and mentors of their
faculty, staff, preceptors and administrators. These efforts would be beneficial not only for student
development but for the recruitment, retention and productivity of these employees (paid and
non-paid). Schools need to consider the following components in order to enhance professional
mentoring.
Recruitment. How does the school recruit new employees and preceptors? Is there discussion
about levels of professionalism and professional expectations? Does the school strategically recruit
those individuals who exhibit high levels of professionalism and would serve as positive role models for
students? Do potential new hires had to have met any prerequisites? Is there any attempt to assess
their level of professionalism before they are hired? Are the school’s efforts related to professionalism
discussed in the recruitment and hiring processes?
Environment. Since the school’s environment, as discussed in the student section, also affects
the behaviors of others working in the school, is there any attempt to assess the impact of the
environment on the level of professionalism? Similarly, practice environments that subtly influence
preceptor behavior should be evaluated.
Orientation. Is there any kind of orientation to the culture of the school? A number of schools
now include an extensive faculty/preceptor orientation to acculturate new hires to the school’s
philosophies, curriculum, expectations of students and faculty, teaching and grant-writing skills, and
promotion and tenure criteria.64,101,102
Professional Development. Are any workshops or retreats related to professionalism in education
as part of the development programs for faculty, staff, preceptors, and administrators? Are employees
encouraged to attend outside education in this area? Many schools and organizations already sponsor
workshops on “how to be a better preceptor.” Do these programs discuss preceptor role in emulating
professionalism? How do these programs evaluate, provide feedback, and encourage development of
student professionalism?
Extracurricular activities. Are faculty and preceptors encouraged to become active participants
in professional organizations and be advisors to student organizations? Are they encouraged to attend
school- or student-sponsored events outside of regularly scheduled class time?
Awards. Does the school sponsor awards that are given to faculty, staff, preceptors, and
administrators that model desired professional behavior? How are these awardees selected? Incentives
and awards for school personnel can help to promote desired behaviors.
Promotion/tenure. Do tenure and promotion or other incentives include emulation of professional
behaviors? Perhaps one of the greatest disincentives for not engaging in professionalism efforts is that
the current reward structure does not demand it. Promotion and tenure criteria should be redesigned
if these efforts are to be expected in school role models.
Faculty mentoring. Is there a program in place to mentor new or junior faculty/preceptors? Do
senior faculty serve as good role models for junior faculty? Literature about the success of new faculty
describes the importance of having senior-level mentorship for junior faculty. A number of schools are
working toward this end to improve retention and success of their junior faculty.103,104 For that matter, all faculty and staff should have continual mentoring and feedback, whether
from a superior or peer.
The purpose of this paper was to provoke thought in the academy about the critical and
comprehensive need to address professionalism in our schools and colleges of pharmacy. Our goal
was to provide a thorough review of the topic and provide suggestions based on evidence,
experience, and expert opinion. The terms have been defined, recommendations are offered
below – now where do you go from here? Hopefully, readers have a clearer picture of what needs
to be done in their school or practice setting. If this message is not clear, it will be like the Mad
Hatter running off to the tea party in Alice in Wonderland: not sure which direction to go and
eventually arriving somewhere. Some schools may need to devote significant effort to implementing
these recommendations, while others will only need to modify existing processes. The key is not to
get overwhelmed, which may be easy to do if schools take to heart that our current cultures and
paradigms need to shift significantly to affect positive change. Similar to implementing pharmaceutical
care in a practice setting, taking small, incremental steps can be an effective strategy when trying to
infuse a culture of professionalism into an entire program. The key is to continue with future steps
and not stop with just one. For example, instituting a white coat ceremony (which many schools
have done to focus on professionalism) will not go a long way to enhance professionalism without
significant changes in other areas. The goal is to develop a comprehensive program that leads to
increased awareness by faculty, students, and preceptors.
In addition, schools and colleges of pharmacy must develop appropriate mechanisms for assessing
professionalism. They must determine what attributes of professionalism will be addressed throughout
their students’ entire educational experience. Institutional objectives should be to produce mature
professionals able to render pharmaceutical care. Curricula that focus on technical proficiency,
‘hoping’ professional socialization will be spontaneous is no longer acceptable. Programmatic outcomes
may need to be redefined, policies regarding faculty and student ‘progression’ edited, and curricula
revised.
The stimulus for change must come from the “top down” with administrators advocating for
change. However, the desire for change must permeate the entire organizational structure. If critical
individuals within the educational experience do not embrace these concepts, efforts to enhance
professionalism will be compromised. Some schools have launched successful programs using professional
development committees or similar groups that help plan, implement, and evaluate change (see Factors
section). Student and faculty members of these committees serve as change agents to assist others in
adopting new attitudes and behaviors. Fortunately, changes in thinking have occurred at several
institutions; and faculty and students are excited about these new approaches.
In his 1991 AACP President-elect address, Nicholas Popovich described ‘educational care’ as a
theme analogous to pharmaceutical care.105 He discussed that just as pharmaceutical care mandates a relationship between pharmacist
and patient, “Educational care mandates establishment of a commitment between the faculty and the
student and cooperation with the student and other faculty in designing, implementing, and monitoring
an educational plan that will produce specific performance-based outcomes for the student.” He
reflected again on this concept the following year in his presidential address: “We in academic
pharmacy must change our approach to education to empower our students to create the future
of pharmacy. . . .As faculty, we must nurture and develop caring, interested practitioners, who will
help patients achieve better health care through provided pharmaceutical services.”106 Becker and Schafermeyer further delineated the role of pharmacy educators in the paradigm
of educational care as “. . .teaching, advising, mentoring, and serving as role models for the purpose
of achieving outcomes that improve students’ abilities to think critically, solve problems, and make
ethical decisions that will ultimately improve patient care.”107
These are high expectations and challenges to live up to – and they support our mission of
positive professional socialization as the reason for pharmacy schools’ existence. We need to
continually assess circumstances, identify areas requiring enhancement, prioritize plans based on
other institutional incentives, and develop assessment and follow-up methods to ensure all progresses
as planned. Although rate of change will be institution-dependent, we must collectively coordinate
our efforts, build from agreed upon recommendations (or standards), remain cognizant of what other
health professions have tried as well as societal needs and emphasize documentation, assessment
and publication of efforts. The suggestions and recommendations offered in this paper hope to aid
pharmacy education and practice to improve their focus on professionalism and will stimulate
additional work in this important area.
Throughout this paper, the authors have provided numerous suggestions and recommendations
on how professionalism can be enhanced based on past experiences and the relevant literature. Many
of these recommendations will be difficult to undertake. Some will not be implemented due to challenges
mentioned earlier. Some may only be partially implemented because they require resources and time
that schools and practitioners may not have. Many will not be addressed at all due to conflicting
priorities, environmental barriers, or practice issues. Thus, it may be unrealistic to assume that all
recommendations will be implemented. If this is the case then the profession must realize that
consequences will occur. If trade-offs must be made, things will happen in the future that may not
be to the profession’s liking – student development will be hindered and patient safety jeopardized.
For example, if faculty members do not stress the importance of academic integrity sufficiently to
entering students, then cheating will more likely occur in the classroom. If ethical behavior is not
stressed in experiential learning, then future pharmacists will work the system to their benefit or
cheat patients. Based on past experience, there appears to be a direct relationship between the
amount of time and effort in dealing with professionalism in the academy with the level of
professionalism in practice. Student affairs personnel can relate numerous cases where they regret
not intervening earlier in a situation that eventually lead to serious inappropriate behavior. If the
academy compromises on the professional development of its students, it must realize that
consequences will occur. The following recommendations were developed to avoid such future
transgressions.
General Recommendations
Before reviewing specific recommendations, it is important to consider the following general
suggestions. First, it is imperative that the various components of the pharmacy profession agree that
enhancement of professionalism is vitally important. To create change requires philosophical agreement
and commitment. Enhancing professionalism necessitates that environments (educational, practice, and
extracurricular) enable this change. Pharmacists and pharmacy organizations must strive to improve
practice settings so that professionalism has an opportunity to flourish.
Concern for others should be paramount in the thinking and actions of faculty, practitioners,
and students. Professionalism and identity with the profession must become part of the souls of these
individuals. In addition, the concepts embodied in professionalism must become part of the entire
pharmacy school culture from the first admission’s inquiry to graduation. A change in thinking needs
to occur. Faculty must begin to understand that technical competence is a part of the professional
curriculum, not the reverse. That is, the focus of the curriculum and culture must be to develop
the individual into a professionally mature practitioner who can render pharmaceutical care, not a
technically competent individual who has learned something about professionalism. Barbara Wells,
AACP Immediate Past President, wrote: “I believe the time is at hand when we can no longer blindly
trust that professionalism will be magically developed in our students. We must intentionally craft a
curriculum that facilitates the development of professional behaviors, design didactic and experiential
environments that support such development, and carefully assess our success in meeting the goals of
the curriculum for fostering professionalism.”108 The critical components of pharmaceutical care must be reinforced throughout the pharmacy
curricula and in practice settings. If these aspects are not addressed, then the professional
socialization of future practitioners will be incomplete.
Schools and colleges of pharmacy must develop appropriate mechanisms for assessing
professionalism. They must determine which attributes of professionalism to address first, the
depth and breadth of the coverage of these important factors, and the environments in which to
focus. Faculty must take advantage of “teachable moments” to further this process. Planning
should include assessment methods and implementation time lines. Schools should be encouraged
to be innovative in their approaches and gather evidence of their successes and failures. As
outlined in this report, research must be completed to explore the various variables involved in
this important area. Funding for this research should be facilitated by foundations and organizations
committed to the enhancement of the profession and health care of patients.
As discussed earlier, pharmacy can certainly learn from other disciplines and should review the
initiatives and best practices from other professions. Their past experiences should provide guidance
to pharmacy; that is, what is working and what needs to be avoided. It would also be wise to learn
from their mistakes. Health professions should work together to discuss common issues and similar
strategies. Focus should be placed on identifying and developing practice environments that promote
the socialization of all health care providers.
Specific Recommendations
In order to enhance professionalism in the profession, schools and colleges of pharmacy
should:
Commit to the professional development of their students, faculty and staff in specific,
concrete ways.
Define professionalism for all aspects of their curricula.
Determine the depth and breadth of training in these areas.
Assess barriers and facilitators to professionalism in their school – complete
comprehensive needs assessments.
Establish a committee or task force to determine how to address professionalism
efforts in all of the school’s programs.
Develop specific strategies to enhance professionalism in the following areas
(refer to the Factors section for specific details): recruitment, admissions, orientation,
curriculum, experiential programs, extracurricular activities, awards, academic progression,
and mentoring, for students and faculty.
Develop/utilize valid assessment instruments to measure professional development in
the didactic and experiential components of the curriculum.
AACP should:
Assist schools in defining professionalism in the academy and practice.
Develop programs to help educate the educators.
Partner with the faculties of other health care disciplines to discuss common issues
and various strategies.
Reaffirm components of the CAPE Outcomes that pertain to professionalism.
ACPE should:
Continue to stress elements of professionalism in its accreditation standards.
Develop measurable criteria for compliance with these standards.
Hold schools accountable for professional development of their students and
professionalism of their faculty.
Individual faculty members should:
Serve as effective mentors and role models to students.
Promote student professionalism in their courses; and when appropriate, design
course elements and activities to emphasize professionalism.
Support the efforts of other faculty, administrators, and students to enhance
professionalism in their institution.
Serve as effective faculty advisors to student organizations.
Monitor their own professional behavior in the classroom, laboratory, or practice
setting; and develop strategies to enhance personal professionalism if warranted.
Monitor the behavior of their peers and confront unprofessional attitudes and
actions when present.
National, state and local pharmacy organizations should:
Partner with pharmacy practice environments to develop public relation activities to
illustrate to society the professional training, skills, and value-added services that pharmacists
provide.
Conduct continuing education programs to enhance the professionalism of pharmacists.
Encourage student participation in meetings, committees, events. Provide free
registration or scholarships where possible.
Establish pharmacist/pharmacist and pharmacist/student mentoring programs.
Provide incentive grants to support professional pilot programs that foster the inculcation
of professional behavior, attitudes and cultures among their members.
Utilize the legislative offices/resources of the organization to assist in heightening
awareness of the professional training, attitudes and tenets of pharmacists and the profession
to legislators and their corresponding constituents.
Pharmacy practice environments (community, institutional, and others) should:
Develop a recruitment process that emphasizes the desired professional attributes of
prospective pharmacists, not just benefit packages that are heavily weighted on financial
remuneration.
Institute within their new-hire orientation process for pharmacy personnel (technicians,
pharmacists, and others) a section that provides the institution’s philosophy on professionalism,
pharmacist-patient relationship, culture and collegiality.
Incorporate in the evaluation process areas that measure professional attributes and
incorporate incentives that recognize professional excellence and the provision of
pharmaceutical care.
Build and remodel pharmacy practice environments that reduce barriers in performing
professional duties (eg, pharmacy design, location, workflow), promote the professional image
of the pharmacist, and enhance patient care.
Provide financial support for marketing and other public relation activities to illustrate
to society the professional training, skills and value-added services that pharmacists provide.
Incorporate within the duties (job description) of the pharmacist and other pharmacy
support personnel participation in professionally related activities that enhance the professional
image of pharmacy and develop a “professional spirit” within pharmacy personnel (eg, health
fairs, guest speaker at community events).
Eliminate functions contrary to patient well being, such as the sale of tobacco and alcohol.
Individual pharmacists should:
Understand the components of professionalism and how behaviors are a direct reflection
of perceived level of professionalism.
Hold each other accountable for their behavior.
Develop environments that foster professionalism and pharmaceutical care.
Serve as effective preceptors, mentors, and role models to students.
Promote, support, and engage in life-long learning.
Empower patients to provide feedback about behaviors, services and levels of professionalism.
Educate patients and students about patient advocacy.
Individual pharmacy students should:
Understand the components of professionalism and how their behavior reflects on their
perceived level of professionalism.
Hold each other accountable for their behavior.
Actively participate in experiences both curricular and extracurricular that enhance
their professional and personal development.
Serve as mentors to pre-pharmacy students and their younger colleagues.
Society and individual patients should:
Expect more from their pharmacists with regard to professional behaviors.
Never sign a document in the pharmacy unless it has been thoroughly explained first.
Never refuse counseling.
Have more respect for drug therapy and adhere to health care providers’ recommendations
Ask questions of pharmacists.
Change pharmacies if not satisfied with the professional service of a pharmacy.
Pressure insurance companies to reimburse pharmacists for clinical services provided which
ultimately enhance therapeutic outcomes.
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Corresponding Author: Dana P. Hammer, PhD Address: University of Washington School of Pharmacy, Box 357630, Seattle, WA 98195-7630 Tel: (206) 221-3632 Fax: (206) 221-3225 E-mail: dphammer@u.washington.edu
Hammer DP, Berger BA, Beardsley RS, Easton MR.
Student Professionalism.
Am J Pharm Educ. 2003; 67(3):article 96.
