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The Development of a Pharmacist Model of Professional Obligation Using Bandura's Theory of Moral Disengagement

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Title:
The Development of a Pharmacist Model of Professional Obligation Using Bandura's Theory of Moral Disengagement
Creator:
Lee, Christine S
Place of Publication:
[Gainesville, Fla.]
Florida
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (206 p.)

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Pharmaceutical Sciences
Pharmaceutical Outcomes and Policy
Committee Chair:
Segal, Richard
Committee Members:
Smith, Walter Thomas
Kimberlin, Carole L
Weiler, Robert M
Graduation Date:
8/11/2012

Subjects

Subjects / Keywords:
Asthma ( jstor )
Banduras ( jstor )
Diseases ( jstor )
Drug design ( jstor )
Lifestyle ( jstor )
Medical personnel ( jstor )
Morality ( jstor )
Pharmaceutical services ( jstor )
Pharmacies ( jstor )
Pharmacists ( jstor )
Pharmaceutical Outcomes and Policy -- Dissertations, Academic -- UF
disengagement -- moral -- non-compliance -- obligation -- pharmacy -- professionalism -- smoking
Genre:
bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Pharmaceutical Sciences thesis, Ph.D.

Notes

Abstract:
The primary goal of this dissertation is to develop a theoretical framework to explain how pharmacists’ underlying beliefs affect their decision pathways when given the opportunity to counsel a non-smoker compliant asthmatic, a non-smoker and non-compliant asthmatic, and a smoker but compliant asthmatic. The goal will be accomplished by gaining insight on how Bandura’s theory of moral disengagement relates to pharmacists’ application of pharmaceutical care on different severity levels of lifestyle related diseases. A self-administered written survey for pharmacists containing measures based on the operationalization of constructs from Bandura’s Theory of Moral Disengagement was conducted. The validity of the model was examined by testing proposed relationships between the measures using survey responses from pharmacists in Florida. Subjects’ responses to items intended to measure moral disengagement factors displayed evidence of convergent and discriminant validity.  Pharmacists’ sense of professional obligation varied significantly when presented with different conditions surrounding a patient presenting with asthma, controlling for time pressure and work environment.  Pharmacists were less likely to have a sense of professional obligation to patients presenting with non-compliance or whom were smokers. Professional obligation had a significant positive direct effect on the application of pharmaceutical care. For the smoker asthmatic patient, the moral disengagement mechanism, obscure and minimal, had a negative effect on the application of pharmaceutical care and also acted as a mediating variable between professional obligation and the application of pharmaceutical care. This study shows that pharmacists’ beliefs on certain patient behaviors, such as non-compliance and smoking, play a significant role in predicting the level of professional obligation the pharmacists feels towards the patient. Furthermore, beliefs that diffuse and displace the responsibilities of pharmacists and instead place blame on stressful conditions, corporate headquarters pressuring pharmacists to increase prescription volume and blaming colleagues and other health care professionals in not actively participating in the provision of care, negatively affect pharmacists’ behavior. The findings of this study have practical implications for pharmacist, as well as theoretical implications. Furthermore, the findings of this study extend what is known regarding Bandura’s Theory of Moral Disengagement. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (Ph.D.)--University of Florida, 2012.
Local:
Adviser: Segal, Richard.
Statement of Responsibility:
by Christine S Lee.

Record Information

Source Institution:
UFRGP
Rights Management:
Copyright Lee, Christine S. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Classification:
LD1780 2012 ( lcc )

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1 THE DEVELOPMENT OF A PHARMACIST MODEL OF PROFESSIONAL OF MORAL DISENGAGEMENT By CHRISTINE LEE A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

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2 2012 Christine Lee

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3 To my son, Aiden Paul Flemming And to my h usband, Robert Paul Flemming

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4 ACKNOWLEDGMENTS I would like to thank my wonderful husband, Robert Paul Flemming, for all his love, support and help driving through the state of Florida collecting data. I also thank my parents, Henry and Mali Lee in their unwavering support and their ability to guide me in my life. I would also like to thank my son, Aiden Paul Flemming, in inspiring me to be the best that I can be. My sincere appreciation goes to my major advisor s: Dr. Richard Segal, for his wisd om, support, kindness, inspiring ideas and always having confidence in my abilities ; to Dr. Kimberlin for her valuable comments and thoughtfulness; to Dr. Tommy Smith for his friendship and insightfulness; and to Dr. Robert Weiler for his support and enthu siasm. I wish to thank my fellow graduate students, past and present, for their friendship and guidance. I would also like to thank the University of Florida Pharmaceutical Outcomes and Policy department faculty and staff in their support and training. I also extend many thanks to the pharmacists who participated in this study and also the Florida Pharmacy Association for collaborating with me in the data collection process.

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5 TABLE OF CONTENTS ACKNOW LEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATI ONS ................................ ................................ ........................... 11 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 14 ................................ ....................... 14 Ethical Responsibility ................................ ................................ .............................. 18 Morality and Ethics ................................ ................................ ........................... 18 Clinical Ethics and Moral Rights Versus Law ................................ ................... 23 Conflicting Professional Roles and Responsibilities ................................ ............... 24 The Duty to Treat Patients with Lifestyle Diseases ................................ .......... 24 Sources of Obligation ................................ ................................ ....................... 28 Ethics and Professionalism ................................ ................................ ..................... 29 Professional Characteristics ................................ ................................ ............. 31 The Importance of Moral and Ethical Engagement ................................ .......... 32 Ethical Dilemmas ................................ ................................ ................................ .... 34 Allocate Resourc es Justly ................................ ................................ ................ 35 Distributive Justice ................................ ................................ ........................... 36 Problem Statement ................................ ................................ ................................ 39 Preliminary Work Conducted by the Investigator ................................ .................... 42 Significance ................................ ................................ ................................ ............ 43 Contribution to the Fi eld of Pharmacy ................................ .............................. 43 Theoretical Contribution ................................ ................................ ................... 44 Broader Impacts ................................ ................................ ............................... 45 2 THEORETICAL MO DEL ................................ ................................ ......................... 47 ................................ ............ 47 ................................ ................................ 52 Rationale and Theoretical Introduction ................................ ............................. 52 The Universal Value of Morality ................................ ................................ ........ 53 Perceptions of the Situation ................................ ................................ .............. 54 Motivations ................................ ................................ ................................ ....... 54 Dynamics of Moral Decision ................................ ................................ ............. 56 Motivated Reasoning: The Mechanics of Moral Rationalization ....................... 56 Study Assumption ................................ ................................ ................................ ... 58 Description of Theory ................................ ................................ .............................. 58

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6 Psychological theories of morality ................................ ................................ .... 59 Reciprocal determination ................................ ................................ .................. 60 An Agentic Perspective ................................ ................................ .................... 61 Exercise of Moral Agency ................................ ................................ ................. 64 Mechanisms of Disengagement ................................ ................................ ....... 67 Rese arch findings ................................ ................................ ................................ ... 72 3 ME T HODS ................................ ................................ ................................ .............. 80 Overview ................................ ................................ ................................ ................. 80 Survey Development ................................ ................................ ............................... 80 Pharmacist Interviews ................................ ................................ ...................... 81 Content Validity, Readability, and Face Validity ................................ ............... 81 Delphi Panel ................................ ................................ ................................ ..... 82 Survey Pretest ................................ ................................ ................................ .. 83 Description of Pha rmacists Moral Obligation Instrument ................................ .. 85 Operationalization of Study Constructs ................................ ............................ 87 Test retest reliability ................................ ................................ ......................... 93 Summary of Survey Development ................................ ................................ .......... 94 St udy Sample and Data Collection ................................ ................................ ......... 95 Data Analysis ................................ ................................ ................................ .......... 96 Reliability of Measures ................................ ................................ ..................... 96 Convergent and Discriminant Validity ................................ ............................... 96 Construct validity ................................ ................................ .............................. 98 Sample Size Determination ................................ ................................ .................. 102 Summary of Methods ................................ ................................ ............................ 102 4 RESULTS ................................ ................................ ................................ ............. 111 Response to survey ................................ ................................ .............................. 111 Item Responses and Scale Reliability ................................ ................................ ... 111 Professional Obligation ................................ ................................ ......................... 112 Application of Pharmaceutical Care ................................ ................................ ...... 112 Moral Disengagement items for the smoking patient ................................ ............ 113 Moral Disengagement items for the non compliant patient ................................ ... 113 Convergent and Discriminant Validity ................................ ................................ ... 114 Test of Hypothesis ................................ ................................ ................................ 116 Hypothesis 1 ................................ ................................ ................................ ... 116 Model testing for Hypothesis 2 to 4 ................................ ................................ 117 Hypothesis 2. ................................ ................................ ................................ .. 121 Hypothesis 3 ................................ ................................ ................................ ... 122 Hypothesis 4. ................................ ................................ ................................ .. 123 Statistical Assumptions ................................ ................................ ......................... 125 5 DISCUSSION AND CONCLUSIONS ................................ ................................ .... 150 Overview ................................ ................................ ................................ ............... 150

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7 Discussion of Findings ................................ ................................ .......................... 150 Prediction of Severity of Lifestyle Di sease on Professional Obligation ........... 150 Prediction of Professional Obligation on the Application of Pharmaceutical Care ................................ ................................ ................................ ............ 154 Prediction of Moral Disengagement Mechanisms on the Application of Pharmaceutical Care ................................ ................................ ................... 155 Prediction of Moral Disengagement Mechanisms acting as a mediating variable between Professional Obligation and the Application of Pharmaceutical Care ................................ ................................ ................... 159 Study Limitations ................................ ................................ ................................ .. 160 Variable Design and Measurement ................................ ................................ 160 Generalizability ................................ ................................ ............................... 160 Implications of Findings ................................ ................................ ........................ 161 Practical Implications for Pharmacy ................................ ............................... 161 Theoretical implications ................................ ................................ .................. 164 Recommendations for Future Research ................................ ............................... 166 Conclusion ................................ ................................ ................................ ............ 167 APPENDIX A PHARMACIST PROFESSIONAL OBLIGATION SURVEY ................................ ... 1 69 B PHARMACY STUDENT PROFESSIONAL OBLIGATION SURVEY .................... 170 C PRETEST PROFESSIONAL OBLIGATION INSTRUMENT ................................ 171 D PROFESSIONAL OBLIGATION INSTRUMENT ................................ ................... 186 LIST OF REFERENCES ................................ ................................ ............................. 199 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 206

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8 LIST OF TABLES Table page 3 1 Delphi Panel Results ................................ ................................ ........................ 104 3 2 Categories of psychological me chanisms ................................ ......................... 104 3 3 Mechanisms of Moral Disengagement ................................ ............................. 105 3 4 Description of Independent and Dependent Variables for Hypothesis 1 ........... 107 4 1 Demographic and Practice Characteristics of Respondents ............................. 126 4 2 Demographic and Practice Characteristics of Respondents ............................. 127 4 3 Item description for scenarios ................................ ................................ ........... 128 4 4 a lpha for the three scenarios ................................ ......................... 129 4 5 Item total Statistics for Scenario 1 ................................ ................................ .... 129 4 6 Item Total Statistics for Scenario 2 ................................ ................................ ... 129 4 7 Item Total Statistics for Scenario 3 ................................ ................................ ... 129 4 8 Item Description for the Three Scenarios ................................ ......................... 130 4 9 alpha for the three scenarios ................................ ......................... 131 4 10 Item Total Statistics for Scenario 1 ................................ ................................ ... 131 4 11 Item Total Statistics for Scenario 2 ................................ ................................ ... 131 4 12 Item Total Statistics for Scenario 3 ................................ ................................ .. 131 4 13 Item Total Statistics for Moral Disengagement Items for the Smo ker Patient. .. 132 4 14 Item Total Statistics for Non Compliance Moral Disengagement Items ............ 133 4 15 Disease effect on Professional Obligation ................................ ........................ 134 4 16 Disease effect on Professional Obligation ................................ ........................ 134 4 1 7 Latent variables and Observed Variables for the proposed models ................. 135

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9 LIST OF FIGURES Figure page 2 1 Hypothesized Model ................................ ................................ ........................... 78 2 2 Model framework for application of pharmaceutical care for smoking cession (Similar Models for counseling on non compliant patients) ................................ 79 3 1 Development of Professional Moral Obligation Instrument ............................... 107 3 2 Proposed Measurement model for the Smoker Compliant Asthmatic .............. 108 3 3 Proposed Measurement Model for Non Compliant Non Smoker Asthmatic ..... 109 3 4 Proposed model ................................ ................................ ............................... 110 4 1 Revised Proposed Measurement model for CR, OM, BD for Smoker Asthma Patient ................................ ................................ ................................ .............. 136 4 2 Measurement model for CR, OM, BD for Smoker Asthma Patient ................... 137 4 3 Proposed Measurement Model for CR, BD, OM for Non compliant, non smoker asthma patient. ................................ ................................ .................... 138 4 4 Measurement Model for CR, BD, OM for Non compliant, non smoker asthma patient. ................................ ................................ ................................ .............. 139 4 5 Proposed Model ................................ ................................ ............................... 140 4 6 Structural Equation Model Standardized Estimates for Non Compliance Non Smok er Asthma Patient ................................ ................................ .................... 140 4 7 Proposed Structural Equation Model for Smoker Asthma Patient .................... 141 4 8 Structural Equation Model Standardized Estimates for Smoker Asthma Patient with Disengagement Mechanisms Obscure and Minimize (OM) .......... 142 4 9 Proposed Structural Equation Model for Smoker Asthma Patient with Disengagement Mechanism Cognitively Reconstrue (CR) and Blame and Dehumanize (BD) ................................ ................................ ............................. 143 4 10 Structural Equation Model Estimates for Smoker Asthma Patient with Disengagement Mechanism Cognitively Reconstrue (CR) and Blame and Dehumanize (BD) ................................ ................................ ............................. 144 4 11 T values for the Structural Equation Model for Model 1 ................................ .... 145 4 12 T values for the Structural Equation Model for Model 2.1 ................................ 146

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10 4 13 T values for the Structural Equation Model for Model 2.2. ................................ 147 4 14 Residual plot for Model 1 ................................ ................................ .................. 148 4 15 Residual plot for Model 2 ................................ ................................ .................. 148 4 16 Normal distribution for Model 1 ................................ ................................ ......... 149 4 17 Normal distribution for Model 2 ................................ ................................ ......... 149

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11 LIST OF ABBREVIATION S AIDS Acquired Immuno Deficiency Syndrome APC Application of Pharmaceutical Care APhA American Pharmaceutical Association BD Blame and Dehumanize CEO Chief Executive Officer COPD Chronic Obstructive Pulmonary Disorder CR Cognitive Reconstrue Di sengage Disengagement Mechanism DUR Drug Utilization Reviews ED Emergency Department et al. et ali HIV Human Immunodeficiency Virus LRD Life style related diseases. Diseases in which the patient has engaged in behaviors directly or indirectly leading to the disease condition. MTM Medication Therapy Management Oblig Professional Obligation OM Obscure and Minimize PCP Primary Care Provider Pharmcare Provision of Pharmaceutical care POI Professional Obligation Instrument SCT Social Cognitive Theory

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12 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE DEVELOPMENT OF A PHARMACIST MODEL OF PROFESSIONAL OF MORAL DISENGAGEMENT By Christine Lee August 2012 Chair: Richard Segal Major: Pharmaceutical Sciences The primary goal of this dissertation is to develop a theoretical framework to the opportunity to counsel a non smoker compliant asthmatic, a non smoker and non compliant asthmatic, and a smoker but compliant asthmatic. The goal will be ls of lifestyle related diseases. A self administered written survey for pharmacists containing measures based on was conducted. The validity of the model was examined by te sting proposed relationships between the measures using survey responses from pharmacists in Florida. factors displayed evidence of convergent and discriminant validity. nse of professional obligation varied significantly when presented with different conditions surrounding a patient presenting with asthma, controlling for time pressure and work

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13 environment. Pharmacists were less likely to have a sense of professional obl igation to patients presenting with non compliance or whom were smokers. Professional obligation had a significant positive direct effect on the application of pharmaceutical care For the smoker asthmatic patient, the moral disengagement mechanism, obscure and minim al had a negative effect on the application of pharmaceutical care and also acted as a mediating variable between professional obligation and the application of pharmaceutical care. This study shows beliefs on certain pa tient behaviors, such as non compliance and smoking, play a significant role in predicting the level of professional obligation the pharmacists feels towards the patient. Furthermore, beliefs that diffuse and displace the responsibilities of pharmacists an d instead place blame on stressful conditions, corporate headquarters pressuring pharmacists to increase prescription volume and blaming colleagues and other health care professionals in not actively participating in the provision of care, negatively affec The findings of this study have practical implications for pharmacist s as well as theoretical implications. Furthermore, the findings of this study extend what is known

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14 CHA PTER 1 INTRODUCTION P rovision of L ifestyle C ounseling The societal purpose for the profession of pharmacy has been referred to as pharmaceutical care, which responsible provision of drug therapy for the purpose of achieving defined outcomes mission statement for the profession of pharmacy by the Joint Commission of Pharmacy Practitioners and is endorsed by ind ividual professional organizations including the American Association of Colleges of Pharmacy, the American Society of Health Systems Pharmacy and the American Pharmacists Association. The activities that may be performed by a pharmacist, which constitute pharmaceutical care include identifying potential and actual drug related problems, resolving actual drug related problems, and preventing potential drug related problems (Hep ler & Strand, 1990) Although pharmaceutical care has gained recognition, most pharmacists do not routinely practice pharma ceutical care (Odedina and Sega l, 1996 ) even for chronic medical conditions such as asthma, diabetes, and hypertension. It has been noted by Odedina Segal & Hepler (199 5 ) that getting pharmacists, particularly community pharmacists, to accept the responsibility to carry out the provision of pharmaceutical care is difficult at best and a lot remains unaccomplished with achieving this goal. Barriers to pharmaceutical c are Pharmacists are trained to provide pharmaceutical care to their patients. Unfortunately, many pharmacists do not routinely provide services consistent with the standard of care as defined by the profession (Walker, Wat son, Grimshaw et al. 2004). Despite substantial investments in research,

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15 dissemination, and advocacy, a huge gap exists between what is known about effective world practice. Regulatory and educational interventions have been utilized in an att empt to change the behavior of pharmacists. However, in spite of these interventions, pharmacists have found it difficult to change their behav ior beyond the dispensing role (Kimberlin, Berardo Pendergast et al. 1993) Select examples illustrating the s low progress in implementing pharmaceutical care include work by Walker Watson, Grimshaw et al. (200 4 ) who undertook a randomized controlled trial to assess the effectiveness and efficiency of educational strategies to implement evidence based guidelines for OTC treatment of Vulvovaginal Candidiasis in the community pharmacy setting. The intervention included dissemination of evidence based guidelines for OTC management of thrush by postal dissemination (control) educational outreach visit or attendance at a continuing professional education session. The authors however were unsuccessful in improving the appropriateness of OTC management of Vulvovaginal Candidiasis by community pharmacy staff through their e ducational sessions. Weinberger Murray, Marrero e t al. (2001) further noted that even when community pharmacists were presented with clinically relevant patient specific data to provide appropriate care, and possessed the knowledge and skills needed to provide pharmaceutical care, asthma patients in the pharmaceutical care group had more breathing related ED or hospital visits. The authors noted that despite ample pharmacy visits, during which pharmacists had opportunities to implement the pharmaceutical care program for patients with both asthma and COPD pharmacists only accessed data from the study computer about half

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16 of the time, and documented actions only about half the time these records were accessed. The authors commented that the lack of patient outcomes due to the pharmaceutical care program cou ld be explained by several factors. First, their intervention was cumbersome and required pharmacists to access data on a separate computer, second, implementation of the program may require release time or other incentives for the pharmacists. Thirdly al though all pharmacists participated in the program, they were not universally enthusiastic about their expanded role. Some barriers to the implementation of pharmaceutical care noted by Penna ; preoccupation of pharmacists with service process; lack of organizational support; lack of cooperation of other health care professionals; lack of financial incentives; logistical barriers; lack of money for development; and pharmacist ignorance and init iative. Some of these barriers could be overcome by adequate training; however, emotions and compulsions are unpredictable and thereby cannot be easily resolved. It could be that one of the greatest barriers to the implementation of changes in practice are the pharmacists themselves. (Penna, 1990) Bagozzi ( 1992, 1993) noted that in order to have pharmacists provide cal outcomes. Hepler (1990) also noted that little can be done by pharmacy organizations unless individual members initiate the change at the level of individual practice. A behavioral change by individual pharmacists towards implementing pharmaceutical ca re is thus a necessary step for change.

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17 Previous research suggests that attitudes, beliefs and self efficacy may be crucial predictors of practice barriers among health care professionals. Walker et al. 2004; Perkins Jensen, Jaccard et al 2007) values, beliefs, and attitudes play a significant role in patient care, especially in addiction treatment and HIV treatment. Stiernborg (199 2 ) found that nursing students had prejudicial attitudes and fears that impeded care t owards HIV patients. While Earl & Penney HIV has not ch anged over the past decade. Rel f, Laverriere, Devlin et al (2009) noted that nursing students in the Uni ted States were more likely to have attitudes and beliefs that were not consistent with the ethical principles of autonomy, beneficence, non maleficence and justice in the context of testing, confidentiality, disclosure and the environment of care related to HIV and AIDS when compared to their South African is possible that clinicians may continue to hold negative attitudes and beliefs that may hinder clinical practic e that is ethical and supportive of persons living in HIV and AIDS. Similarly, Martinez & Murphy Parker (2003) found nursing students often held negative and often inaccurate perceptions and beliefs toward patients with substance abuse problems. Imhof Hir sch & Terenzi (1983) noted that therapists may experience a formidable array of negative feelings, reactions and stereotypical attitudes towards patients being treated for drug dependence. Pharmacists are also heavily influenced by their personal beliefs a s evident when the Washington Post reported that pharmacists across the country are refusing to fill prescriptions for birth control and the morning after pills, saying that dispensing the medications violated their personal beliefs (Stein 2005;

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18 page A O1) These studies and reports indicate that for certain disease states, personal beliefs may act as a significant barrier to implementation of patient care. Thus, to profe ssional obligation. Ethical Responsibility Traditionally, physicians, not pharmacists, were the health care professionals who held ultimate responsibility for monitoring the progress of a patient and ensuring that the desired outcome was achieved (Mont agne & McCarthy, 2006 ) However the concept of n the prescriber and pharmacist. (Hepler & Strand, 1990) According to the Commission to Implement Change in Pharmaceutical Care (1991), the mission of pharmacy practice is behaviors, commitments, concerns, ethics, functions, knowledge, responsibilities, and skills on the provision of drug therapy wi th the goal of achieving definite outcomes toward the improvement of the quality of life of the patients. Pharmaceutical care forces pharmacy practitioners to change their focus and broaden th eir professional responsibility. (Montagne & McCarthy 2006 ) Mor ality and Ethics standards of right and wrong behavior; however there are important distinctions between these terms. Moral choices ultimately rest on values or beliefs that cannot be 2009 ). Morality is concerned with relations between people and how ultimately they can best live in peace and harmony.

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19 T he goal of morality is to protect a high quality of life for an individual or for the community as a whole. People try to act in accordance with morality in their everyday lives. Morality provides meaning to life and is made up of values and duties based o n beliefs that people take for granted most of the time. Moral values describe certain peace and harmony with others. Moral duties describe certain actions required of you if you are to play your part in building a society (Purtilo, 1999). In contrast to morality, ethics connotes deliberation and explicit arguments to justify particular actions. Ethics also refer to a branch of philosophy that deals with the people to justify their positions and beliefs by rational arguments that can persuade others (P urtilo 1999) Morality informs many decisions that people use in their everyday experience, usually people move through life in accordance with its values and duties with little conscious awareness of it. Morality is habitual, shaping the character of individuals and communities without individuals even realizing it (Purtilo, 1999) Ultimately, such which usually provide an adequate guide for daily conduct, might fail to provide clear directions in many clinical situations. Pharmacists, like everyone, draw on many sources of moral guidance, including parental and family, cultural traditions, and religious beliefs. These create the roots of a reate a disposition to do the right actions. According to Lo

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20 ( 2009 ) however, these moral roots cannot be the only guidance for dilemmas in clinical ethics. First, personal moral values might not address important issues in clinical ethics. Often, pharmacis ts face many difficult ethical issues for the first time during their training and clinical practice Personal moral values may also offer conflicting advice on a particular situation and pharmacists may hold several fundamental beliefs that are in conflic t with professional obligations. Secondly, pharmacists have role specific ethical obligations that go beyond their obligations as good citizens and good persons; the address special professional roles According to Lo ( 2009 ) health care professionals must contend with at least three subgroups of morality: the personal morality, societal morality and the morality of the health professions and its institutions. Everyone has a personal morality, which is made up of the values and duties the individual has adopted as relevant. Health care professionals often have to deal with differences between their own personal moral beliefs and habits and the personal moralities of their pati ents with whom they interact (Lo, 2009 ) Furthermore, large components of personal morality represent a common denominator of shared beliefs about values and duties called societal morality. According to Lo ( 2009 ) these are often generated from culture, et hnicity, class, or geography. These beliefs may also spring from deeper religious and philosophic beliefs about humans and their relationship with God or with each other. Almost always some tensions exist between personal and societal morality. Examples of such tensions include views on abortion, euthanasia, and contraception. Additionally, pharmacists must content with group morality, which consist of moral values and duties that do not

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21 apply to others in society. These special values and duties of the hea lth profession include traditional oaths and codes of ethics as wells as modern customs and standards of professional practice (Lo, 2009 ). As noted by Lo ( 2009 ) much of the morality of the health professions is embedded in the policies, customs, and practi ces of health care institutions. Federal and state laws embody and codify moral values and duties that should govern individuals and institutional conduct. Laws about informed consent, confidentiality, and the competence required of persons working as prof essionals are based on moral values and duties the professional has to society (Lo, 2009 ) Occasionally the values and duties of a person come into conflict with the morality of a group that he/she has joined (Arras & Steinbock, 1995). According to Arras & Steinbock (1995) in health care today the accepted professional morality may conflict issue that has caused deep dismay for some health professional because of their pe rsonal morality. Similarly some health professionals may object to treating gay patients with AIDS because of a personal morality that rejects a gay lifestyle (Arras & moral ity of this type today overrides the professional duty to provide due care to Morality keeps individuals and groups directed toward behaviors and values that assure they can sustain themselves. The path of morality is one that individuals and groups can follow with ease and confidence most of the time because of good customs, laws, traditions, and other markers that have been posted. For an individual, the path will be most trouble free when her or his personal, societal, and group moralities are

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22 identical (Lo, 2009 ) However, as previously discussed, there is a possibility of problems and conflicts that could arise when personal, societal and group moralities do not align. To address these issue s and concerns, we often look to ethical theories and principles for language, methods and guidelines for studying the components of personal, societal, and group morality (Arras & Steinbock, 1995) consciously calls into question assumptions about existing components of morality that fall into the category of habits, customs, or traditions. Ethic s is a fundamental part of the life of every thoughtful individual and takes specific forms when someone assumes a special role as a health care professional ( Lo, 2009 ). Ethics, using the inherent dignity of human life and deep respect for all life and th e 2009 ) Ethics also addressees the subsequent questions: Do our present values, behaviors, and character traits pass the test of further examinat ion when measured against this standard; in situations where conflicts arise, which values, duties, and other guidelines are the most important and why; when new situations present uncertainty, what aspects of present moralities will most reliably guide in dividuals and societies on a sustainable path for survival and thriving; what new thinking is needed in such situations and why ? (Lo, 2009 ) re issues that must be addressed by health care providers, including pharmacists, and by society in general. These include among other

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23 things, abortion, assisted suicide, genetic engineering, organ transplantation and in vitro fertilization. Micro situatio ns in contrast, are specific to an individual pharmacist. These include specific issues that an individual pharmacists encounters in the course of his/her daily practice. These situations may include the pharmacist choosing to spend his/her time/energy cou nseling certain patients with specific disease states while refraining from counseling other patients with other types of disease states or medical conditions. course o f action (Montagne &McCa r thy, 2006 ). Clinical E thics and M oral R ights V ersus L aw Health care professionals often confuse what are really legal rights with moral rights. Legal rights are either guaranteed fundamentally in the US Constitution (e.g., the rights of free speech and assembly) or are provided by laws and regulations promulgated at the general, state, or local level (Lo, 2009 ) Moral rights are quite different from legal rights. Although these rights may be reinforced by laws, their basis lies not in law but in ethical theories and principles. Such rights might include the right to live without fear of harm and the right to receive equal medical care regardless of disease state or patient characteristics (Lo, 2009 ) Laws, through statues, regula tions, and decisions in specific court cases provide guidance as to what health care professionals may or may not do. However the law is limited in providing definitive answers to ethical dilemmas. Laws, especially criminal laws, set only a minimally acce ptable standard of conduct. These laws indicate what acts that, if performed will render the health care professional legally liable for having committed them (Lo, 2009 ) In contrast, ethics focuses on the right or the best decision in a situation. Further more as according to Lo ( 2009 ), ethical standards require health

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24 care professionals to act with compassion and integrity; it is impossible for the law to enforce such standards. Conflicting Professional Roles and Responsibilities The Duty to T reat P atients with Lifestyle D iseases Society may argue that the health care professionals have a Hippocratic duty to their patients, and that this responsibility focuses solely on what is best for the patient, irrespective of the consequences to others. This view is s upported by the Code of (1994) Code suggests that pharmacists have a moral obligation to do whatever they deem may not be without exceptions. It is possible that some pha rmacists may hold the view not contributed to their disease states and whom are compliant with drug regimens and lifestyle choices. Although most physicians, nurses, and pharmacists in American health care seem to have accepted the duty to provide suitable care regardless of the type of patient with whom they are presented, a growing number of Americans are now presenting with lifestyle related diseases. At the center of all educational efforts stands the fundamental moral dilemma, is it ethically permissible for a provider of health care to refuse or provide less care for patients with lifestyle related diseases.

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25 According to Arras & Steinbock (1995) this is a question o f conscience, it is a question posed by an individual to himself or herself in order to decide how his/her conduct should reflec t certain values and principles : It is a deeply personal question, but it goes beyond personal choice to the acceptance or reje ction of values and principles beyond the private self and deriving from social, cultural, and religious sources that surround the individual. Answering this question expresses the willingness to be identified with and by a certain cause of action and to b ear the burdens of being so identified (Arras & Steinbock, 1995) Although the question of conscience might sometimes involve legal obligation, in this dissertation the duty to treat will be defined as a moral rather than a legal obligation. This particular question of conscience is not familiar for most modern health professionals. As they generally go about their work, caring for patients that come into this such as the extremely non complaint patient or patients that have contributed to their own lifestyle disease. In general, however health care professionals take it for grant ed that they have duties to care for patients that they, or their institutions, have accepted (Arras & Steinbock, 1995) So, the problem of conscience with regard to patients with lifestyle disease is particularly difficult because it is unfamiliar to thos e struggling to resolve it. Health care professionals may be unclear about the terms of the problem, about the reasons it is a problem, and about the principles that might be used to reflect upon it. Ultimately, resolution depends on the conscientious judg ment of individuals (Arras & Steinbock, 1995)

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26 As noted by Arras & Steinbock (1995) the problem of conscience has several salient components: the influence of prejudice, the burden of caring for patients with lifestyle diseases, and the presumption of professional freedom of choice. The problem of the duty to treat and the quality of treatment may be dependent on the disease type. Smokers and many obese patients may contribute to their own disease states. Fu r ther more these groups are viewed in a negative light by American society, in what sociologists called stigmatization. This t erm designates a complex social and psychological process whereby certain persons are perceived as without social value and even as threatening to the dominant society (Arras & Steinbock, 1995) According to Arras & Steinbock (199 5), people who are stigma tized : Are marked for exclusion from certain social benefits and interactions. The stigma goes far beyond the actual features of the stigmatized and creates a negative social image that extends into all aspects of judgment about them, making it difficult to be objective about their behavior and their needs. ( Arras & Steinbock, 1995) Health care professionals have long honored an ethic of objectivity about their patients. However, there may be some instances where this honored ethic becomes stressed. It is possible that health care professionals may allow their personal opinions about the values, lifestyle, and morality of their patients to influence their professional judgments about t (Arras & Steinbock, 1995) Further, som e professionals may find certain persons so repugnant that they will not accept them as patients and, if they must serve them, they do so reluctantly and sometimes negligently. Negligent treatment is condemned as unethical, although reluctant treatment may be implicitly tolerated. Stigmatization influences the judgments of individuals in more subtle ways than overt dislike and frank prejudice. Accord ing to Arras & Steinbock (1995) :

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27 Professionals may disvalue the stigmatized in ways they hardly recognize. Even when professionals believe they are not prejudice, they may perceive and treat stigmatized p ersons differently from others. ( Arras & Steinbock 1995) Compounding the problem of prejudice, hea lth professionals may find the care of patients presenting with lifestyle related diseases a demanding task. Many patients come from groups with whose lifestyle the health professional may be unfamiliar and even unsympathetic (Arras & Steinbock, 1995). For example, a majority of pharmacists show interest in smoking cessation counseling, but according to Hudmon Prokhorov & Corelli (2006) only four percent of community pharmacists regularly ask their patients about tobacco use. In general, the caring for pa tients with lifestyle related disease may pose notable stress on professionals. Thus as health professionals are exposed to increasing number of patients presenting with lifestyle related diseases, their sense of responsibility toward these patients may b e influenced by their perceptions of the stress involved in caring for such patients and their overt prejudices and covert complicity with stigma (Arras & Steinbock, 1995) Arras and Steinbock (1995) also noted the importance of not discounting the strong value that Americans, including health professionals, place on freedom of choice. There is reluctance to force one person to provide services to another against his/her will. The principles of Ethics of the American Medical Association state that : A physi cian may choose those whom he/she wishes to serve. No law requires health care professionals to provide services to any particular patients, unless some special relationship already exists. The right to refuse to care for a particular patient, either by no t accepting that person as patients or by discharging oneself from responsibility in a recognized way is deeply embedded in those of American medicine. It is difficult to challenge this ethos by stating the health care professionals have an obligation that

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28 prohibits them from exercising such a presumed moral right (Arras & Steinbock, 1995) Sources of Obligation In the recent literature on the subject of professional responsibility, philosophers, physicians, and historians have attempted to articulate a bas ic principle that applies to the very work of providing help to the sick. Some have found it in the nature and character of the health care professional role, while others see it as the reciprocal obligations between society and the profession (Montagne & McCarthy, 2006 ) These arguments suggest that undertaking the role of a professional within a healthcare profession implies a commitment to certain virtues including the duty to care for the sick. It also stresses the implicit contract between a professio n to which society grants a monopoly on the healing arts and the society whose needs it serves. Edmund Pellegrino (2000) states the case in favor of a strong obligation most comprehensively. He suggests that three things specific to medicine impose an obli gation that interest to a duty of altruism : First, medical need itself constitutes a moral claim to those who are equipped to help because illness renders that patient uniquely vulnerable and dependent. Physicians invite trust from those in a position of relative powerlessness. Second, the is not proprietary, since it is gained under the aegis of the society at large for the purpose of having a supply of medical personnel. Those who acquire this knowl edge hold it in trust for the sick. Third, physicians in entering the profession, enter a covenant with society to use competence in service of the sick. (Pellegrino, 2000) These three reasons, Pellegrino (2000) argues, support the conclusion that physicia ns and other health professionals, collectively and individually, have a moral obligation to attend the sick. Thus there are multiple reasons to support the affirmation that service to the sick at risk and inconvenience it oneself is a matter of great

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29 impo rtance tradition, the solemn declaration of professionals, the nature of the profession itself and its virtues, the conditions of the sick and their relationship to providers, the expectations of society as a whole, and its social contract with profession s. Thus, as John Arras (1995) noted : All these reasons are open to some critical comment, but taken together they converge to the same point, namely that there appears to be a stringent and serious moral obligation, closely bound up with the very profess ion of being a physician or other provider of health care (Arras& Steinbock, 1995) However at the same time, it must be noted that even this stringent and serious obligation has certain limitations and exceptions. The ethical duty of attending the sick ca nnot be interpreted as an obligation on the health care professional to respond to any and every request for help; that would be physically impossible (Arras& Steinbock, 1995). Ethics and Professionalism Socrates approached ethics as a science, as being go verned by principles of universal validity, so that what was good for one was good for all, and what was my carefully thought out or how well constructed, can provide th e individual professional with guidance for each decision about clients, peers, or society. It is often believed that because each situation is different, each decision require separate analysis of possible outcomes from different actions and the weighing of right and wrong. Regardless of continuous self examination of professional duties and ethical principles to be prepared for the conflicts and dilemmas they will face (Mo ntagne & McCarthy, 2006 ).

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30 In this dissertation, professional ethics is used only to denote interpretation of the will of society for the conduct of the members of that profession augmented by the special knowledge that only the memb ers of the profession possess. As such, professional ethics involves those ethical principles to which society believes any individual claiming professional status should subscribe. Ethical principles, as well as codes of ethics, provide direction to professional s and professionals are expected to abide by them. These principles are important, in such that the code of ethics makes the decision making process more efficient (Montagne & McCarthy, 2006 ) In addition to therapeutic guidelines that provide pharmacist s and other health professionals a place to begin solving clinical problems, ethical principles and theories are needed to serve the same purpose. Ethical principles can act as rules of thumb for handling cases unfamiliar to the health care professional; b y serving as guidelines for formulating thinking about the problem at hand (Lo, 2009 ) Health care professionals must look to professional ethics for guidance when confronted with situations that they have never considered in great detail. Professional et hics also established a pattern of behavior that clients come to expect from members of the profession. Once a consistent pattern of behavior is discerned by clients, they expect that behavior to remain constant, and their expectations become part of the r elationship they establish with the professional. According to Lo ( 2009 ) pharmacists have an ethical obligation to care for their patients. Moral rules and ethical principles are tools used by pharmacists on a daily basis as they face ethical situations. E thical principles and moral rules provide guidance for practitioners about what the commitments of patient care entail (Lo, 2009 ).

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31 The ethics of pharmacy in the US has experienced a continuous evolution as the profession itself has changed. Pharmacy practi ce is far different today than it was when APhA issued its first code of ethics in 1852. The current changes that pharmacy experiences makes the existence of an ethical framework and personal ethic ever more vital today than it was in the past. The concept of pharmaceutical care continues to responsibilities and moral obligation to the patient (Montagne & McCarthy, 2006 ). Professional Characteristics According to Montagne & McCarth y ( 2006 ), the first characteristic of a professional is possession of a specialized body of knowledge. This body of knowledge allows the practitioner to perform a highly useful social function. Pharmacists possess the relevant professional knowledge about drugs and patients that permit the pharmacists to advise patients and prescribers concerning drug therapy, detect drug interactions, select appropriate product sources, and exercise professional judgment. Using this specialized body of knowledge and the in tellectual abilities, the professional makes a judgment as to the best course of treatment for each individual. Professionals are generally regarded to be generally more socially useful than other occupation, but social utility alones does not make an occu pation a profession (Montagne & McCarthy, 2006 ). The second characteristic of a professional is a set of specific attitudes that influence professional behavior. The basic component of this set of attitudes is altruism, an unselfish co ncern for the welfare of others. As such, the practitioner must consider the ne ed of the patient as paramount, relegating his or her own material needs to an inferior position (Montagne & McCarthy, 2006 ). The third characteristic of a professional is social sanction. Whether a n occupation is considered to be a profession depends, to

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32 a large degree, on whether society views it as such One measure of social sanction is the gaining of exclusive rights of practice through the licensing power of the state (Montagne & McCarthy, 2006 ). Licensing creates a relationship of trust between society and the professionals, because within the sphere of professional activities, the trust is a measure of the permitting the exercise of sovereign power over professional matters. As such professions are not controlled by society but rather allowed to self regulate (Montagne & McCarthy, 2006 ). All profess ions have been found to fall short of being a complete profession in at least a few respects. Pharmacy has often fallen short on the lack of autonomy and potential or real conflicts regarding professional compensation based on providing services opposed to products. However given that pharmacy has a legitimate claim to a theoretical body of knowledge, to a growing degree of socially sanctioned decision making authority and to a commitment of service as articulated by a code of ethics and an oath, pharmacy h as a prominent place in society as a profession. The I mportance of M oral and E thical E ngagement Pharmacists are morally and ethically responsible to their patients. The Code of Ethics for Pharmacists is as follows: I. A pharmacist respects the covenantal relationship between the patient and pharmacist. II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.III. A pharmacist respects the autonomy and dignity of each patient. IV. A pharmacist acts with honesty and integrity in professional relationships. V. A pharmacist maintains professional competence.VI. A pharmacist respects the values and abilities of colleagues and other health professionals.VII. A pharmacist serves individual, community, and societal nee ds. VIII. A pharmacist seeks justice in the distribution o f health resources (APhA, 1994)

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33 As noted previously, professionalism is the fiduciary relationship, which is a relationship and a covenantal relationship. The covenantal relationship is the essence of all professional relationships and is the foundation of the Code of Ethics that governs pharmacists as well as other health care professionals. Considering the patient pharmacist relationship as covenant means that a pharmacist has moral obliga tions in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust (Brown and Ferril l, 2009). Brown & Ferrill (2009) developed a taxonomic model of professionalism, in which the focus is shifted from learning to performance. Professionalism, as noted by the authors, can be envisioned as the product of three hierarchical domains of perform ance that can be represented as three levels of a pyramid referred to as the Professionalism Pyramid. Competence (professional expertise) forms the basic foundation. The ability to he next level. The highest level of professionalism, commensurate with strong fiduciary relationships, results from progressing to the character domain, which adds the dimensions of trust and morality. For a pharmacist to reach the pinnacle of professional ism the top of the pyramid character is the final domain, leading to personal reliability. Without character, a fiduciary relationship cannot thrive. A pharmacist of character functions from a solid base of morality and ethics. This requires a clear sens e of right and wrong based on ethical professional standards and a well defined foundation of moral truth. For some, the source of truth may be religious or spiritual in nature. For others, moral and ethical standards might come from societal norms or phil osophies.

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34 The character domain not only implies that one has the integrity to be consistent in distinguishing right from wrong, but also the moral courage to act accordingly. Professionals that reach the highest pinnacle of the taxonomic model perceive th at they are part of something larger than themselves and that their lives have meaning. Pharmacists who feel an altruistic drive to function as patient care advocates are more likely to behave in a reliable manner. Without a moral influence, self interest might tend subject to the influence of changing circumstances or conditions (Brown & Ferrill, 2009). armacy as being a moral issue. Health care professionals that are able to honor their fiduciary responsibilities, despite external pressures to the contrary are able to do so on moral grounds ( Brown & Ferrill, 2009 ). Professionalism is built on a cognitive foundation, but professional expertise serves little purpose unless it is effectively applied with affective skill and a moral perspective. Unfortunately the moral and ethical foundation that governs health care professionals is being eroded amid a climat e of declining professional ethics in which health care professionals are encouraged to practice social rather than individual patient ethics ( Brown & Ferrill, 2009 fiduciary nature of professionalism is being eroded with a soc iety that promotes self Ethical Dilemmas Ethical dilemmas are a common type of problem that involves two (or more) morally correct courses of action that cannot both be followed. As a result the a gent is ethical conduct or allocating societal benefits and burdens justly (Lo, 2009 ).

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35 Allocate R esources J ustly airness that is, people should get what they deserve. In addition, people who are situated equally should be treated equally. It is important to act consistently in cases that are similar in ethically relevant ways. Otherwise, decisions would be arbitrar y, biased, and unfair. More precisely, people who are similar in ethically relevant respects should be treated similarly, and people who differ in ethically significant ways should be treated differently ( Lo, 2009 ). efers to the allocation of health care resources. Ideally, allocation decisions should be made as public policy and set by government officials or judges, according to appropriate procedures. However rationing medical care at the bedside should be avoided because it might be inconsistent, discriminatory, and ineffective. At the bedside, pharmacists and other health care professionals should act as patient advocates within constraints set by society and sound practice ( Lo, 2009 ). Pharmacists are ethically o acting in the best interest of one patient might sometimes make it impossible for the pharmacist to act on behalf of another patient who is much more likely to benefit from care. Dilemmas arise because r supply and people have different priorities for limited resources. Patients do not always g et al l the treatment and attention they deserve or need because of lack of resources. Discrimination against some i ndividuals or groups creates lack of justice. It is possible that one group dis proportionately carries a heavier burden. A lack of due process regarding who received priority in situations of conflict raises

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36 concern, in that all similarly situated person s are not receiving their fair share of benefits (Purtilo, 1999). Traditionally, bedside rationing has been considered unethical although this belief is not universally held. It is argued that health care professionals should act as fiduciaries and patien t advocates, helping patients receive all the beneficial care that the system allows. This fiduciary role is deemed essential for maintaining patient trust. It is considered unethical for health care professionals to limit care to one patient primarily to benefit other patients (Lo, 2009 ). However, it is possible that some health care Distributive Justice Questions of distributive justice arise when more than one group is competing for t he same resources, each believing itself to be deserving of the resources. The principle of distributive justice requires equitable distribution of benefits and burdens (Purtilo, 1999). The idea of justice is to show respect for people by not making arbitr ary or capricious distinctions and by not discriminating against some groups on that basis. Justice requires that morally defensible differences among people be used to decide who gets what. To apply justice as an ethical principle, we must deal with a re source that is prized but is in such short supply, not every group who wants or needs it can have it. The to examine consumption inequalities on a global basis from the ethical perspective advanced by the philosopher John Rawls. According to Rawls (1996), a theory of distributive justice should provide a set of standards by which the distribution system of good within a society can be judged. The premise behind such a system is that a

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37 satisfactory existence for any particular individual is dependent upon the cooperation of all member of society. Thus, the division of economic advantages should be acceptable to everyone, regardless of status or position. Specially, no o any of the others are taken advantage of, or forced to give in to claims which t hey do not regard as legitimate (Rawls, 1996) Distributive justice is concerned with the fair allocation of resources among diverse members of a community. Fair allocation typically takes into account the total amount of goods and services to be distributed, the distributing procedures, and the pattern of distribution those results. Because societies have limited amount of wealth and resources, and similarly health care professionals have a limited amount of time and resources, a question arises as to how those benefits ought to be distributed (Rawls, 1996). Rawls In order for this perspective to embrace society in total, its guiding principles are derived from the original position, which is defined as a situation in which a person is unaware of his/her status among peers. This position results in principles of ju stice that delineate the ethical distribution of the primary goods of society. Rawls (1999) describes two fundamental principles : F compatible with a like liberty for all; and second, inequalities are arbitrary advantage. The second principle is in stark contrast to the ethical paradigm of utilitarianism, which allows greater advantages for one group in society to outweigh disadvantages for another group. ( Rawls 1999 ) al status, and family influences are matters of luck, and should not unduly influence the

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38 amount of benefits we receive in life. He maintains that the job of distributive justice is to limit the influence of such characteristics, so that goods might be dis tributed more fairly The first principle advocates for basic rights, while the second concentrates on social and economic inequalities. The second principle, often referred to utilita rian, and h olds that social and economic inequalities, for example, inequalities of wealth and authority, are just only if they result in compensating benefits for everyone, and in particular the least advantaged members of society (Rawls, 1999) Also refe rred t the second principle suggests that distributive justice exists only if inequalities maximize the situation of those who exist in the minimum societal position (Rawls, 1999). As such, inequalities, especially misfortune of birth (e.g. Childhood poverty) or discrimination (e.g. Bias based on certain characteristics), must be compensated for by those who are better off socially and economically. Thus all members of society are bound by the duty of fair play, which limits their pursuit of self interest (Rawls, 1999). The main moral motivation for the Difference Principle is similar to that for strict equality: equal respect for persons. As such, using the principles of distr ibute justice, patients should not be discriminated against based on their presenting characteristics. All patients should receive equal resources and time from health care professionals regardless of disease they are presenting with. A sense of injustice is aroused when individuals come to believe that their outcomes are not in balance with the outcomes received by people like them in similar situations. While it is clear that skin color or religion should not be valid criteria of distribution, it is uncl ear if health care professionals make such distinction for

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39 distribution of their time and resources based on the disease state/other defining characteristic with which the patient presents. Problem Statement Health care professionals are well educated on the negative consequences of lifestyle related diseases. Lifestyle related diseases are diseases in which the patient has engaged in behaviors directly or indirectly leading to their disease condition. Lifestyle related diseases include, but are not limite d to, COPD, cholesterol, and obesity. However, despite their participation in many educational programs aimed to increase knowledge of healthcare providers, lifestyle related disease counseling is lacking. While one might explain this apparent discrepancy from the perspective of several competing psychological models, it may be due to some form of cognitive dissonance. Cognitive dissonance is usually experienced when an individual has two or more cognitions that are dissonant in relation to one another res ulting i n motivational tension (Kleinja n, Van den Eijnden & Engels 2006). As previously explained, pharmacists, as health professionals, are held to its professions code of ethics, which serves to guide and set a standard of practice for pharmacists. Howe ver, some pharmacists may hold personal values/beliefs that are at odds with the Code of Ethics and the fiduciary relationship they promised to uphold. In the case of counseling decisions involving lifestyle diseases, some pharmacists may be guided by pers onal values/beliefs inconsistent with standards expressed in the code of ethics and these personal values may override professional standards leading to a decision to not counsel patients presenting with distinctive characteristics, such as lifestyle disea se, and thus disregarding their moral responsibilities. Pharmacists may rationalize or justify reasons why they do not counsel patients suffering from lifestyle diseases. These

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40 rationalizations or justifications are referred to as disengagement beliefs (a lso known as self exempting beliefs or permission giving beliefs). Having these beliefs may make it easier for pharmacists to disengage from their ethical and moral responsibilities (Oak e s, Chapman, Bor land et al 2004). It is postulated that disengagement beliefs may play a significant effect in a health care professional involvement in the application of pharmaceutical care (APC) Even though endorsement of disengagement beliefs may be an important predictor in the lack of involvement in APC the extent of health care professional s adherence to disengagement beliefs, as well as the importance of possessing disengagement beliefs in explaining APC has not been studied. Since health care professionals gen erally are not actively involved in APC even when aware of the negative consequences, this study will examine whether disengagement beliefs helps to explain why pharmacists often do not engage in APC es often lack a well developed theoretical framework for guiding the interventions employed. Presently, there is a lack of empirical work that have utilized a moral socio cognitive approach to explain the lack of lifestyle related disease counseling or if pharmacists make judgments on which type beliefs that may deter pharmacists from i mplementing pharmaceutical care and the means by which pharmacists make decisions to counsel or not counsel patients presenting with lifestyle diseases will provide a good guide to designing effective

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41 interventions. By targeting these variables and identif ying obstacles, these interventions can thus be used to influence community pharmacy practice. Consistent with recent arguments that the best explanations for unethical decision making may reside in underlying psychological processes, my intention is to explore regulatory processes are deactivated via the use of moral disengagement mechanism. Our understanding of moral disengagement remains at an early stage, despite its poten tial importance for explaining unethical decision making. Bandura (1991) noted that morality is so ingrained in people that it is not easily ignored. However, how does one explain, then the lack of the fiduciary relationship between health care profession welfare? Traditionally, the dispositional approach was focused on the idea that because of certain psychopathologies, some people fail to internalize the moral standards of society. However current resea rch has moved away from an exclusively dispositional model to more interactional explanations. It is thought that certain situational and psychological factors can prevent people from realizing how their behavior violates their moral principles. Thus immor al or unethical behavior arises from our failure to activate our moral standards. Social psychological models claim that all of us have the potential to violate out moral and ethical standards given the right circumstances. Once individuals realize the mor al ramifications of their actions, it is possible for them to within moral standards (Tsang, 2002)

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42 Given that health care providers are well informed of the dangers of smo king/other lifestyle choices and the benefits of APC (Application of Pharmaceutical Care) it seems plausible that disengagement beliefs may be used to deny or distort this knowledge, thus leading to an interest in discovering whether disengagement beliefs play an important role in the lack of APC Thus, the goal of this dissertation is two fold. First, to assess whether the adherence to disengagement beliefs is associated with lack of involvement in APC ; it is expected that disengagement beliefs are negati vely related to the provision of pharmaceutical care for patient presenting with lifestyle related diseases. Secondly, this study investigates the mechanisms of moral disengagement, defined as a set of cognitive mechanisms that deactivate moral self regula tory processes, used to explain why community pharmacists let personal beliefs override professional standards leading to a decision to not counsel patients without guilt or self censure. This research also sets to advance our understanding of the beliefs that underlie the mechanisms of moral disengagement and also an understanding of which mechanisms may be involved in cognitively misconstruing reprehensible behavior in a way that increases its moral acceptability. Preliminary W ork C onducted by the I nvesti gator Preliminary work include (a) two focus groups to investigate barriers and beliefs about smoking cessation counseling and (b) a pilot survey to investigate professional and personal values and beliefs of pharmacists regarding smoking cessation counsel ing. The focus groups were conducted with 40 practicing pharmacists. It was discovered that when faced with a decision to counsel their patients about a new or refill medication, pharmacists prioritize patients according to the type of disease states with which they present. In addition, it was found that pharmacists hold negative beliefs

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43 towards certain types of diseases or medical conditions that influence their decisions to counsel a patient, and that pharmacists see themselves as employees of large bur eaucratic corporations rather than as professionals who have control over all practice related decisions within their own practice settings. The pilot survey was administered to 140 pharmacists with a 72% response rate. The primary aim of the study was to explore professional and personal values and beliefs of pharmacists when confronted with patients who were specifically identified as smokers, an example of a life style related medical condition, compared with patients for whom a specific medical conditi on was not identified. The findings from the focus groups and the survey support supports the conjecture that some pharmacists decide whether to counsel patients depending on a states and that some pharmacists hold negative beliefs towa rd certain lifestyle related diseases. Significance Contribution to the F ield of P harmacy Examining the topic of moral disengagement within the context of professional moral and ethical obligations seems pessimistic. However there does exist a positive c ounterpoint, since this research seeks to uncover factors that can encourage moral behavior Although current research describes how certain aspects of the individual and situation can make moral behavior less likely, it also suggests that other situationa l and psychological factors may make disengaging from ethical and moral responsibilities more difficult and thus encourage more prevalent professional ethical conduct. Hence, it is possible that the explanation for the lack of the application of pharmaceu tical care ( APC ) does not reside in simply a lack of knowledge or skill that pharmacists possess, but in a complex interplay between situational factors and normal

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44 psychological processes with an emphasis on the role of moral disengagement beliefs. Knowled APC will not only help researchers explain the lack of occurrence of pharmaceutical care, but also Theo retical C ontribution This study may also make a theoretical contribution to the literature of moral socio cognitive theories. Reviews of relevant literature has not found research on socio cognitive theories as explanations of decisions or actions of healt h care professionals. As well, Bandura (1996 2002 ) demonstrated that individuals have many different methods of moral disengagement at their disposal, and did not rule out the presence of other motivations in addition to guilt avoidance. Thus situational factors (disease state type, patient characteristics) and motivational factors (time pressure on pharmacists ) power. By testing the predictive validity of this decision m aking model, this study seeks disengagement theory with patient characteristics, motivational factors, and a construct in disease occurrence and progression. A test of the predictive validity of this model will provide evidence for or against APC Based on the results obtained from th engage pharmaceutical care will be developed.

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45 Broader Impacts barriers. As such, understanding the be liefs that may deter pharmacists from implementing pharmaceutical care and how pharmacists make decisions as to whether or not to provide care to patients presenting with lifestyle diseases, would provide a good guide to designing effective interventions. By targeting these variables and identifying obstacles, these interventions can thus be used to influence community pharmacy practice. We anticipate that professional associations and others may wish to offer this program to their constituents. For pharma cists to fully benefit society in reducing the burden of lifestyle related making process when providing pharmaceutical care to patients This information could then be used to design effectiv provision of pharmaceutical care Previous research suggests that attitudes, beliefs and self efficacy may be crucial predictors of practice change among health care professionals (Walker et al. 2004; Perkins, J ens en, Jaccard et al., 2007). Odedina Segal & Miller (1997) found that attitudes toward pharmaceutical care, subjective norms, and perceived behavioral control to the provision of pharmaceutical care were key motivators of pharmacists. The authors also noted that behavioral intention, self efficacies, affect toward means and instrumental beliefs may directly affect behavior. Furthermore, there h ave been reports that pharmacists are heavily influenced by their personal beliefs. These studies and reports indica te that for certain disease states and medical conditions, especially as a significant barrier to provision of high quality patient care.

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46 Current intervention studie developed theoretical framework for guiding the interventions employed. As of present, there are disengagement theory to explain health The primary goal of this dissertation is to develop a theoretical framework to the opportunity to counsel a non smoker compliant asthmatic, a non smoker and non compliant asthmatic, and a smoker but compliant asthmatic. The goal will be application of pharmaceutical care on different severit y levels of lifestyle related diseases. For the purposes of this dissertation and to test the theoretical framework, asthma non smoker is considered a low lifestyle related disease, non compliant and non smoker is considered a moderate lifestyle related di sease, and smoker asthmatic is considered a high lifestyle related disease.

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47 CHAPTER 2 THEORETICAL MODEL Pharmaceutical care entails not only the clinical knowledge and skills that a pharmacist possesses but also a philosophy of practice. This philosophy of practice is termed pharmaceutical care. Pharmaceutical care entails the responsible provision of drug therapy for the purpose of ac quality of life. These definite outcomes include (1) cure of a disease, (2) reduction or elimination of symptoms, (3) arresting or slowing a disease process, and (4) preventing a disease or symptoms (Heple r & Strand, 1990) For pharmaceutical care to directly benefit the patient, the pharmacist must accept direct responsibility for the quality of that care. According to Hepler & Strand (1990) professional maturity can only be reached when pharmacists turn f rom self examination of professional well being toward greater responsibility to the public. Furthermore, Hepler & Strand (1990) noted that patient and are the primary ethi an interplay of statutory and regulatory law, ethical obligations, moral codes, and professional responsibilities (Brushwood & Belgado, 2002) Although p harmacists an expanded role for pharmacists that are more active and patient oriented. Ethical reforms and the enactment of OBRA 90 have also made the pharmacist a more a ctive reviews (DUR) and medication therapy management (MTM) (Smearman, 2006)

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48 What pharmacists ought to do for patients to whom they provide pharmaceutical products and services is both a moral and legal question. It is a moral question because pharmacists are capable of acting for both voluntary and conscious reasons to protect and promote the interests of others. It is a legal question because in exchange for the exclus ive rights to distribute medications, legal authorities impose duties upon pharmacists (Brushwood, 1996). According to Brushwood (1996), what pharmacists should legally do and what pharmacists should morally do are interrelated normative structure of Furthermore, Brushwood (1996) noted that pharmacists should provide information to their patients regarding medications because it is morally right to do so. This moral responsibility is based on capacity. As such, responsible individuals ought to do what they can for those for whom they are responsible. Capacity responsibility is based on the result of a perso (Brushwood, 1996). Pharmacists are capable of improving a patient quality of life through achieving definite outcomes. Thes e outcomes includes (1) cure of disease, (2) reduction or elimination of symptoms, (3) arresting or slowing of a disease process, and (4) preventing a disease o r symptom (Hepler & Strand, 199 0 ). Furthermore, pharmacists have a responsibility, beyond the es sential role of dispensing, to their patients. Pharmacists are considered moral agent for patien ts. Brushwood (1996) noted that : M oral agency implies that pharmacists understand they have defined responsibly which must be met. The moral imperative require s an individual

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49 to have the capacity to understand guidelines for action, be able to act on them, and unde rstand that one ought to do so. (Brushwood, 1996) Pharmacists willingly enter their profession and adopt its obligations, unlike participants in the military draft. Pharmacists are aware of their legal and ethical obligations and to being first. Similar to other professionals, t hey benefit from license that grants them exclusive franchise to practice a s a professional, and they obligate themselves to use their knowledge and expertise to help members of ts and welfare above their own (Smearman, 2006). Pharmaceutical c are r esponsibilities Brushwood and Hepler (1996) noted that there are three types of pharmaceutical care responsibilities. These are technical, judgmental, and normative. Knowledge and skill are included in technical responsibilit ies; judgmental responsibilities are based on applying the knowledge and skill and decision making; and normative responsibilities are based on role obligations and expectations within relationships. Pharmacists have a responsibility for drug therapy outc omes according to Hepler (1990) definition of pharmaceutical care. According to the definition of pharmaceutical care, pharmacists have a responsibility as defined by ly trustworthy within a Furthermore Brushwood and Hepler (1996) described the pharmacy philosophy as responsibility consisting of two parts: a retrospective component and a prospective component. Acc ording to Brushwood & Hepler (1996) the retrospective components is related to accountability in which pharmacists are answerable for their conduct and

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50 duties, while the prospective portion outlines the duty of pharmacists to respond to drug therapy probl ems. This duty is bound by (1) reasonable foreseeability of harm to a patient, (2) come before those moral trustworthiness, of a pr ivate duty yet to be fulfilled (Hepler, 1996, p. 36). Therefore, taking into consideration Brushwood & (1996) definition of the reasonably foresee that such actions are harmful to the patient and that the pharmacist is within their capacity to take action. This action may be counseling or referral to appropriate health care providers. Drug related morbidity may be considered preventable, according to Hepler & Strand (1990) when the following sequence of events occur: (1) the drug related morbidity is procee ded by a drug therapy problem that is recognizable; (2) given the drug therapy problem, the likelihood of a drug related morbidity is foreseeable; and the causes of the drug therapy problem are (3) identifiable and (4) controllable. In the case of a smoker patient: (1) the drug therapy problem is recognizable, the patient is not receiving medication (for example nicotine replacement therapy or other type of smoking cessation medication such as Chantix) for his/her nicotine addiction; (2) given that the pat ient is not receiving the appropriate medication for their disease state, it is very likely that the patient will suffer from a foreseeable drug related morbidity (for example breathing related diseases); and the causes of the drug therapy problem are (3) identifiable and (4) controllable.

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51 Through accepting responsibility, a pharmacist recognizes a duty to respond to circumstances where as a result of drug therapy or the lack of drug therapy, a patient is at significant risk of harm or is impeded from atta ining therapeutic objectives. Three factors bind pharmacists to this duty. First, harm from drug therapy problem or lack of drug therapy problems are legally permissib & Hepler, 1996).However, it is possible, in given circumstances, that even though a pharmacist may recognize that a drug re lated morbidity may be preventable, the pharmacist may choose not to participate in the prevention of the drug related morbidity. Pharmacists may hold personal beliefs and moral objections to the circumstances associated with certain patients such as those presenting with certain disease states. absolve him/her of all responsibilities and duties owed to the patient. The patient should pharmacist holds personal and moral views about patients presenting with certain therapy (APhA, 2004) The refusal clause endeavors to balance the rights of pharmacists and the rights of patients by requiring pharmacists to adopt a system of to the patient, a system where : The patient is unaware that the pharmacist is stepping away from the situation. Thus, refusals by pharmacists for reasons other than scientific

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52 legal and eth ical obligations (Smearman, 2006). Rationale and Theoretical Introduction Unethical behavior is persistent in virtually every sector of society including the medical professions. This leads us to raise an obvious and i arguments that the best explanations for unethical decision making reside in underlying psychological processes, this dissertation explores B people make unethical decisions when moral self regulatory processes that normally inhibit unethical behavior are deactivated via use of several interrelated cognitive r understanding of moral disengagement remains at an early stage, despite its potential importance for explaining unethical decision making. Research has primarily focused on aggression in children (Ba ndura, Barbarenelli & Caprara, 1996) or why people s uppo rt military action (Aquino Reed, Thau et al., 2007 ). We know little about the role moral disengagement plays with ethical decision making in the health professions. Similar to physicians and nurses, pharmacists, as health professionals, are held to a stan dard of conduct defined by their practice for pharmacists. However, some pharmacists may hold personal values and beliefs at odds with the code of ethics they promised t o uphold, resulting in what may be viewed as unethical practice behaviors by these practitioners. When pharmacists encounter patients with certain medical problems or conditions, they may withhold certain services during their patient encounters and yet p rovide these services to other

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53 decisions to counsel regarding certain lifestyle diseases, some pharmacists may be guided by personal values and beliefs inconsistent with standa rds expressed in the standards, leading to a decision to not counsel patients. Thus this study seeks to contribute to our current level of scientific knowledge about moral dis engagement by investigating eight mechanisms of disengagement, defined as a set of cognitive mechanisms that deactivate moral self regulatory processes, used to explain why pharmacists often make the decision to not counsel patients without experiencing gu ilt or self censure, as well as the relationship between moral disengagement and subsequent decision making in pharmacists. description of this theory and research findings will be presented in this chapter The Universal Value of Morality Morality emerges out of the social nature of human beings. Society develops in part because an individual who works in concert with others can accomplish goals that cannot be reached alone. Ho wever, social goals may compete with individual goals. another. Thus, within all societies, there exists some form of morality that is present and valued. Within each society, individuals are raised with a set of moral codes and thus strive to be moral or at least make efforts to refrain from being seen as immoral (Tsang, 2002) Based on the high value placed on upholding moral standards, it is not possible for people to simply violate their moral principles when they wish to reach goals in conflict

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54 with a moral or ethical code. Instead, individuals rationalize through the process of moral disengagement so that their actions still fall within moral standards. However, b efore disengagement beliefs are relevant, the individual has to perceive that moral principles are relevant to the present situation. Perceptions of the Situation It is possible that certain elements present in a situation can obscure the moral relevance. Pharmacists may perceive that a situation is not relevant to moral or immoral actions, which at this point the individual is not aware that his/her behavior violates moral principles and therefore has yet to engage in disengagement beliefs. Situational fa ctors that can conceal moral relevance may include perceptions of certain lifestyle diseases that the pharmacist may not perceive as being morally relevant. As such, certain lifestyle disease may serve to hinder perceptions of moral relevance. These factor s can work to obscure the relevance of moral principles, however when morality does become salient, individuals may engage in other motivations that will be influential in determining whether one chooses to uphold morality or to apply disengagement believ es to rationalize immoral actions. Motivations Moral rationalization evolves from the conflict between morality and other equally strong motivations. If an individual has no strong motivations that come in conflict with moral principles, then moral action is less costly, and he/ s he will be more likely to act morally. Yet, often, there exists motivations that complete with moral motivations. Individuals may have a number of motivations that can potentially compete with moral motivations. Difficult life cond ition, everyday self interest, obedience are examples of motivations that might come into conflict with moral principles. These are

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55 only a few examples of motivations that can potentially compete with moral motivations. Any motivation that would lead to th can conflict with moral motivations and lead to the activations of disengagement beliefs. For example, in the case of pharmacists, a conflicting motivation may be caused by the limited time that the p harmacist may be experiencing. Under situations when there is a high competing motivation (i.e. situations when time is very limited) pharmacists may be more likely to activate disengagement beliefs. Regardless of the motivations that health care professio (1990 a, 1990b 2002 ) theory of moral disengagement can be applied to both every day and extraordinary motivations that conflict with morality. Bandura stated that when competing motivations be it simple interests or more complex n eeds become sufficiently strong, individuals, including health care professionals, seek to violate their moral principles and fulfill these goals. However, because health care professionals are held certain moral standards that keep them in adherence to m oral principles in the absence of external reinforcements, they cannot simply behave immorally. Instead, they need to disengage their moral self sanctions to engage in non moral behaviors without the self condemnation that the sanctions would normally brin theory of moral disengagement, people can be motivated to engage in actions that violate moral principles and moral self sanctions need to be short circuited (morally disengaged) to enable individuals to act immorally. Individual s activate disengagement beliefs to release the strain associated with their conflict of motivations and their moral obligations.

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56 Dynamics of Moral D ecision to engage in AP C standards. However, certain aspects of the situation may obscure the relevance of morality and thus pharmacists may not counsel on lifestyle related diseases, unaware that they are n ot practicing professional moral conduct. Yet, at some point, pharmacists may realize that their behaviors violate their moral principles and covenantal relationship that they promised to uphold. When the moral relevance of their behavior becomes salient, pharmacists are faced with motivational conflict. The pharmacists may on APC moral princip les is also costly and may results in self condemnation. Acting on competing motives may be involved with self condemnation for engaging in immoral behavior. If the ratio of costs to benefits of acting morally is high, then instead of choosing to uphold mo ral principles, the individual may instead engage in moral rationalization and reconstrue potentially immoral behavior as being moral or irrelevant to morality. Through moral disengagement, this lowers the cost of acting immorally by reconstruing the act a s being irrelevant. Disengagement beliefs may be involved in the final decision of pharmacists whether or not to counsel patients presenting with certain characteristics and lifestyle diseases, this dissertation will involve looking at factors that affect certain point s of the moral decision making process Motivated R easoning: The Mechanics of Moral R ationalization Individuals are motivated not only to justify themselves to others but to convince themselves of the rationality of their conclusions. Kunda (1990) theorized that when

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57 individuals approach a situation with a preference towards a particular situation, this preference distorts their cognitions in the direction of the desired decision or interpretation. However, motivated reasoning will not work if the individual blatantly distorts information; the motivation toward a predetermined outcomes and its effects on the decision making process is largely unconscious (Kunda, 1990) (1990) theory of motivated reasoning to morality, people about to engage in moral rationalization have a preference for seeing their desired immoral behavior as still consi stent with moral principles. It is possible that pharmacists and other health care professionals may approach the decision to provide pharmaceutical care to patients al low them to appear moral and still choose the immoral action. 1990a, 1990b, 1996, 2002, 2004 ) moral disengagement theory addresses different aspects of the motivation to avoid the appearance of immorality. Bandura noted that an individual, thro ugh social learning, internalizes moral principles as self sanctions that bring self worth when they are upheld and self condemnation when they are violated. Before a person can engage in behaviors that violate moral principles he/she has to disengage from moral self sanctions to avoid self condemnations. Thus individuals are thought to be motivated by guilt avoidance. This dissertation will discuss the specific methods of moral rationalization that pharmacists can use to reduce the cost of immoral action. It will examine the ways in 1990a, 1990b, 1996, 2002, 2004 ) theory of moral disengagement identifies four difference categories of rat ionalization that can lead to

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58 moral disengagement: reconstruing conduct, obscuring causing harm, disregarding or distorting the impact of harmful behavior, blaming and t will be used to help guide the dissertation process Study Assumption In the model presented, the pharmacist is faced with the choice of either upholding moral principles or engaging in disengagement beliefs to justify a potentially immoral behavior, all owing him/her to violate moral principles but still believe that he/she is behaving morally. The first assumption of the model is that morality is valued by the individual. For, if people did not care about upholding moral standards, there would be no need to rationalize immoral behavior through disengagement mechanisms. Second, the individual needs to perceive that moral principles are relevant to the particular situation. Certain structures present in the situation, such as certain lifestyle diseases, ca n prevent morality from being salient. Third, once morality is salient, the individual weighs the costs and benefits of acting morally versus choosing a potentially immoral behavior. Though upholding moral principles, the individual can benefit through rec eiving praise from self or others. However, if the person has other motivations that compete with morality, then behaving morally will carry the cost of forfeiting the goals of the competing motivations. Description of Theory theory will be used to assess why community pharmacists morally disengage from their ethical and moral obligation to counsel or offer less quality of care to patients presenting with certain characteristics, and how personal beliefs may interfere with thei r professional responsibilities. For

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5 9 pharmaceutical care to fully materialize, professionalism needs to be actualized. And in order to fully actualize professionalism; an understanding of how pharmacists morally disengage from their professional and ethica l responsibility is required. Pharmacists are morally and ethically responsible to their patients. To understand decisions to not provide pharmaceutical care patients presentin g with certain lifestyle decisions when moral self regulatory processes that normally inhibit unethical behavior are deactivated via use of several interrelated cognitive m echanism collectively labeled moral disengagement. Bandura (1986) argued that moral disengagement explains why normal people are able to engage in unethical behavior without apparent guilt or self censure. Despite its potential importance for explaining un ethical decision making, our understanding of moral disengagement remains at an early stage. Psychological theories of morality Psychological theories of morality have traditionally focused heavily on the moral reasoning and the neglect of moral conduct. H owever, according to Bandura (2002) the regulation of human conduct involves much more than moral reasoning and includes also linking moral knowledge and reasoning to moral conduct. According to Bandura, individuals who differ in delinquent conduct do not necessarily differ in abstract moral values. Most everyone is virtuous at the abstract level, in which most everyone understand the difference between morally right and wrongs. It is, however, with the ease of moral disengagement of moral self sanction, th e ease of moral disengagement under the conditions of life, that the differences lie. Thus the regulation of conduct involves much more than moral reasoning. A theory of morality must specify the

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60 mechanisms by which people come to live in accordance with m oral standards. In social cognitive theory (Bandura, 1991 a, 1991c ), moral reasoning is translated into actions through self regulatory mechanisms through which moral agency is exercised. Reciprocal determination Social C ognitive T heory (SCT) developed by Alfred Bandura is based on the operation of established principles of learning within the human social context. There are five key concepts of SCT: (1) psychological determinants of behavior, (2) observational learning, (3) environmental determinants of b ehavior, (4) self regulation, and (5) moral disengagement (Bandura, 1986a, 1991a, 1991c ). SCT emphasizes reciprocal determinism in the interaction between people and their environments, in which human behavior is the product of the dynamic interplay of per sonal, behavioral, and environmental influences. The SCT adopts an integrationist perspective to morality, in which moral actions are the product of the reciprocal interplay of cognitive, affective, and social influences. It is thought that human behavior can only be fully understood via an integrated perspective in which social influences operated through psychological mechanism s to produce behavior effects ( Bandura, 1986a, 1991a, 1991c ). The self regulation of morality is thus not entirely an intra psyc hic matter. People do not operate as autonomous moral agents impervious to the social realities in which they are immersed. Moral agency is socially situated and exercised in particularized ways depending on the life conditions under which people transact their affairs. Due to this reciprocal interplay of personal and social influences, individuals may find themselves conflicted between self and social sanctions when they are socially punished for courses of action they regard as right and just ( Bandura, 1 986a, 1991a, 1991b, 1991c, 1991b, 1999, 2001 ) Conflicts thus arise, when individuals are socially

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61 pressured to engage in conduct that violates their moral standards. Responses to such moral dilemmas are determined by the relative strength of self sanction s, social sanctions, and the conditional application of moral standards (Bandura, 2002 ). An Agentic Perspective Accordingly, although environment plays an important role in shaping behavior, uct environments to suit purposes they devise for themselves. For the essences of humanness, is the capacity Social cognitive theory offers an agentic perspective on human behavior whereby ind ividuals exercise control over their own thoughts and behaviors through self just on looking hosts of internal mechanisms orchestrated by environmental events. They are agents of experiences rather than simply under goers of experiences. There exists, sensory, motor, and cerebral systems and tools that people use to accomplish the tasks a nd goals that give meaning, directions and satisfactions to their lives (Bandura 1986b, 1991b,1999, 2001; Harre & Gillet 1994).The human mind is not just reactive, rather it is generative, creative, proactive, and reflective. All agents embody their own belief systems, and self regulatory capabilities. Beliefs systems are a working model of the world that enables people to achieve desired outcomes and avoid untoward ones. In order to make their way through a complex and challenging world, effects of different events and courses of actions, size up socio structural opportunities and constraints and regulate their behavior accordingly. Agency enables people to play

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62 a part of their self development, adaptation, and self renewal with changing times (Bandura, 2001). The core features of human ag ency address the issue of what it means to be human and are as follows: intentionality, forethought, self reactiv e ness, self re f lectiv e ness, and a gency refers to acts done intentionally. An intention is a representation of a future course of action to be p erformed. It is not simply an expectation or prediction of future actions, but a proactive commitment to bring them about and center on plans of actions. Intentions and actions are separated only by time. Forethought is a temporal extension of agency that goes beyond forward directed planning (Bandura, 2001). Through the exercise of forethought, people motivate themselves and guide their actions in anticipation of future events. Foresight provide directions, coherence, and future events are converted into current motivators and regulators of behavior. Behavior is motivated and directed by projected goals and anticipated outcomes through anticipatory self guidance, rather than being pulled by an unrealizable future state. I n regulating their behavior by outcomes expectations, people adopt courses of action that are likely to produce positive outcomes and generally discard those that bring unrewarding or punishing outcomes. Afterward, individuals adopt personal standards, and regulate their behavior by self evaluative outcomes, which may augment or override the influence of external outcomes (Bandura, 2001). Bandura further noted that an agent is not only a planner and fore thinker but a motivator and self regulator as well. Agency involves the deliberative ability of people to make choice and action plans and also the ability to give shape to appropriate courses

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63 of actions and to motivate and regulate their execution. This multifaceted self directedness operates through self regulatory processes that link thought to action. Self referent sub functions (self monitoring, performance self guidance via personal standards, and corrective self reactions) are thought to govern the self regulation of motivation, affect and action. Act ions give rise to self reactive influence through performance comparison with personal goals and standards. Goals, rooted in a value system, gives rise to a sense of personal identity and motivate activities with meaning and purpose. Moral agency forms an important part of self directedness. Moral reasoning is translated into actions through self regulatory mechanisms, which include moral judgment evaluated against personal standards and situational circumstances, and self sanctions by which moral agency is exercised (Bandura 1991a 1991b ). It is important to note that moral standards do not function as fixed internal regulators of conduct. Self regulatory mechanisms do not operate unless they are enlisted in given activities. Lastly, according to Bandura, self reflectiv e ness, the meta cognitive capability to distinctive core human feature of agency. Through reflective self consciousness, people evaluate their motivation, value s, and the meaning of their life pursuits. At this higher level of self reflectiveness, individuals address conflicts in motivational inducements and choose one act in favor of one over another. Central among the mechanisms of personal agency, is the self efficacy beliefs that people have to exercise some measure of control over their own functioning and over environmental effects. According to Bandura, e fficacy beliefs are the foundation of human agency. Unless people believe

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64 they can produce desired resul ts and forestall detrimental ones by their actions, they have little incentive to act or to persevere in the face of difficulty. Efficacy beliefs affect adoption and change in a own right, but also through their impact on other determinants. Effic acy beliefs play a central role in the self regulation of motivation through goal challenges and outcome expectations. Efficacy beliefs affect what challenges people choose to undertake, how much effort to expect in the endeavor, how long to persevere in t he face of obstacles and failure, and whether failures are motivating or demoralizing. Efficacy beliefs also play a key role in shaping the courses lives take by influencing the types of activities and environments people choose to get into. Social influen ces operating in selected environments can promoted certain competencies, values, and interests, long after the decisional determinant has rendered its inaugurating effect. Thus, by choosing and shaping their environment, people can shape what they become (Bandura, 2001) Exercise of M oral A gency The exercise of moral agency has dual aspects inhibitive and proactive. The inhibitive form is the power to refrain from behaving inhumanly, while the proactive form is expressed in the power to behave humanely. I n situations that encourage inhumane behavior, people can choose to behave otherwise, by exerting counteracting self influence. Anticipatory self sanctions thus keep conduct in line with internal standards. It is the ongoing exercise of self influence that motivates moral conduct (Bandura, 1999). In SCT, moral reasoning is translated into actions and self sanctions by which moral agency is exercised. As described previously, the moral self is thus embedded in a broader, socio cognitive self theory, encompa ssing self organization, proactive, self reflective, and self regulative mechanisms. Moral reasoning is linked to moral action

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65 through affective self regulatory mechanisms by which moral agency is exercised. These self referent processes provide the motiv ational as well as the cognitive regulators of moral conduct. In early phases of development, conduct is largely regulated by external dictates and social sanctions. Through socialization, moral standards are constructed from information conveyed by direct expose to the self evaluative standards modeled by others. Once formed, such standards served as guides and deterrents for actions. As previously mentioned, morality is rooted in a self reactive selfhood, rather than in dispassionate abstract reasoning. During the self regulatory process, people monitor their conduct and the conditions under which it occurs, judge it in relation to their moral standards and perceived circumstances, and regulate t heir actions by the consequences they apply to themselves. They do things that give them satisfaction and a sense of self worth, and refrain from behaving in ways that violate their moral standards because such conduct will bring self condemnation. During situational inducements to behave in unethical ways, people can choose to behave otherwise by exerting self influence. Thus, through the ongoing exercise of evaluative self influence, moral conduct is motivated and regulated (Bandura, 1996). The constraint of negative self sanctions for conduct which sanctions for conducting faithful personal moral standards operate anticipatorily (Bandura, 1999). The self regulatory system that grounds moral a gency, according to Bandura, operates through three major sub functions: self monitoring, judgmental, and self reactive sub functions. Self

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66 exercising control over it. Action gives rise to self reaction s through a judgmental function in which conduct is evaluated against internal standards and situational circumstances. Moral judgment sets the occasions for self reaction influences. People get themselves to behave in accordance with values and morals thr ough anticipatory positive and negative self reactions for different courses of action. Of importance, self reactive influences do not operate unless they are activated and, according to Bandura there are many psychosocial processes by which self sanctions can be disengaged from inhuman conduct. Selective activation and disengagement of internal control permits different types of conduct with the same moral standards. Bandura proposed moral disengagement as the key deactivation process. Through moral diseng agement, individuals are freed from the self sanctions and accompanying guilt that would ensue when behaviors violate internal standards, and they are therefore more likely to make unethical decisions (Bandura, 1999). Bandura (1996 2001, 2002 ) noted that disengagement practices will not instantly transform a considerate person into a one without morals. Rather this change is achieved by gradually disengagement of self censure. In fact, it is quite possible that individuals may not even recognize the change s they are undergoing. Initially, they perform milder aggressive acts they can tolerate with some discomfort. The individual gradually becomes more and more de sensitized to their immoral actions through repeated enactments. The levels of disengagement pra ctices increases, and are eventually carried out with little personal anguish or self censure. Inhuman practices, as noted by Bandura, become thoughtlessly routinized.

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67 Mechanisms of D isengagement Self sanctions can be disengaged by (a) the reconstrual of the conduct itself so that it is not viewed as immoral, (b) the operation of the agency of action so that the perpetrators can minimize their role in causing harm, (c) the consequences that flow from actions, or (d) how the victims of maltreatment are regarded by devaluing them as human beings and blaming them for what is being done to them (Bandura, 1999 2002, 2004 ) Bandura ( 1990a, 1990b ) suggested that moral self regulation can be deactivated or disengaged via eight interrelated moral disengagement mechanisms: moral justification, euphemistic labeling, advantageous comparison, displacement of responsibility, diffusion of responsibility, disregarding or distorting the consequences, dehumanization and attribution of blame. Bandura Barbaranelli & Capr ara (1996) demonstrated that individuals have many different methods of moral disengagement at their disposal, and did not rule out the presence of other motivations in addition to guilt avoidance. Thus situational factors (severity of lifestyle disease) a nd motivational factors (time pressure on healthcare its predictive power with healthcare provider behaviors. By testing the predictive validity of this decision making mo del, this study seeks to assess the interplay between the occurrence ( Figure 2 1 and Figure 2 2 )

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68 Moral j ustification harm to others in ways that make it appear morally justifiable. In this process of moral justification, detrimental conduct is made personally and socially acceptable by portraying it as serving socially worthy or moral purposes. People then can act on a moral imperative and preserve their view of themselves as moral agents while failing to help others even though helping is a professional responsibility (Bandura, 1999 2002 ). Vogt & Marteau (2007) showed that British G eneral P ractitioner consider ed quitting smoking was not cost effective for the patient. Fewer than half the Beliefs about cost effectiveness were directly related to recommend smoking cessation servi ces, and this relationship was particularly strong for local services. In context of community pharmacists: the detrimental conduct of not counseling patients on smoking cessation may be made personally and socially acceptable by portraying that smokers ne ed to smoke to relieve the stress in their lives. For example, refraining from counseling smokers about cessation may be justified by stating that without the ability to smoke, smokers would not be able to relieve stress. Similarly, pharmacists may justify their lack of counseling by stating that smoking cessation is too expensive to the patient. It is also possible that pharmacists may justify the lack of counseling non compliant patients as it is alright to not counsel non compliant persons because it is their choice ( Figure 2 2 ). Euphemistic labeling With euphemistic language, individuals use morally neutral language to make questionable conduct seem less harmful or even benign. Activities can take on very different appearances depending on what they are called. Therefore,

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69 euphemistic language may be u sed to make harmful conduct respectable and to reduce opposed to going out for a smoke, thus they label the act of inhaling carcinogens as socially acceptable. Also, labe the act to be seen as non harmful ( Figure 2 2 ). Advantageous comparison. With advantageous comparison, unethical behaviors are compared with even more harmful conduct thus, making the original behavi or appear acceptable. By exploiting the contrast principle, acts can be made righteous. Likewise, pharmacists may note that other possibly more deserving patients require their time and energy. Furthermore, pharmacists may compare themselves against physic harmful than pharmacists counsel ( Figure 2 2 ). Displacement of responsibility. Bandura (1986) postulated that people will behave in ways they typically repudiate if a legitimate authority accepts responsibility for the effects of their conduct. Similarly, when individuals view their behaviors as a direct result of authoritative dictates (e.g. my boss told me to do it), they may displace responsibility for their actions to the authority figure, negating any personal accountability for the unfavorable act. Under displacement responsibility, people may view their actions as stemming from the dictates of authorities thus because they are not the actual agent of their actions they are spared self condemning reactions. In the context of pharmacists, it is plausible that they may see themselves as obliging employees of large corporations whose sole motive is to improve the bottom line. Pharmacists may then displace their profe ssional responsibility to counsel by

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70 mitigating their responsibilities to counsel patients as a direct result of authoritative dictates. Pharmacists may then be seen as functiona ries who honor their obligations to cause ( Figure 2 3 ). Diffusion of responsibility. The exercise of moral control is also weakened when personal agency is obscured by diff using responsibility for detrimental behavior (Bandura barbarnelli & Caprara 1996 ; Bandura 200 2 ). Adverse group behavior may trigger diffusion of responsibility because no one group member feels personally liable A sense of responsibility can be diffused, and thereby diminished, by division of labor. The responsibility to counsel on lifestyle related diseases is thereby diffused among multiple health care providers including physicians, nurses, and pharmacists, un til no one single entity feels personally responsible for the lack of ( Figure 2 2 ). The Vogt & Marteau stopping smoking, preferring instead to refer them to other health professionals. This conse quently involves a transfer of responsibility for helping smokers to stop smoking. A consequence, noted by the authors, is that smokers may try to quit unaided if their GP does not try to assist them. Disregard or d istortion of consequence Individuals may also disconnect harmful activities from self sanctions by distorting the consequences associated with a given act. For example, customers may possibly tell themselves that no one was

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71 suffering is not visible and when injurious actions are physically and temporally remote from their effects. Most organizations involve hierarchical cha ins of command in which superiors formulate plans and intermediaries transmit them to functionaries who then carry them out. The farther removed individuals are from the destructive end results, the weaker the restraining powe r of injurious effects (Detert Trevino & Sweitzer, 2008). disease states and lifestyle habits and thus can feel distantly removed from their Figure 2 2 ). Dehumanization. Finally, dehu manization and attribution of blame can disengage moral sanctions by reducing identification with the targets of harmful acts. Research has consistently shown the tendency of individuals to form groups and quickly develop us versus them thinking based on g roup membership (Brewer, 19 9 9; Gaertner and Insko, 2000). Similarly, attribution of blame can exonerate the self by placing fault with the target of the harmful behavior. For example, smokers and/or non compliant patients can be seen as being a group of we ak willed individuals who are unworthy of the time and energy needed to counsel these individuals ( Figure 2 2 ) There is a general misconception and stigma attached to addiction and substance dependence. The misconception that addiction is caused by an ind and lack of willpower continues and contributes to the stigma associated with substance abuse. In addition, there is the belief that treatment for those with addiction problems is ineffective (Martinez and Murphy Parker, 2003).

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72 Vogt & Marteau (2005) reported a sizable percentage of primary care providers their patients. Approximately 42% believed that discussing smoking cessation was too time consum ing, 38% believed it was ineffective, and 22% reported lacking confidence in their ability to discuss smoking cessation services. In addition, 20% of PCP s believed that directing smokers to the central services was inappropriate and 9% thought that directing smokers to such services was ineffective. Attribution of blame. Blaming other people or circumstances is another method that can serve self exonerat ive purposes. By fixing the blame on others or on righteous. Victims are often blamed for bringing the suffering on themselves (Bandura, 200 2 ). Similarly, patients may be b lamed for bringing the suffering on themselves (Figure 2 3 ). Bandura has presented initial evidence that these cognitive processes operate as part of a single overarching moral disengagement construct that can be linked to outcomes such as childhood aggres sion or delinquency (Bandura, Caprara, Barbaranelli et al., 2001). Research F indings Previous research has primarily focused on aggression in children ( Bandura, Barbaranelli & Caprara, 1996; Bandura, Caprara, Barbaranelli et al., 2001 ) or why people suppor t military action (Aquino, Reed & Thau, et al. 2007). We know little about the role moral disengagement plays with ethical decision making in the health professional sector, given that health care professionals are held to a higher ethical and moral stand ard. This study therefore seeks to contribute to knowledge about moral

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73 disengagement by investigating the mechanisms of disengagement, as well as the relationship between moral disengagement and subsequent unethical decision making in pharmacists. Bandura et al. (1996) investigated how the full set of moral disengagement mechanisms operate in concert on socially injurious and antisocial conduct under naturally occurring conditions in 124 elementary school children and 675 junior high school students. The authors found that high moral disengagers are more readily angered and behave more injuriously than those who apply moral self sanctions to detrimental conduct. High moral disengagers were less troubled by anticipatory feelings of guilt, and more prone to resort t o vengeful ruminations and irascible reactions. These factors, in turn, related to delinquent behavior. Moral disengagement affects delinquent behavior both directly and indirectly through its influence on pro social behavior, level of guilt, and aggressio n proneness. In summary, the authors noted that controlled variations in displacement and diffusion of responsibility, dehumanization, and euphemistic labeling lead people to behave more aggressively. However, whereas moral disengagement weakens self rest raints over injurious conduct, if the perpetrator views the victim who is humanized and not blamed entirely for their life predicaments, adherence to self sanctions is strengthened via empathy, by assuming personal minimizing their injurious effects. As such, people refuse to behave cruelly, even under high instigation to do so, if victims are humanized and they act under personalized responsibility. The authors concluded that moral disengagement starts operating in the early years of life. Developmental research shows that moral disengagement contributes to social discordance in ways that are

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74 likely to lead down dis social paths. Bandura et al. (1996) reported that high moral disengagers are less troubled by anticipa tory feelings of guilt over injurious conduct, are less prosocial, and prone to ruminate about perceived grievances and vengeful retaliation, all of which are conducive to aggression and antisocial conduct. The higher the moral disengagement, the weaker th e perceived self efficacy to resist peer pressure for transgressive activities led to more involvement in antisocial conduct Menesini Sanchez, Fonzi et al (2003) investigated the degree to which peer nominated bullies, as compared with victims and outsi ders, emphasized emotions associated with moral responsibility (guilt, shame) versus moral disengagement ( indifference, pride) in explaining bully behavior. Peer identified bullies were significantly more likely to describe the bully as feeling pride than were victims or outsiders, and significantly more likely to describe the bully as feeling indifferent for bullying were also more egocentric in orientation, more likely to emphasize the personal consequences or advantages for the bu lly in this situation. Consistent with the construct of moral disengagement, bullies emphasized morally disengaging emotional explanations and focused on benefit s (or costs) for the self. Hyme l, Rocke & Bonanno (2005) further examined the justifications, attitudes and beliefs of students who reported differential experiences with both bullying and victimization. The authors found that students who reported that they frequently bully others exhibited the highest levels of moral disengagement, while student s who never bullied others displayed the lowest levels of moral disengagement. However, although students who admitted to bullying others in the present study were more likely to morally disengage, they were not the only individuals who did so. The majorit y of student surveyed, even those who did not

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75 report bullying activities, were found to endorse items that reflect different degrees of moral disengagement Detert Trevino & Sweitzer (2008) investigated whether moral disengagement is an important precursor of unethical decision making, and set to determine which individual differences may make people more prone to moral disengagement than others. The study was conduct as a multi wave survey study on 824 business and education undergraduates in the business and education colleges of a large public research university in the Northeast. All surveys were administered by one of the authors or a trained graduate assistant. Survey 1 was designed to collect individual differences; survey 2, measured moral disengag and survey 3, which contained items from the Unethical decision making scales, was administered several weeks after survey 2. The authors found that individual differences in empathy, trait cynicism, chance lo cus of control, and moral identity predict moral disengagement, and that moral disengagement predicts unethical decision making. Of importance, the authors found that higher levels of moral disengagement to be positively associated with increased unethical decision making, providing additional support beyond research previously conducted on aggression in children (Bandura et al 1996, 2001) and beyond research that found relationship between a single moral disengagement mechanisms (moral justification) and coworker undermining (Duffy Shaw, Scott et al., 2005). Thus these findings suggest that moral disengagement can theory applied to general transgressive behavior, it is possible that the findings on moral

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76 behaviors that violate societal or organizational norms. McAlister (2001) developed a 15 question scale to measure moral disengagement in suppo rt for military action. The survey was conducted on 128 secondary students in the USA and Finland. The author found that exposure to persuasive communications favoring either moral disengagement or resistance to moral disengagement had a significant impact on moral disengagement. Moral disengagement increased in the group exposed to persuasive communication, and decrease in the group exposed to resistance to moral disengagement. Bandura ( 2004 ) conducted a study to investigate how mechanisms of moral disenga gement are involved in the origins of terrorism. Bandura found that moral justification; displacement of responsibility; disregard for consequences and dehumanization all play a role in the graduation to terrorism. Moral justification can turn killing into a moral act, in such that the perpetrator views that non violent acts are ineffective and justifies their actions by comparing their immoral acts against larger atrocities. Thus their actions are justified as a necessary action for social change. Displace ment of responsibility is another form by which terrorist morally disengage. Terrorist often see themselves as patriots doing the states bidding, thus absolving their responsibility. They further may diffuse the responsibility through the acts of many peop le. Furthermore, terrorists minimize the consequences of acts they are responsible for, by removing themselves physically from the victim. As such victims that are harmed are often not visible to the superiors who make decisions. Dehumanization also plays a

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77 beings. Moral disengagement can affect detrimental behavior both directly and by its impact on other theoretically relevant determinants. Therefore, this research tests a conceptual model of the paths of influence through which moral disengagement produces its behavioral effects. The directional paths are specified both by theory (Bandura, 1991 a, 1991b ) and by empirical tests of particular links in the mode l. Moral courage As mentioned above, individuals can disengage from moral agency via eight disengagement mechanisms. However it is possible in the case of individuals possessing moral courage that the pharmacist triumphs as a moral agent over compelling s ituational pressures to behave otherwise. In the exercise of proactive morality, people act in the name of humane principles, sacrifice their well being for their convictions, take personal responsibility for the consequences of their actions and remain se nsitive to the suffering of others. Finally, they see human commonalities rather than distance themselves from others or divest them of human qualities (Bandura, 1999)

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78 Figure 2 1 Hypothesized Model

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79 Figure 2 2 Model framework for application of pharmaceutical care for smoking cession (Similar Models for counseling on non compliant patients)

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80 CHAPTER 3 ME T HODS Overview The primary objective of this study was to develop a pharmacist model of decision making to exp lain why pharmacists choose to provide pharmaceutical care for some patients and not others. This was accomplished by designing a self administered survey for pharmacists containing measures based on the operationalization of constructs from ry of Moral Disengagement. The validity of the pharmacist model of decision to provide pharmaceutical care on lifestyle diseases was then examined by testing proposed relationships between the measures using survey responses from pharmacists and pharmacy s tudents in Florida. This chapter describes the methods that were used to achieve these objectives. The process by which the survey was designed included operationalization of study constructs, a pretest, and a subsequent revision for the validation study ( Figure 3 1). All of these are discussed in the next section. The section that follows describes the sampling procedure used to identify the potential subjects for the validation study, the data collection methods, data analysis t echniques, and study hypoth eses. Survey Development A self administered survey called the Professional Obligation Instrument (POI) was developed for this study. The process by which the POI was developed is described in this section. First, a convenience sample of community and ambu latory care pharmacists were interviewed regarding their experiences with patients and drug therapy problems. Their comments were used to aid in developing scenarios and items of the POI. Once the POI was designed and reviewed by a Delphi panel for content

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81 validity, it was pretested among a sample of pharmacist members attending a continuing education program and fourth year pharmacy students. Furthermore, test retest reliability to assess the stability of the measures of constructs comprising professional obligation for the presented patient scenarios was tested among fourth year pharmacy students. This section describes how the POI was developed, pretested, and revised in preparation for the validation study. Pharmacist Interviews A convenience sample of 1 8 community and ambulatory care pharmacists were interviewed regarding experiences with patients and drug therapy problems. Interviewees were asked open ended questions about drug related events, how they would perceive a non smoker asthma patient who was compliant with their asthma medications, a non smoker asthma patient who was non compliant with their asthma medications, and a smoker who is experiencing an exacerbation of her asthma likely due to smoking. In addition, questions probed the time pressure s that pharmacists experience, and beliefs they may hold about smokers and patients who are non compliant or compliant with their asthma medications. Comments from the interviewees were used to facilitate the designing of the POI. Three patient care scena rios were written, as well as items intended to measure these constructs is presented in the next section. Before describing the constructs, the various steps that led to th e development of the POI are discussed. Content Validity, Readability, and Face Validity adequately represent a specific domain or construct (Crocker & Algina ,1986 ). Once the

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82 POI was constructed, a Delphi panel assessed it for content validity and rank ordered the disengagement mechanisms and items in importance. To assess the readability and face validity of the POI, the survey was administered to 30 pharmacists. Each took 15 20 minutes to complete the survey. Areas that were confusing or unclear were noted by the pharmacists. Delphi Panel The Delphi process, a quantitative method, was used to determine which items representing the moral disengagement mechanisms to include in the POI. The written instrument was presented individually and simultaneously to selected respondents for answering. Panel members had no contact with each other and remained unknown to each other. This method is considered advantageous over focus groups and key informants and plays a critical role in the accuracy and reliability of the information generated. The Delphi panel method avoids conformity pressure and domination by influential panel members which are weaknesses of focus groups and key informant me thods. Thus the respondents have the opportunity to comment on the consensus individually but not as a group as in the case with focus groups (Oranga & Nordberg, 1993). Panel selection. The Delphi panel member included experts in the community. Members of the panel included health behaviorists, pharmacy residents, and an Associate Pharmacy Dean. In total four experts participated in the Delphi panel. These experts were chosen because they could assess the relevance and importance of the items and moral dise ngagement mechanisms presented in the questionnaire. The panel was provided with definitions of scale domains and instructions for evaluation of the instrument.

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83 Questionnaire development. The Delphi study questionnaire included 40 items reflecting the eig ht moral disengagement mechanisms. The questionnaire sought information in three areas: Which of the moral disengagement mechanisms are of most importance in regards to pharmacy professional practice, whether the items are representative of the disengageme nt mechanisms, and whether the patient care scenarios were representative of real life scenarios that pharmacists would experience. Ranking and scores In the Delphi panel, responses to each disengagement mechanisms were recorded in terms of ranks, assuming some linear or nonlinear relationship between the importance of the outcomes and ranks. Ranking is suitable when more than two disengagement mechani sms are compared and ordering is possible but quantitative scores cannot be assigned. Delphi panel results. The eight mechanisms of moral disengagement were ranked by the Delphi Panel: 1= Most importa nt, 8= least important (Table 3 1). Scores were summated, with lower scores indicating higher importance and higher scores indicated lower importance. According to the Delphi Panel use of euphemistic languages, advantageous comparison, and distorting consequences were removed from the survey instrument, since they were ranked as the least important disengagement mechanisms. Dehumanization was kept in the instrument even though the Delphi Panel ranked this mechanism as not being important because a previous pilot study indicated that this mechanism may b e significant in explaining why some pharmacists may not provide pharmaceutical care to smoker patients. Survey Pretest Following review of the POI by the above individuals, the survey instrument was pretested among a sample of practicing pharmacists and f ourth year pharmacy

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84 students. Objectives of the pretest included documenting reactions and concerns to the drug therapy problems in the patient care scenarios, obtaining a conservative return rate estimated for the POI, and conducting preliminary reliabili ty assessments through estimating internal consistency using coefficient alpha Patient care scenarios were assess whether the scenario represented a possible real life event that pharmacists may encounter. An alpha estimate greater than or equal to 0.65 was considered acceptable (Nunnally, 1978). Item analysis was also conducted by examining the corrected item total correlation for each item. The item total correlation is the correlation between the item score and the total for the remaining items in the corresponding domain (Crocker & Algina, 1986). For the pretest, 122 pharmacists attending a continuing education program and 42 fourth year pharmacy students were asked to par ticipate. A cover letter accompanying the survey stated the purpose of the study, provided instructions, and assured the respondents of confidentiality (Appendix I and Appendix III). A total of one hundred and forty four completed surveys (88 %) were retu rned. Of these, 51 (38%) were from pharmacists who indicated that they worked in community pharmacy setting, 43 (32%) were from a non community setting, and 42 (31%) were students. Thirty six percent of the pretest sample was male. The number of years that these pharmacists had practiced pharmacy ranged from 0 50 with a mean of 12 years. The mean age of respondents was 38 years of age with a range of 23 years old to 72 years old.

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85 Based on analyses from the pretest, several revisions were made to the POI be fore testing it in the validation study. The next section describes the professional obligation instrument and the revisions made from the pretest version. Description of Pharmacists Moral Obligation Instrument Survey s cenarios The POI consisted of three experience with a drug related morbidity was described (i.e., Treatment failure, potential adverse effect). Each scenario consisted of specific information about a patient, including diagnosis, prescription medication, and r efill history. The scenarios were designed to simulate realistic situations in which pharmacists would find themselves and in which they would be faced with decisions regarding identifying, resolving, or preventing a drug therapy problem. Examp le s cenario (a). This scenario described a 28 year old patient named Debbie Clark who regularly fills her albuterol and inhaled corticosteroid inhaler at your pharmacy. When you hand Ms. Clark her prescription, she complains of symptoms such as shortness of breath an d wheezing. You notice, as you are talking to Ms. Clark, that she has a package of cigarettes in her purse and her fingers and teeth are stained with the yellowing from cigarette smoke. Currently, you are quite busy, phones have been ringing consistently a nd there are several prescriptions that need to be verified. This scenario was intended to show respondents that there were several drug therapy problems: (1) Ms. Clark asthma treatment is not controlling her asthma, and (2) that Ms. Clark smoking behavior can exacerbate her asthma condition. management problem. For this scenario, 80% of the respondents agreed that the scenario represents a disease management problem.

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86 Example s cenario (b). This scenario described a 30 year old male named Sam Jones who frequently visits the pharmacy and fills his Zyrtec regularly. He comes in today asking to transfer his asthma medication (albuterol) from another pharmacy. Since it is very bus waiting. He says that it is no problem since he has some shopping to do in the pharmacy front store anyways. When you call the transferring pharmacy, the pharmacist informs you that he had just filled Mr. Jones albuterol about 2 weeks ago. The pharmacist also shares with you that he has had problems in the past in mastering his inhaler technique. When you mention this to Mr. Jones, he acknowledges that he has been overusing his albuterol, but has had a lot of trouble breathing which is extremely frustrating since he plays tennis regu larly and lives a healthy smoke free lifestyle. The albuterol inhaler is the only medication that he takes for his asthma. Upon interviewing Mr. Jones, he denies use o f alcohol and tobacco. Currently, the pharmacy is still hectic and you notice a line of new patients forming and your technician informs you that a physician is on the phone wanting to talk to you. The facts of this scenario were intended to imply the Mr Jones was currently experiencing a treatment failure due to the lack of a necessary drug (i.e. a corticosteroid to treat his worsening asthma,) s a disease For this scenario, slightly over 80% of the respondents agreed that the scenario represents a disease management problem. Example s cenario (c). The third scenario describes a 35 year old patient named Jonas Wilson. He is a regular patient at your pharmacy, and you recognize him because

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87 you recently had entered his insurance information last week into your computer system. Mr. Wilson is a non smo ker and denies alcohol use. As you are filling his prescription, you notice that he has been overusing his Proventil and has not picked up his inhaled corticosteroid inhaler in over 3 months. When you ask Mr. Wilson if he wants his inhaled corticosteroid filled also, Mr. Wilson says that although his insurance covers both medications, he only wants the albuterol since he still has plenty of the inhaled corticosteroid at home that he never uses. You note in his chart that you and your partner pharmacist hav e counseled Mr. Wilson several times on the importance of using compliance is unknown to you. It has been busy for the past hour and your technician informs you that the nearby physician is waiting for you to call him back The facts of this scenario were intended to imply the Mr. Wilson was currently experiencing a treatment failure due to the lack of use of a necessary drug (i.e. a corticosteroi d to treat his worsening asthma ) In the p that the scenario represents a disease management problem. Each scenario was followed by items in tended to measure professional obligation for drug therapy outcomes, the mechanisms of moral disengagement and the application of pharmaceutical care. Operationalization of the study constructs as well as demographic variables are described next. Operation alization of Study Constructs aspects of a situation that may obscure the relevance of morality. Factors that may

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88 obscure the relevance of morality include situational and motivatio nal factors. Situational factors may include severity of lifestyle disease and motivational factors may include time constraints. Pharmacists may not be aware in certain situation that they are not following professional moral conduct. Yet, at some point, pharmacists may realize that their behaviors violate their moral principles and covenantal relationship that they promised to uphold. When the moral relevance of their behavior becomes salient, pharmacists are faced with motivational conflict. The pharmac ists may choose to behave in line with their moral principles, but often moral action (to provide pharmaceutical care for lifestyle related moral principles is also costl y and may result in self condemnation. Acting on competing motives may be involved with self condemnation for engaging in immoral behavior. If the ratio of costs to benefits of acting morally is high, then instead of choosing to uphold moral principles, th e individual may instead engage in moral rationalization and reconstrue potentially immoral behavior as being moral or irrelevant to morality. Through moral disengagement, this lowers the cost of acting immorally by reconstruing the act as being moral or i a, 1991c 1999) theory of moral disengagement identifies four different categories of rationalization that can lead to moral disengagement: reconstruing conduct, obscuring personal agency, disregarding negative consequences, and b laming and dehumanizing victims. For the purposes of this study, the model elements and linkages were defined and operationalized as described below. The survey instrument also contained a measure of

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89 moral disengagement mechanisms, pharmacist provision of pharmaceutical care services and various demographic variables. Situational factor This variable was defined as the extent to which the severity of presenting lifestyle factors was perceived to act as a factor to obscure the moral relevance of the situat ion. The severity of lifestyle disease was presented within patient scenarios and vary from low lifestyle disease (Compliant, nonsmoker asthmatic) to moderate lifestyle disease (Non compliant, non smoker asthmatic) and high lifestyle disease (Non compliant smoker asthmatic). Motivational factor This variable was defined as the extent to which time constraints was perceived to act as a factor to obscure the moral relevance of the situation. Time constraints were presented within the patient scenarios as hig h time constraint situations (a hectic day in the pharmacy) since this type of time constraint is most realistic. Pro fessional o bligation. This variable was defined as the extent to which a pharmacist perceived she/he had a professional obligation to ident ify, resolve, or prevent a drug therapy problem. In the pretest POI, professional obligation was each of the presented patient scenarios.

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90 Responses were measured on a scale: Strongly agree, somewhat agree, somewhat disagree, strongly disagree. Positi vely worded items were reverse coded so that higher scores were indicative of greater levels of professional moral obligation. As per the pretest: coefficient alpha for scenario (a) was 0.769, coefficient alpha for scenario (b) was 0.623 and coefficient al pha for scenario (c) was 0.704. Moral disengagement mechanisms Moral disengagement mechanisms were assessed with a measure similar to the one developed and used in multiple studies by Bandura and others (Bandura et al. 1996, 2001; Pelton Ground, Forehand et al., item scale was developed for use with children and young adolescents, the scale was adapted to fit the population of the present study and also the specific disease states tested. For example for the smoking specific s fight and misbehave at school it ems are designed to equally tap the sub components of the overarching moral disengagement construct. The items were assessed on a 4 point Likert scale ranging from 1 (Strongly disagree) to 5 (strongly agree). Bandura ( 2002 2004 ) claimed that moral diseng agement should be measured as a single high er order concept. Bandura (1999, 2002) described four major categories of

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91 restructuring of harmful behavior, obscuring or minimizin disregarding or distorting the impact of harmful behavior and blaming and dehumanizing the victim ( T able 3 2). Furthermore, following the results of the Delphi Panel only five of the eight moral disengagement mechanisms were included in the study: moral justification, displacement of responsibility, diffusion of responsibility, attribution of blame, and dehumanization. These five moral disengagement mechanisms were classified according to the categories of psychological mecha nisms ( T able 3 2.) In the pretest, of the 144 surveys that were returned, 16 were excluded due to missing values and a total of 128 surveys were used for reliability analysis. The alpha for the 27 moral disengagement items tested was 0.837.There were two items when deleted would increase the coefficient alpha These were items q4.17 and q25r (reverse coded) However, these items only decreased the coefficient alpha slightly and given tha t pharmacists did not appear to have an issue with answering questions regarding this construct, it was decided that we would keep these items ( Table 3 3). Application of Pharmaceutical C are (APC). For the purposes of the study, the outcome measures based reports of pharmaceutical care activities (self reported behavior). This construct was measured from a scale based on the last five encounters the pharmacist had with his/her patients. This construct was scored as a summated scale. Th e coefficient alpha from the pre test was 0.929. However 42 out of the 144 participants skipped these items.

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92 1. Think of the last five adult asthma patient encounters, for how many of them did you investigate if the patient was experiencing an asthma related breathing problem. 2. Think of the last five adult asthma patients who were experiencing breathing related problems, how many were experiencing a breathing related problem due to non compliance issues? 3. Think of the last five adult asthma patients who were exp eriencing breathing related problems, how many were experiencing a breathing related problem due to lifestyle related behaviors? 4. Think of the last five adult asthma patients who were experiencing breathing related problems, how many were experiencing a bre athing related problem due to not receiving optimal medication? 5. Think of the last five adult asthma patients who were experiencing breathing related problems due to inadequate therapy, for how many did you try to resolve their drug related problem? 6. Think o f the last five adult asthma patients who were experiencing breathing related problems due to compliance issues, how many did you coordinate at least one follow up with patient to monitor his/her progress with asthma management? 7. Think of the last five adul t asthma patients who were experiencing breathing related problems due to lifestyle related behaviors, how many did you coordinate at least one follow up with patient to monitor his/her progress with asthma management? 8. Think of the last five adult asthma p atients who were experiencing breathing related problems due to not receiving optimal drug therapy, how many did you coordinate at least one follow up with patient to monitor his/her progress with asthma management? 9. Think of the last five adult asthma pati ents, for how many of them did you check their patient profile to see if they were refilling their medications on time? 10. Think of the last five adult asthma patients with new asthma medications, for how many did you discuss special directions for use? 11. Think of the last five asthma patients, for how many of them did you personally talk to? 12. Think of your last five asthma adult patient encounters, for how many of them did you inquire whether or not they smoked cigarettes? 13. Think about the last five adult patient s who were smokers that you encountered, for how many of them did you suggest smoking cessation strategies?

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93 14. Think about the last five adult smoker patients that you encountered, for how many of them did you suggest referral to other health care providers o r clinics for smoking cessation? Demographic variables Several demographic variables were measured. These included pharmacist gender, age of the pharmacist, how long in practice, practice setting, current position and pharmacist ethnicity. Test retest re liability Test retest reliability was conducted among 16 fourth year pharmacy students, to assess the stability of measures of professional obligation among the three patient scenarios presented. The time lapse between the first and second administration o f the instrument was one week. The test retest correlation for the smoker compliant smoker correlation was 0.555, for the non compliant non smoker the correlation was 0.907 and for the compliant non smoker asthmatic the correlation was 0.713. The test rete st reliability correlations were moderate to high for the three presented scenarios, thus the instrument appears to be stable over time. For the smoker compliant asthmatic the test retest correlation was lower than the other two scenarios. It is postulated that this is because it was the first presented scenario, and upon examining the raw data, it was noticed that students were reporting a lower professional obligation for the retest compared to the first administration for the smoker compliant patient It is plausible that since this scenario was presented first, students were not able to compare their responses to the other presented scenarios during the first administration. However, during the second administration, students were prepared to compare the smoker compliant patient against the other scenarios presented, and thus rated a lower professional obligation to the smoker compliant asthmatic for the retest.

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94 To adjust for this effect, the order of the scenarios presented was modified to compliant non smoker asthmatic presented first; then non compliant non smoker asthmatic presented second; and smoker compliant asthmatic presented third. This order was chosen, because the intention was for pharmacists to compare their responses to the patient who did n ot exhibit poor lifestyle behaviors patient. As such the the baseline for the other two scenarios to be compared against. Summary of Survey Development This section descri bed how the POI was developed for this study. Following the design of the survey instrument, it was pretested among a sample of pharmacists and fourth year pharmacy students. Results from this pretest indicated that these pharmacists and pharmacy students were able to identify the relevant drug therapy problem in all three scenarios. According to the results from the test retest conducted, the order of the scenario was modified from the pretest. In the pretest the order was: smoker compliant asthmatic, comp liant non smoker asthmatic, and non compliant non smoker asthmatic. The order was changed to: non smoker asthmatic, non compliant non smoker asthmatic, and smoker compliant asthmatic. This order was changed because we wanted pharmacists to compare the non complaint non smoker patient and smoker compliant patient (the good patient) as the first scenario so that pharmacists would have the ability to compare the rest of the scenarios to The length of the application of pharmaceutical care section of the survey was a problem, as many pharmacists skipped this section. For the sake of brevity, these items were shortened to four questions and placed at the end of each s cenario. The

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95 application of pharmaceutical care items were specific to the presented scenario and provided certain types of care. The revised POI did not contain items establishing if the presented scenarios represented a disease management problem as these items had been included in the pretest version for preliminary analysis to establish the appropriateness of the scenarios. These items were not used to measure the st udy construct or a variable in a test of hypothesis. The revised POI was then tested among a sample of Florida pharmacists in order to validate the measures that were developed. The next section describes how the measures were validated. Study Sample and D ata Collection The sample for the validation study consisted of pharmacists attending continuing education programs. This section describes the procedure that was used to select the study sample. Pharmacists attending Florida Pharmacy Association (FPA) and Florida A&M University (FAMU) continuing educ ation programs were used as the sampling frame for the validation study. Given that pharmacists that had contact with patients on a regular basis were community and ambulatory pharmacists, these pharmacists were asked to participate in the study. Pharmacis ts were asked at registration if they worked in a community/ambulatory setting and/or had regular contact with patients. If they responded yes, they were given a survey. 4 48 surveys were handed out at FPA continuing education programs, and 40 surveys were handed out at the FAMU

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96 continuing education program. If the pharmacists returned the survey back to the investigator, they were given a small compensation (water bottle). A cover letter was attached to each survey describing the study, informing the pharm acists that participation is completely voluntary, their responses are completely confidential and the time it should take the pharmacist to complete (Please see Appendix I and Appendix IV). Data Analysis The responses obtained from data collection were co ded and entered into an Excel file spreadsheet and th en analyzed using SPSS and LISRE L programs. Frequency analyses of the variables were then conducted. The reliability of the developed measures was assessed. Then, the convergent and discriminant validity of the moral disengagement constructs were tested using confirmatory factor analysis. Finally, study hypotheses to further validate the measures were tested. Reliability of Measures The internal consistencies of the developed measures were estimated by ca lculating the coefficient alpha Item analyses were conducted by examining the correlation between the respected item and the total sum score (without the respective item) and the internal consistency if the respective item would be deleted. Coefficient a lpha s greater than 0.65 were considered acceptable. Convergent and Discriminant Validity To measure the extent to which observed variables were supposed to measure the same construct, convergent validity was utilized. Furthermore, discriminant validity was used to measure the distinctiveness of the constructs. Convergent factor analysis was used to measure the convergent and discriminant validity of the measurement

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97 model of the constructs. Confirmatory factor analysis provides a test of both of these types of validity by depicting relations between factors and observed variables (Kline, 1998). The measurement model that was tested depicted the tested mechanisms of disengagement as factors; the items from the revised instrument that were intended to represent these factors were depicted as observed. The values of the factor loading on the items were specified a priori. Two measurement models were tested: one for the smoker compliant asthmatic and one for non compliant non smoker asthmatic variables (Figure 3 2 and Figure 3 3). For the measurement model smoker compliant asthmatic: Items 4.1, 4.4, 4.5R 2). For the measurement model non compliant non smoker: Items 4.15R (reverse 3). Each observed variable was presumed to have two direct causal effects: a factor and a measurement error. In Figure 3 2 and Figure 3 3, both types of causal effects are depicted with single arrowhead lines. Furthermore, associations between factors are represented with double a rrowhead lines.

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98 In order to assess the goodness of fit of the data to the proposed model, several goodness of fit indices were assessed. The chi square statistic is a measure of overall fit. The chi square statistic is very sensitive to large sample sizes (>200). To reduce the sensitivity of the chi square statistic to sample size, its value was divided by the degrees of freedom (df). A chi square/df ratio less than 3 is generally considered favorable (Kline, 1998). RMSEA is the average discrepancy between the observed and expected correlations across all parameter estimates with adjustment for parsim ony. According to Jaccard & W a n (1996) a perfect fit will yield an RMSEA of zero; scores less than 0.08 are considered to be adequate and scores less than 0.05 are considered good. Modification indices were also examined. These indices provide detailed assessments of model fit by indicating the expected decrease in chi square if a zero factor loading on an observed variable is relaxed or a pair of measurement errors between observed variables is allowed to covary. The modification index with the highest value results in the greatest decrease in chi square. Construct validity In construct validation, the meaningfulness or importance of a construct will made explicit by establishing i ts hypothesized relationship with other variables in a theoretical system (Crocker & Algina, 1986). The following hypotheses were proposed to test the construct validity of the measures representing the components of the pharmacist decision making to couns el on lifestyle related diseases: 1. Increasing severity of lifestyle disease will have a negative effect on professional moral obligation / 2. Increased professional moral obligation will have a positive direct effect on application of pharmaceutical care.

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99 3. Moral disengagement mechanisms will have a direct negative effect on application of pharmaceutical care. 4. The tested mechanisms of moral disengagement will act as an mediating variable for patients presenting with high severity of lifestyle disease between high professional moral obligation and low application of pharmaceutical care Hypothesis 1. Hypothesis 1 tested whether increasing severity of lifestyle disease will have a negative effect on professional obligation. The statistical test repeated measures t tes t was used to examine the effect of severity of lifestyle disease on professional obligation ( Table 3 4 ) The alpha level was set at = .05. Hypothesis 2 through 4. These hypotheses were analyzed using structural equation modeling (SEM). SEM is a flexible modeling tool for many multivariate statistics, such as regression analysis, path analysis, factor analysis. SEM involves the use of multi equational framework to develop and test theoretically based models in order to understand responses controlled by m ultiple factors (Bollen 1989). Through the use of a simultaneous analysis procedure, SEM derives results that seek to account for the roles of multiple factors in a single analysis. Commonly, SEM provides quite a different perspective by partitioning dire ct from indirect effects and thereby revealing a variety of mechanisms behind the overall patterns. The conceptual model (Figure 3 4) Theory was used to test these hypotheses Following the development of the conceptual model (Figure 3 4), the complete structural equation model which related the observed variables to the latent variables were developed. The latent variables included professional obligation, disengagement mech anisms, and application of pharmaceutical care. The observed variables included the variables that serve as the measure of the latent variables. Structural equation

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100 modeling permits the incorporation of estimates of measurement error for individual indica tors of latent variables, thus allowing for reduced bias in path coefficients (Bollen, 1989). Model estimation was based on maximum likelihood Robust estimation methods. The adequacy of the model fit was evaluated using the model chi square/df as well as the fit indexes RMSEA. Chi Square test is a measure of fit because it detects the degree of fit between the causal model and the data set to which it applies. The difference between the sample covariance matrix and fitted covariance matrix is measured. A c hi square/df ratio less than 3 is generally considered favorable (Kline, 1998). RMSEA is the average discrepancy between the observed and expected correlations across all parameter estimates with adjustment for parsimony. According to Jaccard & Wan (1996) a perfect fit will yield an RMSEA of zero; scores less than 0.08 are considered to be adequate and scores less than 0.05 are considered good. Individual path coefficients were also evaluated using z tests (equivalent to t tests). Lisrel 8.8 program was e mployed. The two models tested were for the non compliant, nonsmoker asthma patient (model 1) and the smoker asthma patient (model 2). Hypothesis 2. This hypothesis tested whether increased professional obligation had a positive direct effect on the appl ication of pharmaceutical care. Structural equation modeling was conducted to assess model testing. Hypothesis 3. This hypothesis postulated that the tested mechanisms of moral disengagement mechanisms will have a direct negative effect on the application of pharmaceutical care. Structural equation modeling was conducted to assess model testing.

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101 Hypothesis 4. This hypothesis postulated that the tested mechanisms of moral disengagement mechanisms will act as a mediating variable between professional obliga tion and application of pharmaceutical care. Structural equation modeling was conducted to assess model testing. For disengagement items to function as a mediator it needs to meet the following conditions (Barron & Kenny, 1986): 1. Variations in levels of th e independent variable significantly account for variations in the presumed mediator (path a). 2. Variations in the mediator significantly account for variations in the dependent variable (path b) 3. And when paths a and b are controlled, a previously significan t relation between the independent and dependent variables is no longer significant, with the strongest demonstration of mediation occurring when path c is zero. The major advantages of structural modeling techniques in testing mediating effects are that all relevant paths are directed tested and none are omitted as in ANOVA. Furthermore, complications of measurement error, correlated measurement error, and even feedback are incorporated directly into the model (Baron & Kenny, 1986). Statistical assumptio ns. Normality and residual plots were examined for gross violation of the homoscedasticity assumption. Residual plots were conducted to determine if the homoscedasticity assumptions was violated. The residual plots should have a constant variance over the terms of the predicted variables (Agresti& Finlay, 1986).

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102 Sample Size Determination To determine the necessary sample size for repeated measures t test, comparing the me ans of three groups, a medium effect size of 0.25 was chosen, and an alpha of 0.8. The necessary sample size of 128 is needed To determine the minimum number of subjects required for the validation study, the necessary sample size estimates for the variou s data analyses were compared. The recommended sample size for a confirmatory domain analysis is 20 subjects per observed variable (Kline, 1998). The maximum number of observed variables that were to be used in the proposed measurement was 12. Thus a minim um sample size of 240 subjects was desirable for confirmatory domain analysis. The recommended sample size for a structural equation modeling is also 20 subjects per variable. The proposed path model contained a total of a total of 13 observed variables (s ummated scales), thereby requiring a minimum of 260 subjects. Summary of Methods To develop a professional obligation model for the application of pharmaceutical administered written survey was des igned and then pretested among a sample of Florida Pharmacists and fourth year pharmacy students. Following a revision, surveys were administered to a sample of 488 pharmacists in Florida. The validity of the pharmacist model of professional obligation fo r the application of pharmaceutical care was examined by testing proposed relationships between measures that were included in the written survey. The convergent and discriminant validity of measures for the moral disengagement items for the two measuremen t models: non compliant nonsmoking asthmatic and smoking compliant asthmatic were

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103 assessed. The direct effects of professional obligation and the application of pharmaceutical care and the direct effects of moral disengagement on the application of pharmac eutical were tested. Moral disengagement as a mediating variable between professional obligation and application of pharmaceutical care was also tested. The results of these anal yses are discussed in C hapter 4

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104 Table 3 1. Delphi Panel Results Disengagement Mechanisms Pharmacy resident Health Education Professor Associate Pharmacy Dean Pharmacy Resident total Moral justification 4 3 1 4 12 Euphemistic Language 7 5 7 8 26 Advantageous comparison 5 4 4 3 16 Displacement of responsibility 1 1 3 2 7 Diffusion of responsibility 3 2 2 6 13 Distorting consequences 8 7 6 5 26 Attribution of blame 2 6 5 1 14 Dehumanization 6 8 8 7 30 Table 3 2. Categories of psychological mechanisms Categories of psychological mechanisms Mechanisms of Moral Disengagement Mechanisms tested Cognitive reconstruing of harmful behavior Moral Justification Euphemistic Labeling Advantageous comparison Moral Justification Obscuring or minimizing Displacement of responsibility Diffusion of responsibility Displacement of responsibility Diffusion of responsibility Disregarding or distorting the impact of harmful behavior Distorting consequences Blaming and dehumanizing the victim Attribution of blame Dehumanization Attribution of blame Dehumanization

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105 Table 3 3. Mechanisms of Moral Disengagement Mechanisms of Moral disengagement Modified Scale for non compliant Modified scale for smoking Moral Justification It is alright to fight to protect your friends. It is alright to beat someone who bad mouths your family It is alright to fight when your group's honor is threatened. It is alright to lie to keep your friends out of trouble. Persons who overuse albuterol a nd underuse corticosteroid are not likely to benefit from compliance counseling (Item 15R) Counseling patients who overuse albuterol and underutilize corticosteroid is effective for non compliant persons (Item 17) I am not obligated to counsel smokers on smoking cessation because I believe this is their source of stress relief. (Item 1R) Smoking Cessation Counseling is effective for smokers (Item 2) I am not obligated to counsel smokers on smoking cessation because nicotine replacement is expensive. (Item 7R) Smokers are not likely to quit when counseled (Item 8R) Displacement of responsibility If kids are living under bad conditions they cannot be blamed for behaving aggressively. If kids are not disciplined they should not be blamed for misbehaving. Kids cannot be blamed for using bad words when all their friends do it. Kids cannot be blamed for misbehaving if their friends pressured them to do it. I am not obligated to counsel people who overuse albuterol and underuse corticosteroid if corporate headqua rters pressures me to increase prescription volume.(Item 21R) I am not obligated to counsel patients who overuse their albuterol and underuse their inhaled corticosteroid when I am working under stressful conditions. (Item 23R) I am not obligated to counsel smokers on smoking cessation when I am working under stressful conditions (Item 10R) I am not obligated to counsel smokers on smoking cessation if corporate headquarters pressures me to increase prescription volume (item 11R)

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106 Table 3 3 Continued Mechanisms of Moral disengagement Modified Scale for non compliant Modified scale for smoking Diffusion of responsibility A kid in a gang should not be blamed for the trouble the gang causes. A kid who only suggests breaking rules should not be blamed if other kids go ahead and do it. If a group decides together to do something harmful it is unfair to blame any kid in the group for it. It is unfair to blame a child who had only a small part in the harm caused by a group. I play only a small part in helping non compliant patients (Item 18R) I am not obligated to counsel patients who overuse albuterol and underuse corticosteroid if physicians, nurses, and other health care professionals are not counseling non complia nt patients. (Item 27R) I play only a small part in helping smokers quit smoking so it is reasonable for me to not counsel on smoking cession. (Item 3R) It is unfair to ask me to counsel on smoking cessation if other health care professionals are not couns eling on smoking cession (Item 5R) I am not obligated to counsel smokers on smoking cessation, if physicians, nurses, and other health care professionals are not counseling on smoking cessation (Item 12R) Attribution of blame If kids fight and misbehave in school it is their teacher's fault. If people are careless where they leave their things it is their own fault if they get stolen. Kids who get mistreated usually do things that deserve it. Children are not at fault for misbehaving if their parents forc e them too much. Non compliant patients who suffer from their disease deserve it (Item 16R) I am not obligated to counsel people who overuse albuterol and underuse corticosteroid because they choose to be non compliant (Item 19R) Patients who suffer from their non compliance deserve to suffer (Item 24R) Patients should be free to choose whether they want to be compliant with their therapy (Item 25R) Smokers who suffer from smoking related diseases deserve it (item 6R) Smoking is a personal lifestyle choice that patients make themselves (Item 13R) Dehumanization Some people deserve to be treated like animals. It is okay to treat badly somebody who behaved like a "worm." Someone who is obnoxious does not deserve to be treated like a human being. Some people have to be treated roughly because they lack feelings that can be hurt Non compliant patients are mentally weak willed (Item 20R) Non compliance is best seen as a form of wrongdoing (Item 22R) Non compliant patients are immoral (Item 26R) Smoker are men tally weak willed (Item 4R) Smokers are immoral (Item 9R) Smoking is best seen as a form of wrongdoing(Item 14R)

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107 Table 3 4. Description of Independent and Dependent Variables for Hypothesis 1 Independent variable (Severity of lifestyle disease) Dependent variable (Professional obligation) Description of scale of measurement Ordinal scale: 1=Non smoker and compliant asthmatic 2= non compliance and non smoker asthmatic 3=Smoker and compliant asthmatic Interval Scale: Likert scale is used with 4 categories, with scale values ranging from1 4 Items are summed to produce a total score. 1=strongly disagree 2= somewhat disagree 3= somewhat agree 4=strongly agree Range of score possible 1 3 4 16 Figure 3 1. Development of Professional Moral Obligation Instrument Survey development Pharmacist interviews Content validity Face validity Delphi Panel Pretest Document reactions and concerns about DTP in patient care scenarios Preliminary reliability assessments Test retest Survey Reliability of measures Convergent and discriminant validity (CFA) Construct validity

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108 Figure 3 2. Proposed Measurement model for the Smoker Compliant Asthmatic

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109 Figure 3 3. Proposed Measurement Model for Non Compliant Non Smoker Asthmatic

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110 Figure 3 4. Proposed model

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111 CHAPTER 4 RESULTS Response to survey A total of 488 pharmacists were surveyed at four different continuing education programs in the state of Florida. Of the total, 318 surveys were returned with a response rate of 65% 1 Demographic and practice characteristics of the study respondents are show in Table 4 1 and Table 4 2. Approximately 46% were male. The mean age and years in practice were 52 and 26, respectively. Approximately 66% of the respondents worked in a communit y/ambulatory setting, 13% worked in a hospital setting and 21% worked in another setting and/or were unemployed/retired. Education, training, and certification characteristics are shown in Table 4 1. The most frequent type of education was a B.S in pharma cy (53%) and the most frequent position held was noted to be staff pharmacist (24%). Item Responses and Scale Reliability This section provides a description of item statistics and scale reliability, including item analyses that were conducted for the foll owing measures: professional obligation, application of pharmaceutical care, moral disengagement items for the smoking patient, and moral disengagement items of the non compliant patient. For each of the measures professional obligation and application of pharmaceutical care, items were excluded from further analysis if they had corrected item correlations less than 0.20 and alpha if the item is deleted. All scales that were used had acceptable coefficient alpha estimates (>=0.65). 1 The response rate may have been slightly higher (68%) surveys were removed if they were accidentally completed by pharmacy technicians

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112 Professional Obligation Respondents were asked about the extent they agree or disagree to following statements regarding different scenarios. The items for each scenario are presented in Table 4 3. In scenario 1, respondents indicated the extent to how mu ch professional obligation they had to a patient presenting with an asthma drug therapy problem (see items 1.1, 1.2R, 1.3, 1.4, Table 4 3). In scenario 2, respondents indicated the extent to how much professional obligation they had to a patient presenting with an asthma drug therapy problem but who was non compliant with therapy (see items 2.1, 2,2R, 2,3, 2,4, Table 4 3). And in scenario 3, respondents indicated the extent to how much professional obligation they had to a patient presenting with an asthma drug therapy problem but who was also a smoker (see items 3.1, 3.2R, 3.3, 3.4, Table 4 3). The coefficient alpha for the items measuring professional obligation was 0.653 for scenario 1, 0.726 for scenario 2, and 0.703 for scenario 3 (Table 4 4). Item tota l statistics are shown in Table 4 5 and Table 4 6, and Table 4 7 for the three scenarios. Oblig 1.2R (Reverse coded), Oblig 2.2R (Reverse coded), and Oblig 3.2R alpha if the item were deleted. Although the corr ected item total correlations were above 0.2, it was determined that these items were problematic because of the reverse scoring of the item. Consequently, these three alpha for the revised 3 item s cale/scenario were 0.689 for scenario 1, 0.774 for scenario 2, and 0.782 for scenario 3. Application of Pharmaceutical Care Respondents were asked to think about their own experiences and remember the last five adult patients who presented with a refill p rescription to treat asthma. Respondents were then asked to indicate how many of these last five patients did they

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113 engage in a particular action. Respondents were asked these questions in regards to the three scenarios mentioned above ( T able 4 8). The coef ficient alpha for the items measuring application of pharmaceutical care was 0.703 for scenario 1, 0.806 for scenario 2, and 0.834 for scenario 3 ( T able 4 9). No items were removed, as none of the items had item corrected item total correlations less than 0.2 and increased the alpha ( Table 4 10, Table 4 11, Table 4 12). Moral Disengagement items for the smoking patient Respondents were asked how much they agree or disagree to items relating to mechanisms of moral disengagement for a smoker patie nt. The items included the domains: Cognitively reconstrue, Blame and Dehumanize, and Obscure/Minimize. Items 4.1, 4.4, 4.5R (reverse coded), 4.7 measured cognitively reconstrue domain; item 4.8, 4.13, 4.2, 4.6, and 4.14 measured the domain blame and dehum anize; items 4.9 and 4.10, 4.3, 4.11, 4.12 measured obscure/minimize domain. Item total statistics are shown in Table 4 13. The coefficient alpha for the scale was 0.793. alpha if item deleted and had item total correlations less than 0.20. These items are 4.13, 4.14, and 4.5R. Consequently these items were excluded from the scale (see Appendix IV, section 4, for description of items). The coefficient alpha for the revised scale was 0.814. Moral Disengageme nt items for the non compliant patient Respondents were asked how much they agree or disagree to items relating to mechanisms of moral disengagement for a non compliant patient. The items are associated with the domains: cognitively reconstrue, blame and d ehumanize, obscure/minimize. Items 4.15R (reverse coded) and 4.17 measured the domain cognitively reconstrue, items 4.16, 4.18, 4.23, 4.24, 4.21, 4.25, 4.26 measured the

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114 domain blame and dehumanization, items 4.20, 4.27, 4.19 and 4.22 measured obscure/mini mize domain. Item Total statistics is shown in Table 4 14. The coefficient alpha alpha if the item were deleted and also had a corrected item total correlation of less than 0.20. These items were item 4.24 and item 4.15R. However, given that item 4.15 was one of two items that measured the domain CR, this item was retained. Item 4.24 was discarded. The coefficient alpha for the revised scale was 0.782. ( Appendix D sec tion 4 ) Convergent and Discriminant Validity A confirmatory domain analysis was conducted to assess the convergent and discriminant validity for the smoker asthma patient moral disengagement factors: blame and dehumanize (BD), cognitive reconstrue (CR) and obscure and minimize (OM). The factor BD consists of the mechanisms dehumanization and attribution of blame, the factor CR consists of the mechanism moral justification, and the factor OM consists of the mechanisms displacement of responsibility and diffusion of res ponsibility. The proposed measurement model that was tested is shown in Figure 4 1. The model hypothesized the following items and factors: items 4.1, 4.4, 4.7 (cognitive reconstrue), 4.2, 4.6, 4.8 (blame and dehumanize); and 4.3, 4.9, 4.10 4.11 4.12, ( overarching construct moral disengagement. Several goodness of fit indices for the measurement model were examined. Initially, the chi square/df ratio of 4.30 (176.37/41) and the R MSEA (RMSEA= 0.101) were at levels that indicated less than favorable fit of the data to the proposed model. The modification indices were examined to ascertain a more detailed assessment of fit. The measurement errors for the following pairs of observed v ariables were then allowed

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115 to covary: Q4.7 and Q4.4; Q4.10 and Q4.3; Q4.10 and Q4.9; Q4.11 and Q4.9; Q4.12 and Q4.3. Since each of the pairs is within the same factors, these modification indices were not considered to change the interpretation of the mod el. The chi square/df ratio decreased to 2.52 and the RMSEA value decreased to 0.069. All these indicated an adequate fit of the proposed model ( F igure 4 2). Confirmatory domain analysis was also conducted to assess the convergent and discriminant validit y for the non compliant non smoker asthma patients moral disengagement factors: blame and dehumanize (BD), cognitive reconstrue (CR) and el that was tested is shown in F igure 4 3. The model hypothesized the following items and factors: items 4.15R, 4.17 (CR), 4.18, 4.21, 4.22, 4.25, 4.26 (BD); and 4.19, 4.20, 4.22, 4.27 (OM). Several goodness of fit indices for the measurement non compliance model were examined. Initially the chi square/df ratio of 5.67 (289.20/51) and RMSEA of 0.122 indicated less than favorable fit of the data to the proposed model. The modification indices were examined to ascertain a more detailed assessment of fit. The measurement errors for the following pairs of obser ved variables were then allowed to covary: Q4.18 and Q4.16; Q4.21 and Q4.18; Q4.23 and 4.16; Q4.23 and 4.18; Q4.25 and Q4.18; Q4.26 and Q4.25; Q4.27 and Q2.30. Since each of the pairs are within the same factors, these modification indices were not conside red to change the interpretation of the model. The chi square/df ratio decreased to 2.41 and RMSEA decreased to 0.067. All these indicated an adequate fit of the proposed model ( F igure 4 4).

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116 All factor loadings for both the smoking and non compliance model were greater than 0.50 except for item 4.21 had a loading of 0.46. This pattern of loadings provided good support for confirming the convergent validity of the measures. For discriminant validity, there is not a standard value, however a correlation less than 0.85 tells us that discriminant validity likely exists between the scales. A result greater than 0.85 however tells us that the constructs overlap and they are likely measuring the sam e thing (Campbell and Fiske, 19 5 9). For the smoking model, correlat ions between the domains were moderate high in size (0.72 0.94), lending support to the discriminant validity of the measures but also the possibility that these domains are part of a higher order construct. For the non compliance models, the correlations between the domains were moderate high in size (0.81 0.89), lending support to the discriminant validity of the measures but also the possibility that these constructs are part of a higher order construct moral disengagement Given that these factors shou ld be theoretically related to each other we would expect that the correlations betwee n them should be relatively high. Test of Hypothesis Hypothesis 1 Hypothesis 1 tested whether increasing severity of lifestyle disease will have a negative effect on professional obligation, controlling for time pressure. The statistical test repeated measures t test was used to examine the effect of severity of lifestyl e disease on professional moral obligation. For scenario 1 items oblig1.1, oblig1.3 and oblig1.4 were summed to create Prooblig1. For scenario 2 items oblig2.1, oblig2.3 and oblig2.4 were summed to create Profoblig2. And for scenario 3 items oblig3.1, obl ig 3 .3 and oblig 3 .4 were summed to

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117 create Profoblig3. The means between Profoblig1, Profoblig2, and Profoblig3 were compared against each other using repeated measures t test with the alpha level set at 0.05 The results of this hypotheses testing is shown in Table 4 15 and Table 4 16 The difference between the mean of Profoblig1 and Profoblig2 was 0.24684. This difference between the two means was significant (p=0.003), with pharmacists reporting a higher mean for Profoblig1 (10.9051) than for Profoblig2 (10.6582). The difference between the mean of Profoblig1 and Profoblig3 was 0.56825 and was significant (p=0.000), with pharmacists reporting a higher mean for Profoblig1 (10.9016) than for Profoblig3 (10.333). The difference between Profoblig2 and Profobl ig3 was 0.333 and was significant (p=0.000), with pharmacists reporting a higher mean for Profoblig2 (10.6540) than for Profoblig3 (10.3206). professional obligation when presen ted with patients with the same disease state (asthma) but varying levels of lifestyle related conditions. Pharmacists had the highest sense of professional obligation for the asthma patient who was a non smoker and was compliant with therapy (Profoblig1) when compared to the non compliant nonsmoker asthma patient (Profoblig2) and also the smoker asthma patient (Profoblig3). Pharmacists had the lowest sense of professional obligation when it came to the smoker asthma patient (Profoblig3). Model testing for Hypothesis 2 to 4 These hypothesis tested whether increased professional obligation had a positive direct effect on the appli cation of pharmaceutical care ( H ypothesis 2), moral disengagement mechanisms had a direct negative effect on the application of pharmaceutical care ( Hypothesis 3), and whether the tested mechanisms will act as an

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118 intervening variable between professional obligation and appli cation of pharmaceutical care ( H ypothesis 4). These hypotheses were analyzed using structural equation modeli ng (SEM). Model s pecification Model specification is the first step in SEM. SEM does not determine which model to test; rather, it estimates the parameters in a model once the model has been specified a priori by the researcher based on theoretical knowl edge. Consequently, theory plays a major role in formulating structural equation models and model ( F igure 4 5) guided by the investigators a priori and theoretical knowl edge of Model testing and model m odification Following the development of the conceptual model (Figure 4 5), the complete structural equation model which related the observed variabl es to the latent variables were developed. The latent variables included professional obligation (oblig), disengagement mechanisms (disengage), and application of pharmaceutical care (pharmcare), and the observed variables included the items that serve as the measure of the latent variables ( T able 4 1 7 ). Structural equation modeling permits the incorporation of estimates of measurement error for individual indicators of latent variables, thus allowing for reduced bias in path coefficients (Bollen, 1989). Model estimation was based on maximum likelihood Robust estimation methods. The adequacy of the model fit was evaluated using the model relative chi square as well as the fit indexe s RMSEA. MacCullum Browne and Sugawara (1996) have used 0.01, 0.05, and 0 .08 to indicate excellent, good, and mediocre fit respectively. However, others have suggested 0.10 as the cutoff

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119 for poor fitting models. Relative chi square, also known as the chi square to df ratio should be in the 3:1 range for a n acceptable model (Car mine s, McIver Bohmstedt et al 1981). Some researchers allow values as high as 5 to consider a model adequate fit (Schumacker & Lomax, 2004:82). Individual path coefficients were also evaluated using t test. Lisrel 8.80 program was employed. The two mod els tested were for the non compliant, nonsmoker asthma patient (model 1) and the smoker asthmatic patient (model 2). Model 1. Following the pre specified model, initially the chi square/df of 2.68 and RMSEA of 0.072 were at levels that indicated adequate fit of the data to the proposed model. The measurement errors for the following pairs of observed variables were then allowed to covary: PC2.3 and PC2.1; NCBD and NCCR; OBLIG2.3 and OBLIG2.1; OBLIG2.4 and OBLIG2.3. ( F igure 4 6). Since each pair was within the same factor, these modifications were not considered to change the interpretation of the model. The Chi square/df decreased to 1.79 and the RMSEA value decreased to 0.050. All of these indicated a good fit of the data to the proposed model. Model 2. Following the pre specified model, the data was unable to fit into the model. As such, we had a structurally mis specified model. The structure of the model was re specified and new models were evaluated. Two new re specified models were tested. Theoreti a logical sequence of events. The first re specified model tested included the latent variables: Oblig, Pharmcare and OM (Model 2.1). The second re specified model included the latent v ariables: Oblig, Pharmcare, SBD, and SCR (Model 2.2).

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120 Model 2.1. The new specified model included the latent variables: Oblig (Professional obligation), Pharmcare( Application of Pharmaceutical care) and OM (Obscu re and Minimize) ( T able 4 1 7 ). Following t he development of the conceptual Figure 4 7) it was postulated that OM would act as in mediating variable between professional obligation and pharmaceutical care. Initially the chi square/df ratio of 2.44 and RMSEA of 0.067 were at levels that indicated adequate fit of the data to the proposed model. The measurement errors for the following pairs of observed variables were then allowed to covary: Q4.10 and Q4.3; Q4.11 and Q4.10; Q4.12 and Q4. 10. Since each pair was within the same factor, these modifications were not considered to change the interpretation of the model. The chi square/df ratio decreased to 1.89 and the RMSEA decreased to 0.058 which indicated a good fit of the data to the prop osed model (Figure 4 8). Model 2.2. The second re specified model included the latent variable: Oblig (Professional Obligation), Pharmcare (Application of Pharmaceutical care), BD (Blame and Dehumanize), and CR (Cognitively reconstrue). Following the deve of moral disengagement ( Figure 4 9) it was postulated that CR and BD would act as mediating variables between professional obligation and pharmaceutical care. Initially the chi square/df ratio of 3 .86 and RMSEA of 0.095 were at levels that indicated less than adequate fit of the data to the proposed model. The measurement errors for the following pairs of observed variables were then allowed to covary: Q4.7 and Q4.4; OBLIG3.4 and OBLIG3.1.Since ea ch pair was within the same factor, these

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121 modifications were not considered to change the interpretation of the model. The chi square/df ratio decreased to slightly to 3.43 and RMSEA to 0.087 which indicated adequate fit ( F igure 4 10). Hypothesis 2. This h ypothesis tested whether increased professional obligation had a positive direct effect on the application of pharmaceutical care. Structural equation modeling was conducted for model testing. Model 1 (non compliant, non smoker asthma patient). Figure 4 1 1 illustrates the t values for the structural relationships among the study variables for model 1. Hypothesis 2 postulated the professional obligation (oblig) will have a positive direct effect on the application of pharmaceutical care (pharmcar). The dire ct path from oblig to pharmcar is significant since the standardized regression coefficient is 0.71 with a t value of t=10.46, and p<0.05. Model 1 revealed that professional obligation has a positive effect on the applicatio n of pharmaceutical care. Thus H ypothesis 2 is supported. Model 2.1 (smoker asthma patient ). Figure 4 12 illustrates the t values for the structural relationships among the study variables for model 2.1. Hypothesis 2 postulated the professional obligation (Oblig) will have a positive di rect effect on the application of pharmaceutical care (Pharmcare). The direct path from Oblig to Pharmcare is significant since the standardized regression coefficient is 0.73 with a t value of 11.10, and p<0.05. Model 2 revealed that professional obligati on has a positive effect on the application of pharmaceutical care. Thus Hypothesis 2 is supported. Model 2.2 (s moker asthma patient). Figure 4 13 illustrates the t values for the structural relationships among the study variables for model 2.2. Hypothesis 2

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122 postulated the professional obligation (oblig) will have a positive direct effect on the application of pharmaceutical care (pharmcar). The direct path from oblig to pharmcar is significant since the standardized regression coefficient is 0.64 with a t value of t=6.60, and p<0.05. Model 2.2 revealed that professional obligation has a positive effect on the application of pharmaceutical care. T hus Hypothesis 2 is supported. Hypothesis 3 This hypothesis postulated that the tested mechanisms of moral disengagement mechanisms will have a direct negative effect on the application of pharmaceutical care. Model 1. The direct path from disengage to pha rmcare has a standardized regression coefficient of 0.01 and a t value of 0.11 (p>0.05) Thus this path is not significant. Thus Hypothesis 3 is not supported although the regression coefficient and t value indicate a trend toward a negative effect of dis engagement on pharmcare. Model 2.1. The direct path from OM (obscure and minimize) which is a disengagement mechanism to Pharmcare has a standardized regression coefficient of 0.12 and a t value of 2.22 (p>0.05). As such the disengagement mechanism obscu re and minimize has a negative direct effect on the application of pharmaceutical care. Thus Hypothesis 3 is supported ( Figure 4 12). Model 2.2. The direct path from CR (cognitively reconstrue) and BD (blame and dehumanize), both which are disengagement me chanisms have a standardized regression coefficient of 0.10 and 0.13 respectively and a t value of 1.67 (p>0.05) and 1.44 (P>0.05) respectively. These paths are not significant. Thus Hypothesis 3 is not supported ( Figure 4 13).

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123 Hypothesis 4. This hypothesis postulated that the tested mechanisms of moral disengagement mechanisms will act as a mediating variable between professional obligation and application of pharmaceutical care. For disengagement items to function as a mediator it needs to meet t he following conditions (Barron & Kenny, 1986): 1. Variations in levels of the independent variable significantly account for variations in the presumed mediator (path a). 2. Variations in the mediator significantly account for variations in the dependent variab le (path b) 3. And when paths a and b are controlled, a previously significant relation between the independent and dependent variables is no longer significant, with the strongest demonstration of mediation occurring when path c is zero. The major advantage s of structural modeling techniques in testing mediating effects are that all relevant paths are directed tested and none are omitted as in ANOVA. Complications of measurement error, correlated measurement error, and even feedback are incorporated directly into the model (Baron & Kenny, 1986). Model 1. For condition 1, Kenny (2011), recommends against testing the relative fit of two structural models, one with the mediator and one without. Rather c, the total effect can be estimated from the formula c 1 + ab or given by Lisrel 8.8. The calculated total effect is significant with a standardized path coefficient of 0.70 and t value of 12.57 (P<0.05). For condition 2, the path from moral disengagement to application of pharmaceutical care had a standardized path coefficient of 0.01 and was not statistically significant with a t value of 0.11 (P>0.05). As such condition 2 is not upheld. Furthermore for condition 3, when paths a and b are controlled for the relationship between the independent and dependent vari able is still significant. Thus condition 3 is also not upheld ( Figure 4 11).

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124 Model 2.1 .For condition 1, the calculated the total effect is significant with a standardized path coefficient of 0.676 (Total effect = direct effect + mediator =0.73 + 0.46( 0. 12) = 0.676) with a t value of 11.45 (P<0.05). For condition 2, the path from moral disengagement to application of pharmaceutical care had a standardized path coefficient of 0.12 and was statistically significant with a t value of 2.22, (P>0.05). As such condition 2 is upheld. For condition 3, when paths a and b are controlled for the relationship between the independent and dependent variable is still significant, however the absolute size of the effect (Standardized path coefficient = 0.73, p<0.0 5) between the independent variable and the dependent variable is reduced after controlling for the mediator variable (Standardized path coefficient = 0.676, p<0.05). Thus the mediation effect is said to be partial The absolute size of the direct effect between oblig and pharmcare is reduced after controlling for the mediator variable (OM). The mediator OM which represents the domains displacement of responsibility and diffusion and responsibility, thereby act as a partial mediator between the variables professional obligation and pharmaceutical care ( Figure 4 12 and Figure 4 14). Model 2.2 For condition 1 the calculated total effect is significant with path coefficient of 1.14 and t value of 11.43 (p< 0.05). For condition 2, the path from CR to application of pharmaceutical care had a path coefficient of 0.10 and was not statistically significant with a t value of 1.67 (p>0.05) and the path from BD to application of pharmaceutical care had a path coef ficient of 0.13 and was not statistically significant with a t value of 1.44 (p>0.05). As such condition 2 is not upheld. Furthermore for condition 3, when paths a and b are controlled for the relationship

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125 between the independent and dependent variable is still significant. Thus condition 3 is also not upheld ( Figure 4 13). Statistical Assumptions Residual tests for gross violation of homoscedasticity assumptions Standardized residuals from the two models were plotted against the standardize d predicted values (Figure 4 14, Figure 4 15). The residual plots were inspected for gross violations of homoscedasticity. This assumption is satisfied if the residuals fluctuate randomly about zero throughout the predicted values. When violated, the homos cedasticity assumption may lead to biased regression coefficient estimators. The residual plots appeared to have no gross violations of homoscedasticity. Hence, both models were used to test the proposed model. Normality The distribution of the data to de termine the appropriateness of the statistical models analysis was examined for the two models; both models show normality with a slight skewness to the right. As such the normality of the data for both models were adequate for the statistical models analy zed.

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126 Table 4 1. Demographic and Practice Characteristics of Respondents Frequency Percent Gender 164 46.2 Male 125 35.2 Female N= 289 Ethnicity African American Caucasian 62 17.5 Asian/Pacific Islander 177 49.9 Hispanic 15 4.2 Other 22 6.2 Managed care 10 Ambulatory/ Outpatient 15 N=301 Degree B.S Pharmacy 189 53.2 PharmD 86 24.2 Masters 12 3.4 Other 4 1.1 N=291 Practice Setting Independent Community 96 32.5 Chain Community 65 22.0 Grocery/Discount Pharmacy 19 6.4 Managed care 10 3.4 Ambulatory/Outpatient Clinic 15 5.1 Hospital pharmacy 38 12.9 Unemployed 6 2.0 Retired 8 2.7 Other 38 12.9 N= 295 Position Held Staff 85 23.9 PRN 17 4.8 Clinical 24 6.8 Assistant manager 9 2.5 Pharm Manager 82 23.1 owner 44 12.4 Other 30 8.5 N= 291

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127 Table 4 2. Demographic and Practice Characteristics of Respondents Minimum Maximum Mean Standard Deviation Age 0 85 51.62 13.808 Years in Practice 0 69.0 25.524 13.1675 N=295

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128 Table 4 3. Item description for scenarios Items for Scenario 1 Oblig1.1 As a pharmacist, I have a professional obligation to help resolve Mr. Jones poorly controlled asthma symptoms. Oblig 1.2R (reverse coded) Helping to resolve Mr. Jones poorly controlled asthma related symptoms is outside of my professional obligation as a pharmacist. Oblig 1.3 As a pharmacist, I am professionally obligated to ensure that Mr. Jones receives the correct optimal asthma medication for his disease. Oblig1.4 As a pharmacist, I am professionally obligated to address Mr. Jones inhaler technique. Items for Scenario 2 Oblig2.1 As a pharmacist, I have a professional obligation to help resolve Oblig2.2R (reverse coded) outside of my professional obligation as a pharmacist. Oblig2.3 As a pharmacist, I am professionally obligated to approach Mr. Wilson and help him to resolve any behaviors that impact control of his asthma (e.g. lifestyle behaviors, medication related behaviors). Oblig2.4 As a pharmacist, I am professionally obligated to address Mr. compliance issues. Items for Scenario 3 Oblig3.1 As a pharmacist, I have a professional obligation to help resolve Oblig3.2R (Reverse coded) symptoms is outside of my professional obligation as a p harmacist. Oblig3.3 As a pharmacist, I am professionally obligated to approach Ms. Clark and help her to resolve any behaviors that impact control of her asthma (e.g. lifestyle behaviors, medication related behaviors). Oblig3.4 As a pharmacist, I am professionally obligated to approach Ms. Clark about her willingness to quit smoking.

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129 Table 4 alpha for the three scenarios Scenario alpha 1 0.653 2 0.726 3 0.703 Table 4 5. Item total Statistics for Scenario 1 Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted OBLIG1.1 10.9340 2.125 .501 .539 Oblig1.2R 10.9308 2.210 .325 .669 OBLIG1.3 11.0252 2.170 .424 .592 OBLIG1.4 10.8176 2.238 .512 .540 N=318 Table 4 6. Item Total Statistics for Scenario 2 Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted OBLIG2.1 10.4842 2.949 .605 .626 O blig2.2R 10.6646 2.554 .401 .773 OBLIG2.3 10.6456 2.903 .607 .622 OBLIG2.4 10.5285 2.885 .537 .654 N= 316 Table 4 7. Item Total Statistics for Scenario 3 Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted OBLIG3.1 10.1044 3.173 .577 .598 Oblig3.2R 10.3323 3.194 .290 .784 OBLIG3.3 10.2025 2.860 .679 .529 OBLIG3.4 10.3259 2.951 .495 .636 N=316

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130 Table 4 8. Item Description for the Three Scenarios Items for Scenario 1 PC1.1 Think of the last five adult asthma patients who were experiencing breathing related problems with circumstances similar to those of Mr. Jones, for how many did you check their refill records? PC1.2 Think about the last five adult asthma patients who were experiencing breathing related problem due to inadequate therapy with circumstances similar to those of Mr. Jones, for how many did you try to resolve their drug related problem(s)? PC1.3 Think about the last five adult patients you encountered who were nonsmokers like Mr. Jones, for how many of them did you personally provide counseling? PC1.4 Think about the last five adult non smoking patients that you encountered with circumstances similar to those Mr. Jones, for how many of them did you coordinate at least one follow up visit? Items for Scenario 2 PC 2.1 Think of the last five adult asthma patients who were experiencing breathing related problems with circumstances similar to those of Mr. Wilson, for how PC 2.2R Think about the last five adult asthma patients who were experiencing breathing related problem due to inadequate therapy with circumstances similar to those of Mr. Wilson, for how many did you try to resolve their drug related problem(s)? PC 2.3 Think a bout the last five adult patients you encountered who were nonsmokers like Mr. Wilson, for how many of them did you personally provide counseling? PC 2.4 Think about the last five adult non smoker patients that you encountered with circumstances similar to those of Mr. Wilson, for how many of them did you coordinate at least one follow up visit? Items for Scenario 3 PC 3.1 Think of the last five adult asthma patients who experienced breathing related problems with circumstances similar to those of Ms. Clark, for how many did PC 3.2R Think about the last five adult asthma patients who were experiencing breathing related problem due to inadequate therapy with circumstances similar to those of Ms. Clark, for how many did you try to resolve their drug related problem(s)? PC 3.3 Think about the last five adult patients you encountered who were smokers, like Ms. Clark, for how many of them did you personally provide counseling? PC 3.4 Think about the last fiv e adult smoker patients that you encountered with circumstances similar to those of Ms. Clark, for how many of them did you coordinate at least one follow up visit

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131 Table 4 alpha for the three scenarios Scenario alpha 1 0.703 2 0.806 3 0.834 Table 4 10. Item Total Statistics for Scenario 1 Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted PC1.1 8.50 16.758 .631 .728 PC1.2 8.83 15.624 .722 .681 PC1.3 8.97 16.479 .648 .719 PC1.4 10.65 18.148 .433 .828 N=293 Table 4 11. Item Total Statistics for Scenario 2 Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted PC2.1 8.89 16.366 .661 .740 PC2.2 9.09 14.906 .784 .678 PC2.3 9.27 15.717 .693 .723 PC2.4 10.90 17.660 .400 .871 N= 292 Table 4 12. Item Total Statistics for Scenario 3 Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted PC3.1 8.15 20.084 .661 .791 PC3.2 8.60 18.560 .808 .724 PC3.3 8.66 19.503 .706 .771 PC3.4 10.13 21.609 .499 .863 N=295

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132 Table 4 13. Item Total Statistics for Moral Disengagement Items for the Smoker Patient. Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Cronbach's alpha if Item Deleted Q4.1 24.0333 32.447 .403 .781 Q4.2 23.3500 32.690 .254 .798 Q4.3 23.8867 30.074 .629 .761 Q4.4 24.1433 31.528 .579 .768 Q4.6 23.6933 33.330 .233 .797 Q4.7 23.2567 32.466 .387 .782 Q4.8 23.9933 32.956 .320 .788 Q4.9 23.8433 29.939 .606 .762 Q4.1.0 23.8700 30.187 .602 .763 Q4.11 24.0267 30.447 .672 .760 Q4.12 23.8767 30.523 .622 .763 Q4.13 22.3667 34.554 .180 .798 Q4.14 24.3533 35.306 .169 .796 Q4.5R 23.7167 34.538 .168 .800

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133 Table 4 14. Item Total Statistics for Non Compliance Moral Disengagement Items Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item Total Correlation Squared Multiple Correlation Q4.16 20.0231 22.744 .480 .499 Q4.17 19.7129 22.609 .438 .288 Q4.18 19.9703 22.055 .653 .518 Q4.19 19.5578 22.082 .440 .279 Q4.2.0 19.9043 22.100 .518 .472 Q4.21 20.2706 24.734 .367 .251 Q4.22 20.0726 22.637 .605 .511 Q4.23 20.0858 23.158 .489 .479 Q4.24 18.5908 24.335 .154 .079 Q4.25 19.7063 23.870 .257 .246 Q4.26 19.6931 23.617 .263 .203 Q4.27 19.9769 22.413 .548 .504 Q4.15R 19.5050 24.483 .158 .091

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134 Table 4 15. Disease effect on Professional Obligation Mean N Std. Deviation Std. Error Mean Pair 1 Profoblig 1 10.9051 316 1.53804 .08652 Profoblig2 10.6582 316 1.60068 .09005 Pair 2 Profoblig1 10.9016 315 1.53924 .08673 Profoblig3 10.3333 315 1.78636 .10065 Pair 3 Profoblig2 10.6540 315 1.60144 .09023 Profoblig3 10.3206 315 1.78869 .10078 Table 4 16 Disease effect on Professional Obligation Paired Differences 95% Confidence Interval of the Difference Mean Std. Deviation Std. Error Mean Lower Lower t Df Sig. (2 tailed) Pair 1 Profoblig1 Profoblig2 .24684 1.44831 .08147 .08653 .40714 3.030 315 .003 Pair 2 Profoblig1 Profoblig3 .56825 1.78394 .10051 .37049 .76602 5.654 314 .000 Pair 3 Profoblig2 Profoblig3 .33333 1.49522 .08425 .16758 .49909 3.957 314 .000

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135 Table 4 1 7 Latent variables and Observed Variables for the proposed models Model Latent variable Observed variable Model 1 (Non compliant, non smoker asthmatic) Professional oblig (oblig) item oblig2.1, item oblig2.3, item oblig2.4 Disengagement mechanisms (disengage) NCCR: Q4.15R(reverse coded) + Q4.17 NCBD:Q4.16+ Q4.18 + Q4.18 + Q4.21 + Q4.23 + Q4.25 + Q4.26 NCOM: Q4.19+ Q4.20 + 4.22 + Q4.22 + 4.27 Application of pharmcare (Pharmcare) Item PC2.1, Item PC2.2, Item PC2.3, Item PC2.4 Model 2.1 (Smoker, compliant asthmatic) Professional oblig (oblig) item oblig3.1, item oblig3.3, item oblig3.4 Disengagement mechanisms (OM) Q4.3, Q4.9, Q4.10, Q4.11, Q4.12 Application of pharmcare (Pharmcare) Item PC3.1, Item PC3.2, Item PC3.3, Item PC3.4 Model 2. 2 (Smoker, compliant asthmatic) Professional oblig (oblig) item oblig3.1, item oblig3.3, item oblig3.4 Disengagement mechanisms (BD & CR) CR: Q4.1, Q4.4, Q4.7 BD: Q4.2, Q4.6, Q4.8 Application of pharmcare (Pharmcare) Item PC3.1, Item PC3.2, Item PC3.3, Item PC3.4

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136 F i gure 4 1. Revised Proposed Measurement model for CR, OM, BD for Smoker Asthma Patient

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137 Figure 4 2. Measurement model for CR, OM, BD for Smoker Asthma Patient

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138 Figure 4 3.Proposed Measurement Model for CR, BD, OM for Non compliant, non smoker asthma patient.

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139 Figure 4 4 .Measurement Model for CR, BD, OM for Non compliant, non smoker asthma patient.

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140 Figure 4 5. Proposed Model Figure 4 6. Structural Equation Model Standardized Estimates for Non Compliance Non Smoker Asthma Patient

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141 Figure 4 7 .Proposed Structural Equation Model for Smoker Asthma Patient

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142 Figure 4 8. Structural Equation Model Standardized Estimates for Smoker Asthma Patient with Disengagement Mechanisms Obscure and Minimize (OM)

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143 Figure 4 9. Proposed Structural Equation Mo del for Smoker Asthma Patient with Disengagement Mechanism Cognitively Reconstrue (CR) and Blame and Dehumanize (BD)

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144 Figure 4 10. Structural Equation Model Estimates for Smoker Asthma Patient with Disengagement Mechanism Cognitively Reconstrue (CR) and Blame and Dehumanize (BD)

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145 Figure 4 11. T values for the Structural Equation Model for Model 1

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146 Figure 4 12. T values for the Structural Equation Model for Model 2.1

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147 Figure 4 13. T values for the Structural Equation Model for Model 2.2

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148 Figure 4 14. Residual plot for Model 1 Figure 4 15. Residual plot for Model 2

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149 Figure 4 16. Normal distribution for Model 1 Figure 4 17. Normal distribution for Model 2

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150 CHAPTER 5 DISCUSSION AND CONCL USIONS Overview The objective of this study was to develop a theoretical framework to explain how opportunity to counsel a compliant smoker asthmatic, a non compliant non smoker asthmatic, and a compliant non smoker asthmatic. This goal was accomplished by Disengagement, developing a nd testing an instrument to measure the constructs, and testing proposed relationships between the constructs. This chapter provides a discussion of the study findings, limitation, implications, and recommendations for future research. Discussion of Findin gs Prediction of Severity of Lifestyle Disease on Professional Obligation professional obligation, pharmacists were shown three different scenarios under the same work and time con asthmatic patients presented with a breathing problem, however the patients varied in their lifestyle behavior, such as smoking or non compliant behavior. The conditions investigated were (i) non smoker asthma patient who was compliant with asthma therapy, (ii) non compliant non smoker asthma patient, and (iii) compliant asthma patient but also a smoker. These findings are discussed below.

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151 l obligation varied significantly when presented with different conditions surrounding a patient presenting with asthma controlling for time pressure and work environment. Pharmacists had a high sense of professional obligation toward the asthma non smoker patients who were compliant with asthma therapy, in which they said they were more likely to help the asthma patient in managing their uncontrolled asthma symptoms, more likely to say they ensured that he received optimal asthma medication, and more likel inhaler technique. However, when pharmacists were presented with a non compliant non smoker asthma patient, they were less likely to say they were involved in resolving likely to say they approached the patient to resolve any behaviors that impact control of asthma and also less likely to compliance issues. Pharmacists were even less likely to have a sense of professional obligation to compliant asthma patients who were also smokers. Compared to the other two patients, pharmacists were least likely to report they helped patients that smoke resolve poorly controlled asthma symptoms, behaviors that may impact control of their asthma, o r to say they approached patients about their possible willingness to quit smoking. Thus, the results show that pharmacists exhibit a different sense of professional obligation and willingness to help patients based on their medication adherence and smokin g status for patients with diagnosed asthma controlling for time pressure and work environment. Specifically, pharmacists were less likely to have a sense of professional obligation and provided less care to disease states/conditions that may be considered non compliance and smoking.

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152 Explanations into why professional obligation diminishes in the presence of lifestyle problems and poor compliance may be because these patient behaviors contravenes professional beliefs, patients and professionals. An aspect of societal reaction framework that has rarely been investigated is how certain behaviors, rather than persons, become iden tified as deviant (N ue hring & Markle, 19 74). The emergence of prohibitive norms against a behavior may be explained by a number of sociolog ical perspectives. Gusfield (19 6 3) describes a perspective in which laws reflect the values of dominant power groups; and reform strategies reflect the degre e to which a violator threatens an important norm. If the violator denies or challenges the norm, he/she is labeled as an enemy of the dominant culture. This perspective can be applied to the role between pharmacists and their patients. Pharmacists have no rms as health care professionals, which consist of rules specifying what patient behaviors are acceptable. These norms govern what pharmacists may see as appropriate patient behaviors. If a patient violates what pharmacists view as appropriate patient beh aviors, the patient may be labeled as deviant or undesirable. Patient behaviors that violate what pharmacists perceive to be appropriate patient behavior may consist of smoking or non compliance behaviors. As noted by N ue hring & Markle (1974) cigarette s moking has a long history of changing normative definitions and is an interesting sociological phenomenon because most people do not perceive the ingestion of its active ingredient, n icotine, as a drug behavior. N ue hring & Markle (1974) noted that society (both smoker and non smokers)

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153 as the American Cancer Society, the American Heart Assoc iation and the American Lung Association have always been vocal in the negative consequences of smoking. Life insurance companies support anti smoking efforts with lower premiums for the non smoker and smoking is restricted from a majority of public places These actions, sanctioned by society, reinforce the negative attitudes and beliefs towards smokers and the labeling of smoking as a deviant behavior. Adherence to (or compliance with) a medication regime is defined broadly as the patient is passi based on a therapeutic alliance or contract established between the patient and the physician (Osterberg, 2005). Regardless of the terms used, the issue of power is still central to the definitions: the power to label patient behavior which does not follow professional prescription as non compliant still rests with the professional (Playle & Keeley, 1998). Applying these terms to patients who do not consume every tablet/capsule/inhaler a t the desired time can stigmatize these patients in their future relationships with health care providers (Osterberg, 2005). Compliance is an ideology Non compliance ca n be seen as a label that denies legitimacy to any action that differs from professional prescription. In our dominant professional world view, there is a commonly understood belief that the role of the professional is to diagnose, prescribe and treat. The reciprocal role of the patient is to comply with such expert diagnosis and

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154 treatment. Patients who resist such a role can be seen as exhibiting behavior that challenges such professional held beliefs, expectations and norms. This has led to a labeling of such behavior as deviant, and an inherent tendency to view such patients as both deviant and culpable (Playle & Keeley, 1998). Research into non compliance generate search terms that included: default, non adherence, failure, refusal, resistance, and non c ooperation (Fawcett, 1995). In essence, such behavior is seen as 1974). Non compliance has been viewed in multiple ways, but common to all of them is the portrayal of the non compliant patient as deviant or having deviant attributes. Certain patient behaviors, such as smoking or not adhering to medications, may patient behaviors. This non compliance lower the sense of professional obligation of pharmacists to the patient, Prediction of Professional Obligation on the Application of Pharmaceutical Care Structural Equation Modeling was conducted to assess whether professional obligation had a positive dir Three models were tested ( F igure 4 11, Figure 4 12, and Figure 4 13). Model 1 depicted the moral disengagement mechanisms (cognitively reconstrue, blame & dehumanize, and obscure& minimize) acting as a mediating variable between professional obligation and the application of pharmaceutical care for the non compliant non smoker asthmatic scenario. Model 2.1 depicted the moral disengagement mechanism (obscure & minimize) acting as a mediating variable between professional

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155 obligation and the application of pharmaceutical care for the smoker compliant asthmatic scenario. And model 2.2 depicted the moral disengagement mechanisms (cognitively reconstrue and blame & dehumanize) acting as a mediating variable between the professional obligation and the application of pharmaceutical care for the smoker compliant asthmatic scenario. These three models were also utilized to assess prediction of moral disengagement mechanisms on pharmaceutical care and prediction of moral disengagement mechanism acting as a mediating variable between professional obligation and pharmaceutical care, which are discussed below. The models assessed if professional obligation had an effect on the application of pharm aceutical care for the scenarios non compliant non smoker asthmatic and the smoker complaint asthmatic. For all three models tested, professional obligation had a positive effect on the application of pharmaceutical care. Pharmacists with a high sense of p rofessional obligation were more likely to be involved in the application of pharmaceutical care. Prediction of Moral Disengagement Mechanisms on the Application of Pharmaceutical Care In social cognitive theory (Bandura, 1991), moral reasoning is transl ated into actions through self regulatory mechanisms through which moral agency is exercised. However this self regulatory function does not create an invariant control system with a person. Self reactive influences do not operate unless they are active, a nd there are many psychosocial processes by which self sanctions can be disengaged from inhumane conduct (Bandura, 1990, 1991). Selective activation and disengagement of internal control permits different types of conduct with the same moral standards. As

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156 such, pharmacists may behave differently towards different types of patients, but retain the same moral standards. This next section will examine each of the moral disengagement mechanisms tested. The first moral disengagement practice tested operated on t he reconstruction of the behavior itself. As noted by Bandura (2002) people do not usually engage in harmful conduct until they have justified to themselves the morality of their actions. Through this process of moral justification, pernicious conduct is m ade personally and socially acceptable by portraying it as serving socially worthy or moral purposes. This type of moral disengagement practice appeared to not play a role in the lack of provision of pharmaceutical care in both scenarios tested. The study findings suggest that pharmacists are not attaching a high moral purpose to their lack of participation in the application of pharmaceutical care. Pharmacists are not reconstruing their lack of action as a source of self valuation nor are they working hard to become proficient in not providing pharmaceutical care nor do they take pride in their destructive accomplishments. According to Bandura (2002), moral control operates most strongly when people acknowledge that they are contributors to harmful outcome s. The second set of disengagement practices tested operated by obscuring or minimizing the agentive role in the harm that one causes. This moral disengagement practice was activated and played a significant role in explaining the lack of provision of ph armaceutical care for the smoker asthmatic. For model 2.1 the moral disengagement mechanism tested (obscure & minimize) had a negative effect on the application of pharmaceutical care. The ent mechanisms:

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157 displacement of responsibility and diffusion of responsibility. The mechanism action on the stressful conditions that they are working in, that their co lleagues are also not participating in pharmaceutical care, and that corporate headquarters pressures them to increase prescription volume. The mechanism diffusion of responsibility reflects other health care professionals are not actively involved and wallow in the point that pharmacists only play a small part in helping smokers quit. The study findings indicate that pharmacists who have these moral disengagement beliefs are less likely to p ractice pharmaceutical care to smoker asthmatics. disengagement mechanisms were most likely activated because pharmacists are most likely well aware that smoking is damaging understand that their lack of action is a contributor to the detriment of their patent. Under displaced responsibility, pharmacists may very well view their actions as stemming from the dictates of authorities ra ther than being personally responsible for them. Because pharmacists are not the actual agents of their actions (or in this case, lack of action), pharmacists are spared self condemning reactions. Furthermore, Bandura noted that perpetuation of inhumaniti es required obedient functionaries. There obligations to authorities but fee l no personal responsibility for the harm they cause.

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1 58 The exercise of moral control is also weakened when personal agency is obscured by diffusing responsibility for detrimental behavior. The study findings suggest that pharmacists shift their attention f rom the meaning of what they are doing to the details of their specific job for the smoker asthmatic scenario. As such, pharmacists were focused on the daily details of their job (dispensing prescriptions, answering phone call etc.) and not focused on the meaning of their profession (the covenantal relationship between the pharmacist and their patient). Through the moral toward their patient may be reasoned as being diffuse d by division of labor. Furthermore, the findings suggest that pharmacists insisted that responsibility to the smoker asthmatic should be shared between them and their colleagues and other health care professionals. This type of group decision making is an other common practice that enables otherwise considerate people to behave inhumanely. Where everyone is responsible no one really feels responsibility. This type of collected action, which provides anonymity, is still another expedient for weakening moral control. As noted by Bandura ( 2002 ), any harm done by a group can always be attributed largely to the behaviors of others. Pharmacists appear to act more detrimentally to the smoker asthmatic under group responsibility than they would if they held themselv es personally accountable for their actions. The final set of disengagement practices tested operates on the recipients of detrimental acts (consisting of the moral disengagement mechanisms dehumanization & attribution of blame). The strength of moral sel f censure depends on how pharmacists regard their patients. It appears that this type of disengagement practice was not a

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159 significant direct contributor to the lack of provision of pharmaceutical care provided for both scenarios presented. However, it is i ntriguing to note that pharmacists felt a lower sense of professional obligation to the non compliant, non smoker asthmatic and even a lower sense of professional obligation to the smoker compliant asthmatic. It appears ehaviors may not be significant in explaining the lack of provision of care directly; it is significant in predicting how much professional obligation the pharmacist felt toward the patient, which is a predictor of how much care the patient receives. Band ura (1996) stated that moral disengagement can affect detrimental behavior both directly and by its impact on other theoretically relevant determinants. As such, this final set of disengagement practices tested in this study may indirectly affect the provi sion of care the patient receives by decreasing the level of professional obligation the patient receives from the pharmacist. Prediction of Moral Disengagement Mechanisms acting as a mediating variable between Professional Obligation and the Application of Pharmaceutical Care For model 1 and model 2.2, moral disengagement mechanisms did not act as a mediating variable between professional obligation and the application of pharmaceutical care. For model 2.1, the moral disengagement mechanism, displacement and diffusion of responsibility (categorized into the psychological category obligation and the application of pharmaceutical care. Pharmacists thus appear to rely on the disengagement mechanisms diffusion and displacement of responsibility in explaining why they are not applying pharmaceutical care to smoker asthmatics.

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160 Study Limitations The study findings should be evaluated with consideration of several study limitations The study limitations concerned issues related to variable design, variable measurement, and generalizability of findings. Variable Design and Measurement The first study limitation regarded the measure of the application of pharmaceutical care. Pharmaci sts were asked to report how many of the last five adults asthma patients did they perform certain behaviors. Although how this specific measure Direct Patient Care co mponent of the Behavioral Pharmaceutical Care Scale (BPCS DPC) (Odedina & Segal, 1996). In the BPCS DPC, respondents are asked to indicate to how many of their last five patients with chronic conditions (e.g., asthma, diabetes) they provided certain servic es The BPCS DPC, developed as a tool for measuring pharmacists' efforts to provide pharmaceutical care, was found to be reliable, sensitive, and valid. Secondly, because the instrument is a self report measure, social desirability may have influenced pharm Generalizability The last two study limitations involve the generalizability of the study results. First, the study utilized hypothetical scenarios as means of questioning pharmacists regarding professional obligation, moral disengageme nt beliefs, and application of pharmaceutical care for a (i) non smoker asthma patient who was compliant with asthma therapy, (ii) non compliant non smoker asthma patient, and (iii) compliant asthma patient but also a smoker. Therefore, the relationships f ound between these variables should not be generalized to other drug related events. Second, the pharmacists who participated in

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161 the study were not randomly selected. Pharmacists were recruited at live continuing education programs. Pharmacists who attend these live CE programs may be different from other pharmacists who choose not to attend live CE programs and instead choose to fulfill their live CE requirement via real time streaming online Thus this study does not permit generalization of the study resu lts to all Florida pharmacists. However, the primary objective of this study was to develop an applied theory, thus generalizability of the results was not crucial to the purpose of the study; rather the internal validity of the study was of main concern. Implications of Findings The study findings have practical implications for the profession of pharmacy as well as theoretical implications. Each of these is discussed below. Practical Implications for Pharmacy This study has implications for pharmaceutical care or medication therapy therapy outcomes. Colleges of Pharmacies, continuing education programs, and Boards of Pharmacies place a strong emphasis on ensuring that pharmacist s have knowledge and skill on how to address drug therapy problems. Additionally, professional attitudes and behaviors have become increasingly recognized as important contributors of ethical pro fessional practice (Caron, 2006 ). The Professional Ethics Com mission has placed strong emphasis on the need for curriculum on professional ethics to be included in all levels of training programs. At the core of the curriculum is the attitudinal and action dimensions of ethics. The attitudinal dimension involves veloping an internal and external awareness of self as part of a complex system of interdependent relationships

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162 that are ultimately based on ethical and social codes The actio n dimension of ethics involves: A c ode of behavior based on personal, social, and professional values and principles that enable persons to evaluate and to correct their actions when these fall short of enabling he alth development. (Caron, 2006) gauge their behavior accordingly to the professional ethical code and abiding commitment to the moral responsibilities distinctive to the profession (Caron, 2006). If pharmacists are able to disengage from their ethical professional re sponsibility, the pharmacy profession is at risk of being unable to attain personal, professional, and social growth and development. non compliance and smoking, play a signif icant role in predicting the level of professional obligation the pharmacist feels towards the patient. Furthermore, beliefs that diffuse and displace the responsibilities of the pharmacists and instead place blame on stressful conditions, corporate headqu arters pressuring pharmacists to increase prescription volume and blaming colleagues and other health care professionals in not Bandura (2002) noted that disengagemen t practices will not instantly transform considerate people into cruel ones. Rather this change is progressive, with individuals initially performing mildly harmful acts they can tolerate with some discomfort, with their detrimental actions increasing as t heir self reproof diminishes through repeated enactments, until eventually acts originally regarded as objectionable can be performed with little anguish or self censure (Bandura, 2002). As the results show, pharmacists have already started with activating the disengagement mechanisms displacement and

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163 diffusion of responsibility Although these mechanisms are built into the organizational and authority structures of societal systems, and these socio structural practices create conditions conducive to moral disengagement, pharmacists are producers as well as products of social systems. Pharmacists have the agentic capabilities to change the nature of their social systems. It is important to address these issues before unethical professional practices become thoughtlessly routinized. Pharmacists may not even recognize the changes they have undergone as a moral self, as the continuing interplay between moral thought, affect, action and its social reception is personally transformative. As noted by Bandura (2002 ), moral disengagement is an active player in daily life and it is important that we recognize the role their moral disengagement practices affect the ethical professional role of pharmacists. The explanation for the lack of application of pharmaceutical care thus does not reside simply in the lack of knowledge or skill that pharmacists possess but in a complex interplay between beliefs that the pharmacists hold on certain patient characteristics and certain moral disengagement beliefs. The findings of thi s study professional obligation as well as provision of pharmaceutical care. Influencing pha patient.

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164 Theoretical implications Unrelenting news about unethical behavior has freque ntly made its way to headlines in virtually every sector of society (e.g. business, government, military, sports, religious institutions) (Detert et al. 2008). Recent arguments insist that the best explanations for unethical decision making may reside in underlying psychological processes (Messick & Bazerman, 1996). Understanding unethical decision making is especially critical in the health profession sector as health professions heavily depend on ethics and ethical professional practice to attain maximum personal, professional, and social growth and development. Bandura (1986) argued that moral disengagement explains why otherwise normal people are able to engage in unethical behavior without apparent guilt or self censure. Despite its potential importa nce for explaining unethical decision making, our understanding of moral disengagement remains at an early stage. Even less is known about moral socio cognitive theories as explanations of decisions or actions of health care professionals. The present stu been tested with subjects who are members of a health profession. Therefore, this Disengagement theory, it also established the use of the model among a new subject population (i.e., pharmacists). Previous research has primarily focused on the outcomes of moral disengagement, such as its positive relationship to aggression in children (Bandura, Ba rbaranelli, C aprara & P astorelli, 1996) or its relationship to decisions to support military action (Aquino et al. 2007). Furthermore, the majority of research has

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165 categorized the specific mechanisms that underlie the propensity to morally disengage as a single higher order construct. As such, our study is one of the few studies that examined moral disengagement mechanisms individually. Bandura (1996) noted in a study performed on school aged children, that although the various mechanisms of moral disengagement operate in concert, moral reconstrual detrimental activities. This study found that the moral disengagement mechanisms, diffusion & displacement of responsibility, contribute d most heavily to the lack of provision of care provided by the pharmacist for the smoker asthmatic scenario. Detert et al. (2008) found that moral disengagement is positively related to unethical decision making and that moral disengagement play a mediati ng role between individual differences studies and unethical decision making This study found that the moral related to unethical professional practice (not providing care to the smoker asthmatic) and also acted as a mediating role between professional obligation and application of pharmaceutical care. Prior to this study, the role moral disengagement mechanisms plays in mediating effects between professional obligation and the application of pharmaceutical care was unknown. The results of the current study show the mediating role of the moral disengagement mechanisms, displacement and diffusion of responsibility, between professional obligation and application of pharmaceutical care for smoker asthma patients. Furthermore, this study found that although the mechanisms attribution of blame and dehumanization did not play a significant role in explaining the lack of provision of

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166 pharmaceutical care, patient characteristics involvi ng lifestyle behaviors did play a role in decreasing the level of professional obligation that the pharmacist felt toward the development (Bandura, 1986), Bandura descri bed moral disengagement as explicitly interactive, the result of continued reciprocal influences of the individual, behavior, and the environment (Bandura, 2002). Acknowledging that disengaging self sanctions through morally disengaged reasoning may be als o triggered by specific contextual factors (Bandura, 1999, 2002), this study reinforces this idea that specific moral disengagement mechanisms are most likely triggered by particular circumstances. As we found that certain situations presented to the pharm acist (smoker asthmatic) triggered the moral disengagement reasoning. Thus this research on moral disengagement is one of the very few studies that examines both the person and the situation simultaneously and captures the interactionism nature that domina nt theories agree characterize our moral selves (Bandura, 1990b; Trevino, 1986). Recommendations for Future Research Given that only five of the eight disengagement mechanisms were tested in this study, it is recommended that possibly the excluded three me chanisms of moral disengagement may have played a role. Future research should include the disengagement mechanisms: distorting consequences, euphemistic language and advantageous comparisons. Additionally, investigation into other reasons why pharmacists are not providing pharmaceutical care should be examined, beyond activation of moral disengagement beliefs. As noted by Bandura et al. (1996), individuals have many different methods of moral disengagement at their disposal and did not rule out the presenc e of other motivations in addition to guilt avoidance. Since

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167 this study was based on self reported measures, this study gives us the knowledge of other motivations t hat may remain unconscious to participants. Furthermore, only two scenarios were examined: non compliant nonsmoker asthmatic and smoker compliant asthmatic. It is possible that other scenarios may elicit different responses with activation of different mor al disengagement responses and future research should address this issue Additionally, pharmacists noted varying levels of professional obligation depending on certain presenting patient characteristics. It is intriguing to investigate the underlying perc eptions that pharmacists may have of these patient characteristics as well as what toward the patient. Further research should address whether morally disengaged think ing can be attenuated through intervention or training. One study conducted by Paciello et al. (2008) found evidence that individual levels of moral disengagement are malleable to external influences over time, which suggested that moral disengagement ev en among those predisposed toward such reasoning may be receptive to training interventions. Such interventions have practical implications for the organizations that are interested in reducing harm caused by morally disengaged thinking. Conclusion Band levels of patient lifestyle behaviors. The results show that pharmacists exhibit a different sense of professional obligation and willingness to help patients based on the behaviors

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168 that patients exhibit. Specifically, pharmacists were less likely to have a sense of professional obligation and reported they provided less care to asthma patients who were non adherent to their medications and/or were smokers. Furthermore, the moral disengagement beliefs distortions and diffusion of responsibility were found to mediate the effects between professional obligation and the application of pharmaceutical care for the smoker asthmatic. The findings of this study have practical implications for the professionalization of pharmacy, as well as theoretical implications for pharmacy administration research. Furthermore, the findings of this study extend what is known r of moral disengagement.

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169 APPENDIX A PHARMACIST PROFESSIONAL OBLIGAT ION SURVEY Dear Pharmacist, To promote better patient care this study attempts to understand how pharmacists make decisions based on different patient scenarios. Please note that your participation is completely voluntary and there is no penalty for not participating in the study or for withdrawing from the study. By completing the questionnaire you are consenting to participate in th is study. This survey should take about 15 minutes to complete. Please answer the questions candidly. There are no right or wrong answers to the questions asked in this survey. We are interested in your honest opinion only and you may be assured of complete presented with different patient care scenarios. Note that you do not have to answer all the questions asked in this survey. Your name will never be placed on th e questionnaire, nor will your responses be linked to you personally during analyses. All responses will be kept as confidential as legally possible. Once completed, please provide the completed survey to the coordinator. If you have any question(s) or co mment(s) about the survey, please contact Christine Lee at 352 672 7272 / CL55@ufl.edu In appreciation of your time participating in the survey, $5 gift will be provided to you. For information regarding your rights as a research participant contact the I RB at 352 392 0433. Thank you for your participation. Best Regards,

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170 APPENDIX B PHARMACY STUDENT PROFESSIONAL OBLIGAT ION SURVEY Dear Pharmacy Student, To promote better patient care this study attempts to understand how pharmacists make decisions based on different patient scenarios. Please note that your participation is completely voluntary and there is no penalty for not participating in the study or for withdrawing from the study. By completing the questionnaire you are consent ing to participate in this study. This survey should take about 15 minutes to complete. Please answer the questions candidly. There are no right or wrong answers to the questions asked in this survey. We are interested in your honest opinion only and y ou may be assured of complete presented with different patient care scenarios. Note that you do not have to answer all the questions asked in this survey. Your name will never be placed on the questionnaire, nor will your responses be linked to you personally during analyses. All responses will be kept as confidential as legally possible. Once completed, please provide the completed survey to the coordinator. If you have any question(s) or comment(s) about the survey, please contact Christine Lee at 352 672 7272 / CL55@ufl.edu No compensation will be provided to you for completing the survey. For information regarding your rights as a research participant contact the IRB at 352 392 0433. Thank you for your participation. Best Regards,

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171 APPENDIX C PRETEST PROFESSIONAL OBLIGATION INSTRUMEN T Instructions Please Read In this survey, you will be asked about your opinions concerning drug therapy problems that patients sometimes experience. For the purposes of this survey, a drug therapy problem is: an undesirable event or circumstance involving drug therapy that actually or potentially interferes with a patient experiencing a desired outcome. Professional obligation is defined as: The survey consists of six(6) sections. Sections 1 3: Each contains a hypothetical situation involving a patient who has come to you pharmacy for a prescription. Please read each situation and respond to the statements that follow. Section 4: You are asked about your beliefs Section 5: You are asked about certain activities performed Section 6: You are asked to provide some demographic information about yourself. Professional Obligation Instrument

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172 SECTION 1: Please consider the following hypothetical situation involving a patient who has come to your pharmacy for a prescription. Name: Debbie Clark Sex: Female Age: 28 Allergies: NKA Health condition: Asthma Medication Dose Directions Prescriber Original Refills Remaining refills Last refill date Proventil HFA 90 mcg 2 puffs PRN Dr. Jon Wells 11 9 20 days ago Flovent HFA 220 mcg 1 puffs bid Dr. Jon Wells 11 9 20 days ago Debbie Clark regularly fills her albuterol and inhaled corticosteroid at your pharmacy. She has had asthma since she was a child. When you hand Ms. Clark her prescription, she complains of symptoms such as shortness of breath and wheezing. You notice, as you are talking to Ms. Clark, that she has a package of cigarettes in her purse and her fingers and teeth are stained with the yellowing from cigarette smoke. Currently, you are quite busy, phones have been ringing consistently and there are several prescriptions that need to be verified. Furthermo re a line of impatient patients has now formed, waiting to be served. Please indicate the extent that you agree or disagree with the following statement: (Circle response) 1. For this scenario there is a disease management problem. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 2. uncontrolled asthma symptoms. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 3. uncontrolled asthma related symptoms is outside of my professional obligation as a pharmacist. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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173 4. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 5. As a pharmacist, I am professionally obligated to approach Ms. Clark about her willingness to quit smoking. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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174 SECTION 2: Please consider the following hypothetical situation involving a patient who has come to your pharmacy for a prescription. Name: Sam Jones Sex: Male Age: 30 Allergies: Sulfa Health condition: Asthma & Seasonal Allergy Medication Dose Directions Prescriber Original Refills Remaining refills Last refill date Proventil HFA 90 mcg 2 puffs PRN Dr. Jane Smith 11 8 14 days ago Zyrtec (Ceterizine) 10mg 1QD Dr. Jane Smith 11 3 30 days ago Sam Jones frequently visits your pharmacy and fills his Zyrtec regularly. He comes in today asking to transfer is asthma medication (albuterol) from another pharmacy. Since it is very busy g. He says that it is no problem since he has some shopping to do in the pharmacy front store anyways. When you call the transferring pharmacy, the pharmacist informs you that he had just filled Mr. Jones albuterol about 2 weeks ago. When you mention this to Mr. Jones, he acknowledges that he has been overusing his albuterol, but has had a lot of trouble breathing which is extremely frustrating since he plays tennis regul arly and lives a healthy smoke free lifestyle. The albuterol inhaler is the only medica tion that he takes for his asthma. Currently, the pharmacy is still hectic and you notice a line of new patients forming and your technician informs you that a physician is on the phone wanting to talk to you. Please indicate the extent that you agree or disagree with the following statement: (Circle response) 1. For this scenario there is a disease management problem. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 2. uncontrolled asthma symptoms. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 3. my professional obligation as a pharmacist. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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175 4. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 5. As a pharmacist, I am professionally obligated to ensure that Mr. Jones receives the correct optimal asthma medication for his disease. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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176 SECTION 3: Please consider the following hypothetical situation involving a patient who has come to your pharmacy for a prescription. Name: Jonas Wilson Sex: Male Age: 28 Allergies: NKA Health condition: Asthma Comments: Counseled patient several times on the impor tance of using his QVAR Medication Dose Directio ns Prescriber Original Refills Remainin g refills Last refill date Proventil HFA 90 mcg 2 puffs PRN Dr. Melanie Wells 11 2 15 days ago Beclometh Diprop (QVAR ) 80 mcg 2 puff bid Dr. Melanie Wells 11 10 96 days ago Jonas Wilson comes into you pharmacy complaining of increasing amounts of shortness of breath and asks you to please fill his Proventil inhaler. Mr. Wilsons is a non smoker and a regular patient at your pharmacy. As you are filling his prescription, you notice that he has been overusing his Proventil and has not picked up his inhaled corticosteroid inhaler in over 3 months. When you ask Mr. Wilson if he wants his inhaled corticosteroid filled also, Mr. Wilson says that although his insurance covers both medications, he only wants the albuterol since he still has plenty of the inhaled corticosteroid at home that he never uses. You note in his chart that you and your partner pharmacist have counseled Mr. Wilson several times on the importance of using his inhaled corticosteroid.It has been busy for the past hour and your technician informs you that the nearby physician is waiting for you to call him back Please indicate the extent that you agree or disagree with the following statement: (Circle response) 1. For this scenario there is a disease management problem. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 2. As a uncontrolled asthma symptoms. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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177 3. professional obligation as a pharmacist. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 4. outcomes. Strongly agree Somewhat Agree Somewhat disagre e Strongly disagree 5. compliance issues. Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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178 Section 4: Please indicate the extent to which you agree or disagree with each of the following statements. 1. It is alright to not counsel smokers because I believe this is their source of stress relief. (MJ) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 2. It is alright to not counsel smokers because nicotine replacement therapy is expensive. (MJ) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 3. Smoking Cessation Counseling is effective. (MJ) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 4. Smokers are not likely to quit when counseled. (MJ) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 5. It is understandable if I am not counseling smokers when I are working under stressful conditions. (DR) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 6. If corporate headquarters pressures me to increase prescription volume it is understandable if I do not counsel smokers.(DR) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 7. If physicians, nurses and other health care professionals are not counseling on smoking cessation, it is understandable if I am not counseling smokers. (Diff) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree

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179 8. If other health care professionals are not co unseling on smoking cessation it is unfair to ask me to counsel on smoking cessation. (Diff) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 9. I play only a small part in helping smokers quit smoking. (Diff) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 10. Smokers who suffer from smoking related diseases deserve it.(AB) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 11. Smoking is a personal lifestyle choice that patients make themselves. (AB) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 12. Smokers are mentally weak willed. (D) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 13. People become smokers because of moral weakness. (D) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 14. Smoking is best seen as a form of wrongdoing. (D) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 15. Non compliant persons are not likely to benefit from counseling. (MJ) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 16. It is alright to not counsel non compliant persons because they choose to be non compliant.(MJ) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 17. If corporate headquarters pressures me to increase prescription volume it is understandable if I do not counsel non compliant patients smokers.(DR)

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180 Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 18. If other health care professionals are not counseling on compliance issues it is unfair to ask me to counsel non compliant patients. (DR) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 19. I play only a small part in helping non compliant patients. (DR) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 20. If non compliant patients suffer consequences from their habitually refraining from refilling their prescriptions, it is their own fault. (AB) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 21. Non compliant patients who suffer from their disease deserve it. (AB) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 22. Patients should be free to choose whether they want to be compliant with their therapy. (AB) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 23. Non compliant patients are mentally weak willed. (D) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 24. Non compliant patients are weak. (D) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 25. People become non compliant because of moral weakness. (D) Strongly agree Somewhat Agree Somewhat disagree Strongly disagree 26. Non compliance is best seen as a form of wrongdoing. (D) Strongly Somewhat Somewhat Strongly

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181 agree Agree disagree disagree Section 5: For this Section, we ask you to think about your own experiences. Please think about your last five (5)adult patients of yours who presented with a refill prescription used to treat asthma Please indicate for how many of these five patients you engaged in ea ch of the following activities. (Circle number) 1. Think of the last five adult asthma patient encounters, for how many of them did you investigate if the patient was experiencing an asthma related breathing problem. None 1 2 3 4 All 5 2. Think of you last five adult asthma patients who were experiencing breathing related problems, how many were experiencing a breathing related problem due to inadequate drug therapy. None 1 2 3 4 All 5 3. Think of the last five adult asthma patients who were experiencing breathing related problems due to inadequate therapy, for how many did you try to resolve their drug related problem? None 1 2 3 4 All 5 4. Think of the last five adult asthma patients who were experiencing breathing related problems due to inadequate therapy, how many did you coordinate at least one follow up with patient to monitor his/her progress with asthma management? None 1 2 3 4 All 5 5. Think of you last five adult asthma patients who were experiencing breathing related problems, how many were experiencing a breathing related problem due to non compliance issues with their medications? None 1 2 3 4 All 5 6. Think of the last five adult asthma patients, for how many of them did you check their patient profile to see if they were refilling their medications on time? None 1 2 3 4 All 5

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182 7. Think of the last five adult asthma patients, for how many did you discuss special directions for use? None 1 2 3 4 All 5 8. Think of the last five asthma patients, for how many of them did you personally talk to? None 1 2 3 4 All 5 9. Think of the last five adult asthma patients who were experiencing breathing related problems due to non compliance issues, how many did you address their compliance issues? None 1 2 3 4 All 5 10. Think of the last five adult asthma patients who were experiencing breathing related problems due to non compliance issues, how many did you coordinate at least one follow up with patient to monitor his/her progress with medication compliance? None 1 2 3 4 All 5 11. Think of your last five asthma adult patient encounters, for how many of them did you inquire whether or not they smoked cigarettes? None 1 2 3 4 All 5 12. Think about the last five adult patients who were smokers that you encountered, for how many of them did you suggest smoking cessation strategies? None 1 2 3 4 All 5 13. Think about the last five adult smoker patients that you encountered, for how many of them did you suggest referral to other health care providers or clinics for smoking cessation? None 1 2 3 4 All 5

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183 14. Think about the last five adult patients who were smokers that you encountered, for how many did you coordinate at least one follow up to monitor progress of their smoking cessation? None 1 2 3 4 All 5

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184 Section 6: Finally, we would like to ask you some questions about yourself. 1. How many years have you been practicing pharmacy? _________ years 2. Which of the following degrees have you received? (Circle all that apply) a. B.S. in pharmacy b. PharmD c. Masters d. Other(s) (Please specify)________________________ 3. Which of the following best describes your current practice setting? (Circle one response) a. Independent community pharmacy b. Chain community pharmacy c. Grocery/Discount store pharmacy d. Managed care pharmacy e. Ambulatory/ Outpatien t clinic f. Hospital pharmacy g. Currently unemployed h. Retired i. Other (Please specify) ______________________ 4. Which of the following best describes your current position at your job? (circle one response). a. Staff pharmacist b. PRN/ Floater pharmacist c. Clinical pharmacist d. Assistant pharmacy manager e. Pharmacy manager f. Pharmacy owner g. Other (Please specify) _____________ 5. Your present age: _____________ years 6. Your gender: a. Male b. Female 7. Which Ethnicity are you

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185 a. African American b. Caucasian c. Asian or Pacific Islander d. American Indian e. Hispanic 8. drug therapy problems or about this survey? If so, please share your comments below.

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186 APPENDIX D PROFESSIONAL OBLIGAT ION INSTRUMENT SECTION 1: Instructions Please Read In this survey, you will be asked about your opinions concerning drug therapy problems that patients sometimes experience. For the purposes of this survey, a drug therapy problem is: an undesirable event or circumstance involving disease management that actually or potentially interferes with a patient experiencing a desired outcome. Professional obligation is defined as: as being trustworthy within The survey consists of five ( 5 ) sections. Sections 1 3 : Each contains a hypothetical situation involving a patient who has come to your pharmacy for a prescription. Pleas e read each situation and respond to the statements that follow. Section 4 : You are asked about your beliefs Section 5 : You are asked to provide some demographic information about yourself. Professional Obligation Instrument

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187 SECTION 1 Please consider the following hypothetical situation involving a patient who has come to your pharmacy Medication Dose Direction Remaining refills Last refill date Proventil HFA 90 mcg 2 puffs PRN 8 14 days ago Zyrtec ( Ceterizine) 10mg 1QD 3 30 days ago Sam Jones frequently visits your pharmacy and fills his Zyrtec regularly. He comes in today asking to transfer his asthma medication (albuterol) from another pharmacy. Since it is very busy at the ays that it is nota problem. When you call the transferring pharmacy, the pharmacist informs you that he had just filled Mr. Jones albuterol about 2 weeks ago. The pharmacist also shares with you that Samhas had problems in the past in mastering his inhale r technique. When you mention this to Mr. Jones, he acknowledges that he has been overusing his albuterol, but has had a lot of trouble breathing, which is extremely frustrating since he plays tennis regul arly and lives a healthy smoke free lifestyle. The albuterol inhaler is the only medication that he takes for his asthma. Upon interviewing Mr. Jones, he denies use of alcohol and tobacco. Currently, the pharmacy is still hectic and you notice a line of new patients forming and your technician informs you that a physician is on the phone wanting to talk to you. Please indicate the extent that you agree or disagree with the following statement: (Circle response) IMPORTANT: As you reflect on the hypothetical situation involving Mr. Jones, please try to consider other patients you have seen in your practice similar to Mr. Jones and respond to the statements as you would for patients in your actual practice setting 1. As a pharmacist, I have a professional obligation to help resolve Mr. Jones poorly controll ed asthma symptoms. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 2. Helping to resolve Mr. Jones poorly controlled asthma related symptoms is outside of my professional obligation as a pharmacist. Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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188 3. As a pharmacist, I am professionally obligated to ensure that Mr. Jones receives the correct optimal asthma medication for his disease. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 4. As a pharmacist, I am professionally obligated to address Mr. Jones inhaler technique. Strongly disagree Somewhat disagree Somewhat agree Strongly agree For this section, we ask you to think about your own experiences. Please think about the last five (5) adult patients who presented with a refill prescription used to treat asthma. Please indicate for how many of these five patients you engaged in each of the following activities. 1. Think of the last five adult asthma patients who were experiencing breathing related problems with circumstances similar to those of Mr. Jones, for how many did you check their refill records? 2. Think about the last five adult asthma patients who were experiencing breathing related problem due to inadequate therapy with circumstances similar to those of Mr. Jones, for how many did you try to resolve their drug related problem(s)? 3. Think about the last five adult patients you encountered who were nonsmokers like Mr. Jones, for how many of them did you personally provide counseling? 4. Think about the last five adult non smoking patients that you encountered with circumstances similar to those Mr. Jones, for how many of them did you coordinate at least one follow up visit? None 1 2 3 4 All 5 None 1 2 3 4 All 5 None 1 2 3 4 All 5 None 1 2 3 4 All 5

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189 SECTION 2: Please consider the following hypothetical situation involving a patient who has come to your pharmacy Medication Dose Directions Remaining refills Last refill date Proventil HFA 90 mcg 2 puffs PRN 2 15 days ago BeclomethD iprop (QVAR ) 80 mcg 2 puff bid 10 96 days ago Jonas Wilson comes into you pharmacy complaining of increasing amounts of shortness of breath and asks you to please refill his Proventil inhaler prescription. Mr. Wilsons is a non smoker and denies alcohol use. As you are refilling his prescription, you notice that he has been overusing his Proventil and has not picked up his inhaled corticosteroid inhaler in over 3 months. When you ask M r. Wilson if he wants his inhaled corticosteroid refilled also, Mr. Wilson says that, although his insurance covers both medications, he only wants the albuterol since he still has plenty of the inhaled corticosteroid at home that he never uses. You note i n his chart that you and your partner pharmacist have counseled Mr. Wilson several times on the importance of regularly using his inhaled corticosteroid. However, the compliance is unknown to you. It has been busy for the past hour and your technician informs you that the nearby physician is waiting for you to call him back Please indicate the extent that you agree or disagree with the following statement: (Circle response) IMPORTANT: As you reflect on the hypothetical situat ion involving Mr. Wilson, please try to consider other patients you have seen in your practice similar to Mr. Wilson and respond to the statements as you would for patients in your actual practice setting. 1. As a pharmacist, I have a professional obligation asthma symptoms. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 2. obligation as a pharmacist. Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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190 3. As a pharmacist, I am professionally obligated to approach Mr. Wilson and help him to resolve any behaviors that impact control of his asthma (e.g. lifestyle behaviors, medication related behaviors). Strongly disagree Somewhat disagree Somewhat agree Strongly agree 4. compliance issues. Strongly disagree Somewhat disagree Somewhat agree Strongly agree For this section, we ask you to think about your own experiences. Please think about the last five (5) adult patients who presented with a refill prescription used to treat asthma. Please indicate for how many of these five patients you engaged i n each of the following activities. 1. Think of the last five adult asthma patients who were experiencing breathing related problems with circumstances similar to those of Mr. Wilson, for how many did you check the 2. Think about the last five adult asthma patients who were experiencing breathing related problem due to inadequate therapy with circumstances similar to those of Mr. Wilson, for how many did you try to resolve their drug related problem(s)? 3. Think about the last five adult patients you encountered who were nonsmokers like Mr. Wilson, for how many of them did you personally provide counseling? 4. Think about the last five adult non smoker patients that you encountered with circumstances similar to those of Mr. Wilson, for how many of them did you coordinate at least one follow up visit? None 1 2 3 4 All 5 None 1 2 3 4 All 5 None 1 2 3 4 All 5 None 1 2 3 4 All 5

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191 SECTION 3: Please consider the following hypothetical situation involving a patient who has come to your pharmacy Medication Dose Direction Remaining refills Last refill date Proventil HFA 90 mcg 2 puffs PRN 9 27days ago Flovent HFA 220 mcg 1 puffs bid 9 27days ago Debbie Clark fills her albuterol (Proventil HFA) and inhaled corticosteroid (Flovent HFA) at your pharmacy. She has had asthma since she was a child. When you hand Ms. Clark her prescription, she complains of symptoms such as shortness of breath and wheezing. You notice, as you are talking to Ms. Clark, that she has a package of cigarettes in her purse and her fingers and teeth are stained with the yellowing from cigarette smoke. Upon interviewing Ms. Clark, she denies use of alcohol and admits use of tobacco (1 to 2 packs daily). Currently, you a re quite busy, phones are constantly ringing, and there are several prescriptions that need to be verified. Furthermore a line of impatient patients has now formed, waiting to be served. Please indicate the extent that you agree or disagree with the following statement: (Circle response) IMPORTANT : As you reflect on the hypothetical situation involving Ms. Clark, please try to consider other patients you have seen in your practice similar to Ms. Clark and respond to the statements as you would for patients in your actual practice setting. 1. As a pharm asthma symptoms. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 2. of my professional obligation as a pharmacist. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 3. As a pharmacist, I am professionally obligated to approach Ms. Clark and help her to resolve any behaviors that impact control of her asth ma (e.g. lifestyle behaviors, medication related behaviors). Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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192 4. As a pharmacist, I am professionally obligated to approach Ms. Clark about her willingness to quit smoking. Strongly disagree Somewhat disagree Somewhat agree Strongly agree For this section, we ask you to think about your own experiences. Please think about the last five (5) adult patients who presented with a refill prescription used to treat asthma. Please indicate for how many of these five patients you engaged in each of the following activities. 1. Think of the last five adult asthma patients who experienced breathing related problems with circumstances similar to those of Ms. Clark, for how many did you check the record? 2. Think about the last five adult asthma patients who were experiencing breathing related problem due to inadequate therapy with circumstances similar to those of Ms. Clark, for how many did you try to resolve their drug related problem(s)? 3. Think about the last five adult patients you encountered who were smokers, like Ms. Clark, for how many of them did you personally provide counseling? 4. Think about the last five adult smoker patients that you encountered with circumstances similar to those of Ms. Clark, for how many of them did you coordinate at least one follow up visit? None 1 2 3 4 All 5 None 1 2 3 4 All 5 None 1 2 3 4 All 5 None 1 2 3 4 All 5

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193 Section 4: Please indicate the extent to which you agree or disagree with each of the following statements. 1. I am not obligated to counsel smokers on smoking cessation because I believe this is their source of stress relief. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 2. S moking is best seen as a form of wrongdoing. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 3. It is unfair to ask me to counsel on smoking cessation if other health care professionals are not counseling on smoking cessation. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 4. I am not obligated to counsel smokers on smoking cessation because nicotine replacement therapy is expensive. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 5. Smoking Cessation Counseling is effective for smokers. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 6. Smokers are mentally weak willed Strongly disagree Somewhat disagree Somewhat agree Strongly agree 7. Smokers are not likely to quit when counseled. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 8. Smokers who suffer from smoking related diseases deserve it. Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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194 9. I am not obligated to counsel smokers on smoking cessation when I am working under stressful conditions. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 10. I am not obligated to counsel smokers on smoking cessation if corporate headquarters pressures me to increase prescription volume. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 11. I am not obligated to counsel smokers on smoking cessation, if physicians, nurses and other health care professionals are not counseling on smoking cessation. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 12. I play only a small part in helping smokers quit smoking so it is reasonable f or me to not counsel on smoking cessation. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 13. Smoking is a personal lifestyle choice that patients make themselves. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 14. Smokers are immoral. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 15. Counseling patients who overuse albuterol and underutilize corticosteroid is effective for non compliant persons. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 16. Patients who suffer from their non compliance deserve to suffer. Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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195 17. Persons who overuse albuterol and underuse corticosteroids are not likely to benefit from compliance counseling. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 18. I am not obligated to counsel people who overuse albuterol and underuse corticosteroid because they cho ose to be non compliant. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 19. I play only a small part in helping non compliant patients. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 20. I am not obligated to counsel people who overuse albuterol and underuse corticosteroids patients if corporate headquarters pressures me to increase prescription volume. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 21. Non compliant patients are immoral. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 22. I am not obligated to counsel patients who overuse albuterol and underuse corticosteroid if physicians, nurses and other health care professionals are not counseling non compliant patients. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 23. Non compliant patients who suffer from their disease deserve it. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 24. Patients should be free to choose whether they want to be compliant with their therapy. Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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196 25. Non compliant patients are mentally weak willed. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 26. Non compliance is best seen as a form of wrongdoing. Strongly disagree Somewhat disagree Somewhat agree Strongly agree 27. I am not obligated to counsel patients who overuse their albuterol and underuse their inhaled corticosteroid when I am working under stressful condition. Strongly disagree Somewhat disagree Somewhat agree Strongly agree

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197 Section 5: Finally, we would like to ask you some questions about yourself. 1. How many years have you been practicing pharmacy? _________ years 2. Which of the following degrees have you received? (Circle all that apply) i. B.S. in pharmacy ii. PharmD iii. Masters iv. Other(s) (Please specify)________________________ 3. Which of the following best describes your current practice setting? (Circle one response) i. Independent community pharmacy ii. Chain community pharmacy iii. Grocery/Discount store pharmacy iv. Managed care pharmacy v. Ambulatory/ Outpatient clinic vi. Hospital pharmacy vii. Curren tly unemployed viii. Retired ix. Other (Please specify) ______________________ 4. Which of the following best describes your current position at your job? (Circleone response). i. Staff pharmacist ii. PRN/ Floater pharmacist iii. Clinical pharmacist iv. Assistant pharmacy manager v. Pharmacy manager vi. Pharmacy owner vii. Other (Please specify) _____________ 5. Your present age: _____________ years 6. Your gender:

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198 i. Male ii. Female 7. Which Ethnicity are you i. African American ii. Caucasian iii. Asian or Pacific Islander iv. American Indian v. Hispanic vi. Other (Please specify)_______________________ 8. Is there anything you would like to tell us about your experiences dealing with comments below THANK YOU FOR YOUR PARTICIPATION

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199 LIST OF REFERENCES AP h A. (1994). Code of ethics for pharmacists. Retrieved from http://www.pharm acist.com/AM/Template.cfm?Section=Code_of_Ethics_for_Pha rmacists&Template=/CM/HTMLDisplay.cfm&ContentID=5420 AP h A. ( 2004 ). Conscience Clause Retrieved from http://www.pharmacist.com/AM/Template.cfm?Section=Issues&Template=/Tagg edPage/TaggedPageDisplay.cfm&TPLID=86&ContentID= 14490 Aquino, K., & Reed, A. (2002). The self importance of moral identity. Journal of Personality and Social Psychology, 83 (6), 1423 1440. Aquino, K., Reed, A., Thau, S., & Freeman, D. (2007). A grotesque and dark beauty: How moral identity and mechanism s of moral disengagement influence cognitive and emotional reactions to war. Journal of Experimental Social Psychology, 43 (3), 385 392. Arras, J. & Steinbock, B. (1995). Ethical issues in modern medicine MI: McGraw Hill Bagozzi R.P. (1992). The self regulation of attitudes, intention, and behavior. Social Psychology Quarterly 55:178 204. Bagozzi, R.P. (1993). On the neglect of volition in consumer research: A critique and proposal. Psychology and Marketing, 10, 215 237. Bandura, A. (1986 a ). So cial foundations of thought and action: A social cognitive theory Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1986 b ). From thought to action Mechanisms of personal agency. New Zealand Journal of Psychology, 15 (1), 1 17. Bandura, A. (1990 a ). Mecha nisms of moral disengagement. In W. Reich (Ed.), Origins of terrorism :Psychologies, ideologies, theologies, states of mind (pp. 161 191). Cambridge, MA: Cambridge University Press. Bandura, A. (1990 b ). Selective activation and disengagement of moral control. Journal of Social Issues, 46 (1), 27 46. Bandura, A. (1991 a ). Social cognitive theory of moral thought and action. In K.W. Murtines & J. L. Gewirtz (Ed.), Handbook of moral behavior and development (Vol 1, pp. 45 103).Hillsdale, NJ: Erlbaum. Bandu ra, A. (1991 b ). Human agency The rhetoric and the reality. American Psychologist, 46 (2), 157 162. ***********

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200 Bandura, A. (1991c). Social cognitive theory of self regulation. Organizational Behavior and Human Decision Processes, 50 (2), 248 287. Bandura, A. (1996 ). Moral disengagement in the perpetration of inhumanities. International Journal of Psychology, 31 (3 4), 3881 3881. Bandura, A. (1997). The anatomy of stages of change. American Journal of Health Promotion, 12 (1), 8 10. Bandura, A. (1999). A Sociocognitive Analysis of Substance Abuse: An Agentic Perspective. Psychological Science, 10 (3), 214 217. Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annu Rev Psychol, 52 1 26. Bandura, A. (2002 ). Selective moral disengagement in the exercise of moral agency. Journal of Moral Education, 31 (2), 101 119. Bandura, A. (2004). The role of selective moral disengagement in terrorism and counterterrorism. In F. M. Mogahaddam & A. J. Marsella (Ed.), Understanding terrorism: Psychologic al roots, consequences and interventions (pp. 121 150) Washington, DC: American Psychological Association Press. Bandura, A., Barbar anelli, C., & Caprara, G. (1996 ). Mechanisms of moral disengagement in the exercise of moral agency. Journal of Personality and Social Psychology, 71 (2), 364 374. Bandura, A., Caprara, G., Barbaranelli, C., Pastorelli, C., & Regalia, C. (2001). Sociocognitive self regulatory mechanisms governing transgressive behavior. Journal of Personality and Social Psychology, 80 (1), 125 135. Baron, R. M., & Kenny, D. A. (1986). The moderator mediator variable distinction in social psychological research: Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51 1173 1182. Bollen Kenneth A. (1989). Structural Equations with Latent Variables Wiley Interscience. Brewer, M. (1999). The psychology of prejudice: Ingroup love or outgroup hate? Journal of Social Issues, 55 (3), 429 444. Brown, D., & Ferrill, M. J. (2009). The taxonomy of professionalism: reframing the academic pursuit of professional development. Am J Pharm Educ, 73 (4), 68.

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201 Brushwood, D. (1995). "The Pharmacist's Expanding Legal Responsibility for Patient Care," 12 Journal of Social and Administrative Pharmacy 53 Brus hwood, D. B. (1995). Limits to pharmacists' duty to warn. Am J Health Syst Pharm, 52 (12), 1337 1339. Responsibilities of Drake Law Review 439 B rushwood, D.B., & Hepler, C.D. (1996). Ethical responsibility in pharmacy practice Madison, WI: American Institute of the History of Pharmacy. Brushwood, D. B., & Belgado, B. S. (2002). Judicial policy and expanded duties for pharmacists. Am J Health Sys t Pharm, 59 (5), 455 457. Campbell, D.T., & Fiske, D.W. (1959). Convergent and discriminant validation by the multitrait multimethod matrix. Psychological Bulletin, 56, 81 105. Carmines, E., McIver, J., Bohmstedt, George W., & Borgatta, Edgar F. (1981). So cial measurement: Current issues. Analyzing models with unobserved variables: Analysis of covariance structures Beverly Hills: Sage Publications, Inc. Caron. (2006). Retrieved from http://www.acpe.edu/NewPDF/Sample%20Ethics%20Curriculum.pdf Commission to Implement Change in Pharmaceutical care (1991). Retri eved from http://www.aacp.org/resou rces/historicaldocuments/Documents/Backg round4.pdf Crocker, L., & Algina, J. (1986). Introduction to classical and modern test theory Fort Worth: Harcourt Brace Jovanovich College Publishers. Detert, J., Trevino, L., & Sweitzer, V. (2008). Moral disengagement in ethical decision making: A study of antecedents and outcomes. Journal of Applied Psychology, 93 (2), 374 391. Duffy, M. K., Shaw, J. D., Scott, K. L., & Tepper, B. J. (2006). The moderating roles of self esteem and neuroticism in th e relationship between group and individual undermining behavior. Journal of Applied Psychology, 91 (5), 1066 1077. Earl, C. E., & Penney, P. J. (2003). Rural nursing students' knowledge, attitudes, and beliefs about HIV/AIDS: a research brief. J Assoc Nur ses AIDS Care, 14 (4), 70 73. Fawcett J. ( 1995). Compliance: Definitions and key issues. Journal of Clinical Psychiatry 56 (Suppl. 1): 4 8.

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202 Gaertner, L., & Insko, C. (2000). Intergroup discrimination in the minimal group paradigm: Categorization, reciprocation, or fear? (Vol. 79, pp. 77, 2000). Journal of Personality and Social Psychology, 79 (2), 162 162. Gusfield, Joseph R. (1963). Symbolic crusade: Status politics and the American temperance movement. Urbana, IL: University of Illinois Press. Hafferty, F.W. (2000). In search of a lost cord hidden curriculum. In: Wear D, Bickel J, eds. Education for professionalism Creating a cult ure of humanisms in medical education. (pp. 11 34). Iowa City, IA: University of Iowa Press. Harr, R. & Gillett, G. (1994). The discursive mind. London: Sage. Haynes R.B. ( 1979). Introduction: In compliance in health care. In Haynes R.B., Sackett, D.L., & Taylor D.W. (Ed.). Baltimore, MD: John Hopkins Press. Hepler, C.D. (1996). Philosophical issues raised by pharmaceutical care. In A.M. Haddad & R.A. Buerki (Eds.). Ethical dimensions of pharmaceutical care (pp. 19 47). Binghamton, NY: Haworth Press. Hepler, C. D., & Strand, L. M. (1990). Opportunities and responsibilities in pharmaceutical care. American Journal of Hospital Pharmacy, 47 (3), 533 543. Hudmon K, Prokhorov A, Corelli R (2006). Tobacco cessation counseling opinions and practices Patient Education and Counseling 61(1), 152 160 Hymel, S., Rocke Henderson, N. & Bonanno, R. (2005). Moral disengagement: A framework for understanding bullying among adoles cents. Journal Of Social Sciences 8, 1 11 Imhof, J., Hirsch, R., & Terenzi, R. (1983). Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction. International Journal of the Addictions, 18 (4), 491 510. Jaccard, James, & W a n, Choi K. (1996). Lisrel approaches to interaction effects in multiple regression. Thousand Oaks, CA: Sage Publications. Kenny, David A. (2011, September 6) Retrieved from http://davidakenny.n et/cm/causalm.htm Kimberlin, C., Berardo, D., Pendergast, J., & McKenzie, L. (1993). Effects of an education program for community pharmacists on detecting drug related problems in elderly patients. Medical Care, 31 (5), 451 468.

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203 Kline, B. Rex. (19 9 8). Pr inciples and practice of structural equation modeling New York: Guilford Press. Kleinjan, M., Van den Eijnden, R. J., & Engels, R. C. (2009). Adolescents' rationalizations to continue smoking: the role of disengagement beliefs and nicotine dependence in smoking cessation. Addictive Behavior, 34 (5), 440 445. Kunda, Z. (1990). The case for motivated reasoning. Psychological Bulletin, 108 (3), 480 498. Lo, B. (2009). Resolving ethical dilemmas: A guide for clinicians (4 th ed.). Baltimore, MD: Lippincott Williams & Wilkins. MacCallum, R. C., Browne, M. W., & Sugawara H. M. (1996). Power analysis and determination of sample size for covariance structure modeling. Psychological Methods 1 130 149. Martinez, R., & Murphy Parker, D. (2003). Examining the relationship of addiction education and beliefs of nursing students toward persons with alcohol problems. Archives of Psychiatric Nursing, 17 (4), 156 164. McAlister, A. (2001). Moral disengagement: Measurement and modification. Journal of Peace Research, 38 (1), 87 99. McAlister, A. L., Ama, E., Barroso, C., Peters, R. J., & Kelder, S. (2000). Promo ting tolerance and moral engagement through peer modeling. Cultur Divers Ethnic Minor Psychol, 6 (4), 363 373. Menesini, E., Sanchez, V., Fonzi, A., Ortega, R., Costabile, A., & Lo Feudo, G. (2003). Moral emotions and bullying: A cross national comparison of differences between bullies, victims and outsiders. A ggressive Behavior, 29 (6), 515 530. Messick, D. M., & Bazerman, M.H. (1996, Winter). Ethics for the 21st century: A decision making approach. MIT Sloan Management Review 37(2), 9 22. Montagne, M., Mc Carthy, R. (2006). Ethics and professionalism, In: Troy BD. Remington, The science & practice of pharmacy. 21 ed. (pp. 20 29). Philadelphia, PA: Leppincott, William & Wilkins. Nunnally, J. C. (1978). Psychometric theory (2 nd ed.). New York: McGraw Hi ll Nuehring, E. &. Markle G.E (1974). Nicotine and norms: The re emergence of a deviant behavior. Social Problems 21, 513 526.

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204 Oakes, W., Chapman, S., Borland, R., Balmford, J., & Trotter, L. (2004). "Bulletproof skeptics in life's jungle": Which self exempting beliefs about smoking most predict lack of progression towards quitting? Preventive Medicine, 39 (4), 776 782. Odedina, F.T., Segal, R., & Hepler, C. (1995). Providing pharmaceutical care in community practice. Journal of Social and Administrative Pharmacy 12(4), 170 180. Odedina, F., & Segal, R. (1996). Behavioral pharmaceutical care scale for measuring pharmacists' activities. American Journal of Health System Pharmacy, 53 (8), 855 865. Odedina, F., Hepler, C., Segal, R., & Miller, D. (1997). The pharmacists' implementation of pharmaceutical care (PIPC) model. Pharmaceutical Research, 14 (2), 135 144. Oranga H. & Nordberg E. (1993) The Delphi panel method for generating health information. Health Policy and Planning 8, 405 412. Osterberg L ., & Blaschke, T (2 005, August 5). Adherence to medication. New England Journal of Medicine 353(5):487 97. Pellegrino, E. D. (2000). Medical professionalism: can it, should i t survive? J Am Board Fam Pract, 13 (2), 147 149. Pelton, J., Gound, M., Forehand, R., & Brody, G. (2004). The moral disengagement scale: extension with an American minority sample. Journal of Psychopathology and Behavior Assessment 26, 31 39. Penna, R. American Journal of Hospital Pharmacy (47), 543 544 Perkins, J., Multhaup, K., Perkins, H., & Barton, C. (2008). Self efficacy and participation in physical and social activity among older adult s in Spain and the United States. Gerontologist, 48 (1), 51 58. Perkins, M. B., Jensen, P. S., Jaccard, J., Gollwitzer, P., Oettingen, G., Pappadopulos, E., & Hoagwood, K. E. (2007). Applying theory driven approaches to understanding and modifying clinicia ns' behavior: What do we know? Psychiatr Serv, 58 (3), 342 348. Playle, J. F. & Keeley, P. (1998). Non compliance and professional power. Journal of Advanced Nursing 27, 304 311. Purtilo, R. (1999). Ethical dimension in the health professions St. Louis, MS: Elsevier Saunders.

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205 Rawls, J. (1993/1996/2005) Political Liberalism New York,NY: Columbia University Press. Rawls. (1999). A Theory of Justice ( rev. ed.), Harv ard University Press. Relf, M. V., Laverriere, K., Devlin, C., & Salerno, T. (2009). Ethical beliefs related to HIV and AIDS among nursing students in South Africa and the United States: A cross sectional analysis. Int J Nurs Stud, 46 (11), 1448 1456. Schumacker, R E. & Lomax, R.G. (2004). structural equation modeling (Vol. 2). Lawrence Erlbaum Associates. Smearman, C. (2006). Drawing the line: the legal, ethical and public policy implications of refusal clauses for pharmacists. Arizona Law Review 48, 469. Washington Post pp. A01 Stiernborg, M. (1992). Knowledge about and attitudes to, HIV/AIDS among students in a Sydney nursing college. Nurse Education Tod ay, 12:207 214 Trevino, L.K. (1986). Ethical decision making in organizations: A personsituation interactionist model. Academy of Management Review 11, 601 617. Tsang, J. (2002). Moral rationalization and the integration of situational factors and psychol ogical processes in immoral behavior. Review of General Psychology, 6 (1), 25 50. Vogt, F., Hall, S., & Marteau T. M. (2007). General practitioners' beliefs about effectiveness and intentions to recommend smoking cessation services: qualitative and quantitative studies. BMC Fam Pract, 8 39. Walker, A., Watson, M., Grimshaw, J., & Bond, C. (2004). Applying the theory of planned behavior to pharmacists' beliefs and intentions about the treatment of vaginal candidiasis with non prescription medicines. Fam Pract, 21 (6), 670 676. Weinberger, M., Murray, M. D., Marrero, D. G., Brewer, N., Lykens, M., Ha rris, L. E., & Tierney, W. M. (2001). Pharmaceutical care program for patients with reactive airways disease. Am J Health Syst Pharm, 58 (9), 791 796.

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206 BIOGRAPHICAL SKETCH Christine Lee started her post secondary education at the University of Toronto wh ere she completed her pre pharmacy requirement. In 2007 she graduated with her PharmD from t he University at Buffalo She continued her studies at the University at Florida and obtained her PhD in Pharmaceutical Sciences in 2012