Research ArticleRESEARCH

Assessment of Moral Development Among Undergraduate Pharmacy Students and Alumni

Rima A. Hijazeen, Mohammed I. Aladul, Khaled Aiedeh, Shereen M. Aleidi and Qais S. Al-Masri
American Journal of Pharmaceutical Education December 2022, 86 (10) ajpe8659; DOI: https://doi.org/10.5688/ajpe8659

Abstract

Objective. This study’s principal aim was to assess the moral development of undergraduate pharmacy students and alumni at a university in Jordan.

Methods. Using the Professional Ethics in Pharmacy (PEP) test, the moral reasoning of 512 pharmacy students and alumni was assessed in a cross-sectional design. The main assessment measure was the Principled Morality Score, which reflects an individual’s level of moral judgment development and is given as a percentage, where higher values indicate greater moral development.

Results. The response rate was 49%. The median Principled Morality Score was 16.7, with no significant differences observed across all five cohorts. No significant differences in median Principled Morality Scores were found between men and women (16.7 vs 20, respectively). Also, no significant differences in median Principled Morality scores were observed between students who had completed the ethics course versus those who had not completed the ethics course at the time of data collection (median Principled Morality Score 20 vs 16.7, respectively). No trends in median Principled Morality Scores were observed.

Conclusion. In this study, the professional moral reasoning of prospective pharmacists was lower than expected. A further longitudinal study of the cohort, which attempts to correlate moral development with age, sex, education level, and moral education strategy, is warranted.

Keywords

INTRODUCTION

Moral reasoning is a cognitive process that drives individual decision-making in an attempt to harmonize an individual’s initial judgment and moral reaction to an ethical dilemma.1 In the late 1960s, Kohlberg developed the cognitive moral development theory, which addresses how people think and the process of arriving at decisions. Kolhberg described three levels with six stages of cognitive moral development, consisting of a preconventional level (cognitive stages one and two), a conventional level (cognitive stages three and four), and a postconventional (or principled) level (cognitive stages five and six). Self-centered interests dominate the preconventional level. At the conventional level, relationships with others become more important; a person determines what is “right” by conforming to society’s norms. At the postconventional level, universal moral principles guide decision-making, even if this means violating a law in the process.

The Defining Issues Test (DIT) is the most widely used moral reasoning test based on Kohlberg’s cognitive moral development theory.2,3 However, its language and dilemmas have become somewhat outdated.4 Therefore, the revised short version DIT-2 is currently widely used in research and has played a significant role in understanding the relationship between participation in higher education and moral reasoning development in college students.3,4 The short-form DIT-2 consists of three moral dilemmas.5,6 Each dilemma is followed by a series of 12 statements relating to the dilemma, most of which represent the six cognitive stages posited by Kohlberg’s cognitive moral development theory.5,6 The individual’s task is to rate and rank the 12 items in order of importance. The most widely used DIT-2 score is the Principled Morality Score, which represents the percentage of an individual’s overall moral functioning at the postconventional level.

Teaching moral reasoning is challenging yet can be developed in students.7-10 In a pre‐post research design using the DIT, Penn found that students’ principled moral reasoning could be achieved and improved by directly teaching students the component skills of moral reasoning, cognitive skills of logic, and justice operations, and by practicing role-playing.11 Rest conducted a review of 57 moral reasoning studies concerning educational interventions’ effects on moral reasoning development.12 He concluded that peer discussion of ethical dilemmas allows students to engage in higher levels of moral discussions.12 Previous research has also suggested that peer discussion of ethical cases in health care ethics courses could potentially improve moral reasoning scores because students would have the opportunity to learn from peers by practicing moral problem-solving skills.8,12-16 These findings were consistent with those reported by Self and colleagues, who successfully integrated a small-group case study discussion throughout the medical ethics curriculum.17 The authors evaluated the impact of this educational intervention on the moral reasoning development of a large sample of medical students in a pre-post study design and observed a significant mean increase in DIT Principled Morality Scores after the course.17 Collectively, these studies and several others provide strong evidence that participation in formal education promotes moral reasoning development among undergraduate students. Thus, there appears to be a moral curriculum in higher education.18

In terms of professional roles, some moral considerations are profession specific and are different from those at play when people are acting as individuals, due to the different normative ethical principles applicable to a profession.19 Therefore, when assessing professionals’ moral development, the use of a test derived from a real-life, profession-specific scenario may work better than one using a hypothetical scenario, as is the case with the DIT.20 Moral reasoning development has been measured in the pharmacy profession among both undergraduate students and practicing pharmacists, predominantly in the United States and mainly with the DIT. Most of these studies’ low rankings of pharmacy students’ moral reasoning skills reflect the inability of the DIT and DIT-2 tests to measure profession-specific concepts.13,19,21-25 In the United Kingdom, Prescott and colleagues and Hanna and colleagues, each employing a longitudinal design, used the DIT-2 to measure moral reasoning development among pharmacy students in UK schools of pharmacy; they found a significant decrease in the mean P-score for all students compared to the mean scores of US pharmacy students and other US health care students. On this basis, many researchers have taken the step to develop profession-specific tests of moral reasoning.26-28

A pharmacy-specific instrument to measure levels of cognitive moral development and reasoning skills related to professional ethics would be fundamental. Thus, Chaar developed the Professional Ethics in Pharmacy (PEP) test from the context of Australian community pharmacy practice. The PEP test measures moral understanding related to professional autonomy, competence, informed consent, confidentiality, and whistleblowing, and it can be used in teaching ethics in professional courses.20,29 By contrast, the DIT measures moral understanding based on justice, social cooperation, and fairness.29

The PEP test had previously been used in Australia, where the tool originated,20 and in a pharmacy school in the United Kingdom.30 Chaar applied the PEP test to fourth-year Australian pharmacy students before and after a teaching intervention. With an initial average Principled Morality Score of 42.0, after the intervention it increased to 50.6 (t (156)=11.48, p=.001), a significant improvement of 8.6. The scores obtained by Chaar were higher than the average Principled Morality Scores from the UK study (ie, first-year undergraduate score=31.4, fourth-year undergraduate score=35.1), but the UK study did show a positive trend of increasing average Principled Morality Scores from first-year to fourth-year undergraduate students.

The primary aim of this study was to assess the moral development of undergraduate pharmacy students through their academic years as they progress from year three through the final year at a school of pharmacy in Jordan with the purpose of expanding the research findings by assessing a cause-and-effect relationship between moral development and ethics teaching.

METHODS

The PEP test was constructed around three pharmacy-specific scenarios providing real-life examples of dilemmas experienced by pharmacists.31 Each scenario is followed by 12 statements. Of the total 36 statements, 30 statements represent a stage of cognitive moral judgment. Six meaningless statements were included among the three scenarios to correct for respondents providing socially desirable answers.18 If participants ranked more than three meaningless statements, their questionnaires were discarded. For each scenario, respondents had to rate and rank the statements. The Principled Morality Score, a measure of higher-level principled thinking, is calculated by assigning points to ranking data and then summing the number of times respondents ranked postconventional statements of Kohlberg’s model as the first, second, third, and fourth most important; scoring is based on the scale of awarding four points to the highest-ranked statement to one point for the fourth-ranked statement. Typically, the Principled Morality Score is calculated by dividing the total number of points across the three dilemmas by 30 (the total number of points) when there are no missing answers.32,33

The PEP test is a pre-validated tool, and, therefore, its reliability and validity are already established.31 Consequently, it was not necessary to conduct a pilot study, but the questionnaire was assessed for face validity by two Jordanian practicing pharmacists to assess whether the questionnaire content made sense in the Jordanian pharmacy setting. Permission to use the PEP test was granted by contacting the author directly.

Regarding data collection and analysis, the target population for this study was pharmacy and Doctor of Pharmacy (PharmD) students and pharmacy alumni from the school of pharmacy at the University of Jordan, Jordan. Ethics is taught in the classroom as a standalone subject called Pharmacy Regulations and Ethics. The one-credit course runs over 16 weeks and is taught by staff from the school itself. The course syllabus covers law, ethics, and regulatory issues, and no other course in the pharmacy programs addresses any aspect of ethics. Assessment of learning is undertaken via theory-based multiple-choice questions. The course is available for students from both programs (Pharmacy and PharmD) to study at any level, starting from the third year of study.

The study was conducted during the 2019-2020 academic year. As the focus of this study was to assess the impact of a teaching intervention throughout each year of undergraduate education, the enrolled students were in their third, fourth, fifth, or final academic year. The number of students from each year were 254 from third-year pharmacy and PharmD programs, 330 from fourth-year pharmacy and PharmD programs, 149 from fifth-year PharmD programs, and 280 from final-year pharmacy and PharmD programs. Additionally, 150 early-career pharmacists who had graduated within the previous three academic years (2016-2019) and whose contact details were available and who had registered at the Jordan Pharmacists Association were asked for their voluntary participation in the study.

Two weeks before the scheduled sessions, an email was sent to early-career pharmacists and all third-, fourth-, fifth-, and final-year students from the pharmacy and PharmD programs. The email provided a brief description of the research, with the participant information sheet attached. Participants were invited to attend a predefined scheduled session. Written informed consent was obtained from all participants who were assured of data confidentiality, their right to withdraw at any time, and who were asked to complete the PEP test individually.

Data were collected using a self-completed questionnaire consisting of two sections: Section A gathered unidentifiable demographic information, specifically the participants’ current primary role, gender, age, and whether they had completed the ethics course. Section B contained the PEP test.

The Principled Morality Score was calculated and checked for each returned questionnaire by two researchers. Responses were coded and entered into SPSS Statistics version 24 (IBM Corp) for statistical analysis. The analysis involved comparing average scores among the five cohort groups against demographics. As Principled Morality Scores represented continuous data, they were initially tested for normal distribution relying on both statistical tests and visual inspection of graphs and plots. Descriptive statistical tests were then applied to the data to calculate means, medians, and standard deviations of scores for each group, ie, age groups, genders, and individual year groups. Inferential statistical tests were then applied to test for any associations. Pearson’s chi-square goodness-of-fit test was applied to the data to determine whether participants’ distribution in a single categorical variable (ie, gender, age group, completing the ethics course or not) was equal or unequal. The Mann-Whitney test was used to compare the median scores of all cohort groups combined against the demographic variable gender, and between cohort groups that had completed the ethics course and cohort groups that had not completed the ethics course at the time of data collection. The Kruskal-Wallis test was used to understand whether Principled Morality Scores differed based on participants’ age range. If significant differences were identified, the next step was to undertake a post hoc test to determine which of these groups differed from the others. The Jonckheere-Terpstra test was used to determine if there was a significant trend between levels of the year of study and the median Principled Morality Score.

Ethical approval for this study was granted by the University of Jordan’s Research Ethics Committee of the School of Pharmacy. All participants gave written informed consent. No personal identifying data were collected during the study.

RESULTS

The Principled Morality Scores demonstrated deviation from a typical bell-shaped graph. A skew value of .77 and a standard error of .11 were found; the distribution skewed to the right (positive skewness). A kurtosis score of .87 and a standard error of .22 also supported deviation from the normal distribution. Tests of Kolmogorov-Smirnova and Shapiro-Wilk of p<.001 suggested that the data were not approximately normally distributed. The data were found to violate the assumptions for normality; therefore, nonparametric statistical tests were applied to the data. While outliers seemed to exist, this did not affect the normality results. A nonparametric Levene test was used to verify the equality of variances in the samples (homogeneity of variance; p=.23).34

A total of 565 participants returned a PEP test questionnaire. Forty were incomplete, and 13 were unsuitable for analysis; therefore, 512 were analyzed. The overall response rate was approximately 49%. All the alumni who responded worked in community pharmacy. Demographic information of participants is summarized in Table 1.

View this table:
Table 1.

Demographics of Participants Who Completed the Professional Ethics in Pharmacy Questionnaire, N=512

A descriptive analysis revealed that the sample constituted 99 students from year three (19.3%), 131 from year four (25.6%), 101 from year five (19.7%), 103 from the final year (20.1%) of pharmacy school, and 78 early-career pharmacists (15.2%). Most respondents were female students (n=428, 83.6%) in the age range of 21 to 25 years (n=403, 78.7%). Approximately half of the respondents (n=265, 51.8%) had completed the ethics course at data collection time. A significant difference in gender and age range was found among all study cohort groups (χ2=231.13, p<.001 vs χ2=1461.48, p<.001, respectively). However, an insignificant difference in completing the ethics course was found among the groups (χ2=.945, p=.33).

For comparing Principled Morality Score scores across demographics, Table 2 shows the spread of Principled Morality Scores achieved. Specifically, it compares the minimum, maximum, and median scores across all five cohort groups. The median score was 16.7, and there was no statistical difference observed across all five cohort groups (p=.112), indicating that students’ moral development did not change during the academic years.

View this table:
Table 2.

Principled Morality Scores of Study Participants by Cohort Group, N=512a

A Mann-Whitney test was conducted to determine whether differences in Principled Morality Scores existed between men and women, and it showed no significant difference between the scores for each gender (20 for female students vs 16.7 for male students, p=.18). No significant differences in median Principled Morality Scores were observed between cohort groups who had completed the ethics course versus the cohort group who had not completed the ethics course at the time of data collection (median score 20 vs 16.7, respectively, p=.63).

A Kruskal-Wallis test was conducted to examine the differences in median Principled Morality Scores according to participants’ year of study. Significant differences (Kruskal-Wallis H=16.24, p=.003, df=4) were found among the five cohort groups. A post hoc test was conducted to compare all pairs of groups (pairwise comparisons) and showed that the difference in scores between final-year students and early-career pharmacists was significant (median score 20 vs 13.3, respectively, p=.003). However, the Kruskal-Wallis test did not show a significant difference in Principled Morality Scores between the six different age groups (Kruskal-Wallis H=4.439, p=.488, df=5) (<20, 21-25, 26-30, 31-35, 36-40 and >41 years old).

A Jonckheere-Terpstra test for ordered alternatives demonstrated that there was not a significant trend of increasing median Principled Morality Scores with more years of study (from third-year students to early-career pharmacists), where the Jonckheere-Terpstra test statistic (TJT)=50640.50, z=−.76, p=.45.

DISCUSSION

The Principled Morality scores achieved by early-career pharmacists were found to be consistently lower than those of undergraduate students, suggesting that the moral reasoning skills of alumni decreased when they left the university environment and that undergraduate teaching did not impact professional practice. The scores could also reflect the complexities of decision-making beyond the safety of the academic classroom, indicating that community pharmacists are subject to the working conditions and requirements set by their employing organizations. Funding cuts and increasing pressures to meet targets and achieve profits can make it difficult at times to perform at the postconventional level of Kohlberg’s model.35

This research suggests that pharmacy students’ age and gender were not significantly related to Principled Morality Scores and that these factors were unlikely to affect moral reasoning scores among research participants. Two studies using the PEP test (by Chaar and by Allinson and Black) reported findings consistent with these, as they found no significant differences in Principled Morality Scores in men versus women and between different age groups.20,30 Likewise, Murphy and Rest found that only two of 22 studies measuring moral reasoning reported a significant difference in gender Principled Morality Scores.33 Furthermore, studies that used age to predict moral reasoning scores among traditionally aged college students found no significant relationship between age and moral reasoning on the DIT.36,37 However, many studies focused on questions relating to gender differences in moral reasoning have found that women score significantly higher than men on the DIT.13,21,38-40 Findings from this research demonstrated no significant trend of increasing median Principled Morality Scores with higher levels of the year of study. These findings could suggest that only minimal professional ethics teaching is being delivered. A series of longitudinal studies examined the effects of age and education on moral reasoning development and showed that students’ use of conventional-level reasoning decreased during college, and their use of postconventional-level reasoning increased,41-47 offering evidence that education experiences promote the development of moral reasoning among undergraduate students. Moreover, a series of consecutive studies conducted by Rest and Rest and Thoma investigated whether gains in moral reasoning are due to education, age, or the interaction between the two; results showed that formal education is the most powerful demographic correlate of DIT Principled Morality Scores.38,48

The low overall scores obtained from this study deserve consideration, given the strong association between moral reasoning development and education. These data provide evidence that the ethics course at the School of Pharmacy falls below the professional expectations and highlights a need for reforming teaching methods within the pharmacy ethics curriculum, with the ultimate objectives of improving students’ moral attitudes, preparing students for medical ethics issues, and developing ethical reasoning skills.7,8,10,49 The reform we propose should longitudinally integrate ethics and professionalism education in all phases of undergraduate education.9,41-48 A learning approach that focuses on bridging the theory-practice gap and integrating academic knowledge into real-world practice would have the potential to encourage moral reasoning skills development.49

The study has several limitations. The current study used a cross-sectional design to assess moral development. The study was limited to one institution, so results cannot be generalized to other Jordanian schools of pharmacy. Another limitation is that the participating pharmacists were early in their careers and, therefore, do not represent the pharmacist population in general. As pharmacists’ roles are changing to have more patient-centered functions, our findings provide a unique contribution to the existing moral reasoning research literature.

CONCLUSION

This research provides empirical data on the moral development of potential future pharmacists. The results of this study will be used as a starting point for a longitudinal study of a single cohort of pharmacy students, using the PEP test, and will seek to demonstrate a causal link between ethics teaching and the increase in moral development. If the results of those studies replicate the present findings, it would seem prudent to reform pharmacy curricula to maximize moral development.

ACKNOWLEDGEMENTS

The authors acknowledge all research participants who took part in the study. All authors have completed the International Committee of Medical Journal Editors uniform disclosure form (www.icmje.org/coi_disclosure.pdf) and declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.

  • Received March 25, 2021.
  • Accepted October 18, 2021.

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Assessment of Moral Development Among Undergraduate Pharmacy Students and Alumni
Rima A. Hijazeen, Mohammed I. Aladul, Khaled Aiedeh, Shereen M. Aleidi, Qais S. Al-Masri
American Journal of Pharmaceutical Education Dec 2022, 86 (10) ajpe8659; DOI: 10.5688/ajpe8659
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