Citation
Board Certified Pharmacists Motivational Influences and Job Satisfaction

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Title:
Board Certified Pharmacists Motivational Influences and Job Satisfaction
Creator:
Rosenthal, Rachel L
Place of Publication:
[Gainesville, Fla.]
Florida
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (143 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 Co-Chair:
BRUSHWOOD,DAVID BENSON
Committee Members:
KIMBERLIN,CAROLE L
JANICKE,DAVID
Graduation Date:
12/13/2013

Subjects

Subjects / Keywords:
Ambulatory care ( jstor )
Diseases ( jstor )
Drug design ( jstor )
Drug therapy ( jstor )
Job satisfaction ( jstor )
Modeling ( jstor )
Motivation ( jstor )
Pharmacies ( jstor )
Pharmacists ( jstor )
Statistical models ( jstor )
Pharmaceutical Outcomes and Policy -- Dissertations, Academic -- UF
certification -- motivation -- pharmacy
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 purpose of this dissertation is to explore and investigate internal and external factors that may impact pharmacists' motivations to become board certified in a specialty area.  Lent, Brown, and Hackett’s Social Cognitive Career theory was used in conjunction with personal illness, disease, and health-care experience constructs to create a model for investigating the relationships between job satisfaction, outcome expectations, self-efficacy,goals, and illness experiences. Through primary data collection methods, 2,767 surveys were administered to board certified pharmacists in all of the Board of Pharmacy Specialties (BPS) specialty certification areas. Participants were asked to complete multiple survey sections including scales measuring self-efficacy,outcome expectations, job satisfaction, and perceived illness experiences.Additionally, other information was collected such as demographic variables related to work, specialty certification, variables measuring professional goal behaviors, and variables indicating types of past illness experiences. This study shows that level of job satisfaction can be predicted through an individual’s self-efficacy, outcome expectations, and goals through our regression model. Additionally, for participants with a personal illness experience, level of job satisfaction was also predicted through our regression model using perceived illness experience score, self-efficacy, outcome expectations, and goals as predictors. The findings of this study are important and relevant to the field of pharmacy because they provide valuable insight into what factors motivated pharmacists to achieve their goal of becoming board certified pharmacists in a specialty area. Additionally, the findings also could be used in future efforts to recruit and retain these specialized pharmacists though increasing self-efficacy, promoting positive outcome expectations, and supporting goal directed and goal participation behaviors. ( 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, 2013.
Local:
Adviser: SEGAL,RICHARD.
Local:
Co-adviser: BRUSHWOOD,DAVID BENSON.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-06-30
Statement of Responsibility:
by Rachel L Rosenthal.

Record Information

Source Institution:
UFRGP
Rights Management:
Copyright Rosenthal, Rachel L. 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.
Embargo Date:
6/30/2014
Classification:
LD1780 2013 ( lcc )

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SATISFACTION By RACHEL ROSENTHAL 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 2013

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2 2013 Rachel Rosenthal

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3 To Rom & Jay

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4 ACKNOWLEDGMENTS I would like to expression my thanks to my family for their love and support. I would like to specially thank my parents, Bubba and Betty Rosenthal, for their guidance, understanding, love and support in my life. I would like to express my appreciation for my major advisor, Dr. Richard Segal, for his reassurance, support, optimistic feedback, and wisdom in my academic life. I also thank all of my committee members, Carole Kimberlin, David Brushwood and David Janicke, for th eir thoughtful feedback and comment s in regards to this work. I would also like to thank Paul K ub i lis for sharing his knowledge and for his support in the data analysis process.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Background ................................ ................................ ................................ ............. 11 Study Purpose ................................ ................................ ................................ ........ 12 Objectives ................................ ................................ ................................ ............... 13 Hypotheses ................................ ................................ ................................ ............. 13 Definition of Terms and Concepts ................................ ................................ ........... 14 Significance ................................ ................................ ................................ ............ 16 Assumptions ................................ ................................ ................................ ........... 20 Organization of the Dissertation ................................ ................................ .............. 21 2 LITERATURE REVIEW ................................ ................................ .......................... 22 Specialty Certification ................................ ................................ ............................. 22 Credentialing in Pharmacy ................................ ................................ ...................... 25 Motivational Benefits of Sp ecialty Certification in Pharmacy ................................ ... 29 Pharmaceutical Care and Specialization ................................ ................................ 31 Theoretical Framework ................................ ................................ ........................... 34 Social Cognitive Career Theory ................................ ................................ ........ 34 The Illness Experience ................................ ................................ ..................... 38 Relevant Research Studies ................................ ................................ .................... 43 Chapter Summary ................................ ................................ ................................ ... 45 3 RESEARCH METHODOLOGY ................................ ................................ ............... 47 Study Approach ................................ ................................ ................................ ...... 47 Sample Population ................................ ................................ ........................... 47 Sample Size and Power ................................ ................................ ................... 48 Instrument Development ................................ ................................ ......................... 48 Informed Consent ................................ ................................ ............................. 49 Basic Demographics Questionnaire ................................ ................................ 49 Illness Experiences Questionnaire ................................ ................................ ... 49 Job Satisfaction ................................ ................................ ................................ 50 Self Efficacy and Outcome Expectations ................................ .......................... 51 Perceived Experiences with Illness ................................ ................................ .. 52 Validation of the Survey Instrument ................................ ................................ ........ 54

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6 Focus Groups ................................ ................................ ................................ ... 54 Expert Review ................................ ................................ ................................ .. 55 Pre Test Validation Results ................................ ................................ .............. 55 Data Collection ................................ ................................ ................................ ....... 57 Analytical Methods ................................ ................................ ................................ .. 58 4 RESULTS AND FINDINGS ................................ ................................ ..................... 64 Data Collection ................................ ................................ ................................ ....... 64 Response Rate ................................ ................................ ................................ ....... 65 Non Response Bias ................................ ................................ ................................ 65 S ample Demographics ................................ ................................ ............................ 66 Specialty Certification Demographic Variables ................................ ................. 68 Work Place Demographic Variables ................................ ................................ 71 Descriptive Statistic s ................................ ................................ ............................... 72 Job Satisfaction ................................ ................................ ................................ 72 Illness Experiences ................................ ................................ .......................... 73 Self Efficacy ................................ ................................ ................................ ..... 76 Outcome Expectations ................................ ................................ ..................... 77 Test of Hypotheses ................................ ................................ ................................ 78 Hypothesis I ................................ ................................ ................................ ...... 79 Hypothesis II ................................ ................................ ................................ ..... 80 Hypothesis III ................................ ................................ ................................ .... 81 Hypothesis IV ................................ ................................ ................................ ... 81 Hypothe sis V ................................ ................................ ................................ .... 83 Hypothesis VI ................................ ................................ ................................ ... 86 Hypothesis VII ................................ ................................ ................................ .. 88 Summary ................................ ................................ ................................ ................ 88 5 STUDY DISCUSSION AND CONCLUSIONS ................................ ....................... 103 Overview ................................ ................................ ................................ ............... 103 Discussion of Research Findings ................................ ................................ .......... 103 Social Cognitive Care er Theory ................................ ................................ ...... 104 Illness Experiences ................................ ................................ ........................ 110 Convergence of Theoretical Models ................................ ............................... 114 Study Limitations ................................ ................................ ................................ .. 120 Final Conclusions and Future Resear ch Direction ................................ ................ 121 APPENDIX A INFORMED CONSENT FOR FOCUS GROUPS ................................ .................. 125 B RECRUITMENT EMAIL FOR DATA COLLECTION ................................ ............. 127 C INFORMED CONSENT FOR PRIMARY DATA COLLECTION ............................ 128 D MOTIVATIONS IN PHARMACY SPECIALTIES INSTRUMENT ........................... 130

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7 E 2011 BPS CERTIFICATION EXAMINATION RESULTS ................................ ...... 136 LIST OF REFERENCES ................................ ................................ ............................. 138 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 143

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8 LIST OF TABLES Table page 4 1 Mean difference in responder groups ................................ ................................ 90 4 2 Sample population gender ................................ ................................ .................. 90 4 3 Sample population ethnic group classification ................................ .................... 90 4 4 Sample population countries of residence ................................ .......................... 91 4 5 Study population specialty certifications ................................ ............................. 92 4 6 Study population multiple specialty types ................................ ........................... 93 4 7 Sample population work place settings ................................ .............................. 93 4 8 Job satisfaction descriptive statistics ................................ ................................ .. 94 4 9 Frequency of health experiences in sample population ................................ ...... 95 4 10 Descriptive statistics for R PIE adaptation in sample population ........................ 96 4 11 Descriptive statistics for self efficacy in sample population ................................ 97 4 12 Descriptive st atistics for outcome expectations in sample population ................ 98 4 13 Job satisfaction composite scores by voluntary certification status group .......... 99 4 14 areas ................................ ................................ ................................ ................ 100 4 15 areas ................................ ................................ ................................ ................ 101 4 16 Logistic regression analysis for predicting illness in specialty. ......................... 102

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9 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 SATISFACT ION By Rachel L Rosenthal December 2013 Chair: Richard Segal Major: Pharmaceutical Sciences The primary purpose of this dissertation is to explore and investigate internal and in conjunction with personal illness, disease, and health care experience constructs to create a model for investigating the relationships between job satisfaction, outcome expectations, self efficacy, goals, and illness experiences. Through primary data collection methods, 2 767 surveys were administered to board certified pharmacists in all of the Board of Pharmacy Specialties (BPS) specialty certification areas. Participants were ask ed to complete multiple survey sections including scales measuring sel f efficacy, outcome expectations, job satisfaction, and perceived illness experiences. Additionally, other information was collected such as demographic variables related to work, specialty certification, variables measuring professional goal behaviors, an d variables indicating types of past illness experiences. This study shows that level of job satisfaction can be predicted through an efficacy, outcome expectations, and goals through our regression

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10 model. Additionally, for participants with a personal illness experience, level of job satisfaction was also predicted through our regression model using perceived illness experience score, self efficacy, outcome expectations, and goals as predictors. The findings of this study are important and relevant to the field of pharmacy because they provide valuable insight into what factors motivated pharmacists to achieve their goal of becoming board certified pharmacists in a specialty area. Additionally, the findings also could be used in future efforts to recruit and retain these specialized pharmacists though increasing self efficacy, promoting positive outcome expectations, and supporting goal directed and goal participation behaviors.

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11 CHAPTER 1 INTRODUCTION Background Over the past several decades a new type of pharmacist has emerged in terms o f qualifications and education. Th is pharmacist is the board certified specialist and is quite possibly the archetype or new standard for all clinical pharmacists in the not so distant future. Although certification has been growing in popularity both in terms of membership and research, little scholarly attention has been given to intrinsic motivational factors and life experiences that impact the decision to become certified in specific specialties This prompts the question: The potential value of becoming board certified in a specialty area is wide reaching and may include personal benefits such as increased knowledge, competence and recognition, as well as professional benefits including greater acceptance by health care professionals, merit salary increases, tenure and in some geographic areas, pre scribing authority. Because of their increased knowledge and competence, board certified pharmacists offer improved patient care which may in turn lead to better health outcomes for patients (Connor & Hamilton, 2010). While collectively, all of the se fo rmerly mentioned benefits may provide some incentive to the pharmacist in terms of seeking certification, it may also be likely tha t additional life experiences and personal influe nces motivate them to exceed the minimum requirements of their chosen profes sion and to embark on the process of becoming board certified in a specialty area.

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12 in to the ex planation of how academic and career interests develop, how these interests promote career choices, and ultimately how the se interests and choices interact and and lead to achievement and persistence in career performance and academic pursuits. Using this theoretical framework, this study examine s motivational factors for becoming a board certified pharmacist in terms of self efficacy, beliefs, goals, and outcome expectations/outcome expectancies (values) Th is study also examine s the origin of reinforcing motivational influences such as experiences with certain illness es which may act as guiding forces in the lives of board certified pharmacists. These illness experiences could not only spur interest in certain specialty fields, but they also may continually sustain and impact other motivational influences such as job satisfaction Investigating all of these factors may lead the health care profession and researchers to a better understanding of the fortificatio n of personal and professional influences on career choice and the desire to obtain further specialty certification. Study Purpose The primary intention of this study is to identify which internal and external factors motivate pharmacists to obtain specia lty certification. F ew studies have focused on motivational factors in pharmacy specialties allowing this study to add greatly to the professional body of literature in this evolving area. The second intention of this study is to investigate differences i n the motivations of individuals to become board certified within specific sub specialties in pharmacy. Currently there is a disproportion in the distribution of pharmacist s seeking board certification across all specialty areas.

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13 Pharmacists have overwhelm ingly chosen to become board certified pharmacotherapy specialists over any of the other specialty types combined. This study also identif ies differences in motivational factors between groups of pharmacists in each specialty area as well as delves deeper into the ir personal motivational factors Objectives This study has 5 main study objectives. The first objective is t o explore the relationship between individual and interpersonal motivational factors that impact the desire to become a board certified p harmacist The second study objective is t o investigate the differences in motivational factors between pharmacists in generalist specialty areas (e.g., pharmacotherapy) and pharmacists that have selected more concentrated specialty areas (e.g., oncology) Thirdly this study examine s whether personal life experiences serve as motivational influences in terms of selecting a specialty area The fourth study objective is t o differentiate motivational factors and chosen specialties for those required to become certified for career purposes and those who voluntarily specialize. Lastly, the fifth study objective is t o determine whether differences in job satisfaction exist between board certified pharmacists in generalist specialty areas and pharmacists that hav e selected more concentrated specialty areas. Hypotheses seven research hypotheses were formulated. The first hypothesis (H1) is that i n board certified pharmacists, amount of time per work week spent using their specialty certification will be positively associated with levels of job satisfaction. The second research hypothesis (H2) is that p harmacists that have become board certified independent of work

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14 requirements will report higher leve ls of job satisfaction compared to those pharmacists who become certified to fulfill job requirements. The third research hypothesis (H3) is that i n board certified pharmacists, working in a setting where specialty certification is used is positively assoc iated job satisfaction. The fourth research hypothesis (H4) is that h igh levels of self efficacy, outcome expectations and goals will be predictive of higher levels of job satisfaction among board certified pharmacists. The fifth hypothesis (H5) is that p harmacists that are board certified in specific specialty areas that have had an illness experiences will choose to become certified in a corresponding specialty area. The sixth hypothesis (H6) is that i n p harmacists that are board certified in specific sp ecialty areas that have had a self identified previous or present illness experience in their specialty area self efficacy and outcome expectations will be predictive of having an illness in the specialty area in which they hold certification Lastly, th seventh research hypothesis (H7) is that i n pharmacists with a past or present personal illness experience, self efficacy, outcome expectations, impact of illness experience, and goals will be predictive of job satisfaction. Definit ion of Terms a nd Concepts Social Cognitive Theory (SCT) Developed by Albert Bandura in 1986 to explain efficacy, beliefs, values, outcome expectancies, and outcome expectations pertaining to the specific behavior Social Cognitive Career Theory (SCCT) A daughter theory of SCT, which was developed by Lent, Brown, and Hackett (1994) to explain and predict career decisions and career performance throughout the lifespan of individuals through r interests, intent, goals, and performance in addition to Self efficacy perform specific skills and activities associated with a particular anticipated behavi oral performance. As a central tenant of SCT, self efficacy is thought to

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15 heavily influence all aspects of planning and performing behaviors (Bandura, 1986). Belief or behavior (Ba ndura, 1986). Values Formed prior to performing an action or behavior, a reference to an behavior or action performed in terms of both outcome expectations and outcome expe ctancies (Bandura, 1986, Lent et. al, 1996). Outcome Expectancies anticipated outcome of a specific course of action or behavior. These expectancies are thought to strongly influence the outcomes expe ctations of the individual (Bandura, 1986, Lent et. al, 1996). Outcome Expectations outcome occurring after individual attempts to perform certain courses of action or specific behaviors (Bandura, 1986, Lent et. al, 1996). Goals and actions to achieve a desired outcome or consequence. Goals can be general, which pertain to completion of a specific behavior, or they can be more sp ecific, i.e. performance goals, where they related to achieving a certain level of success while achieving the outcome (Lent et. al, 1996). Career Interests indifferences pertaining to differe nt occupations and career related tasks and duties. Interests are thought to become long lasting when individuals view themselves as competent and efficient when performing tasks that produce an outcome of positive value associated with the career (Bandura 1986, Lent et. al, 1994, & Lent et. al, 1996). Career Intentions intentions are thought to be stimulated by career interests that have been positively reinforced over time (Lent et. al, 1994, Lent et. al, 1996). Career Performance proficiency in completing career related tasks. The two main aspects of career performance are the degree of success individuals attain in their career tasks and the extent of pers istence to perform tasks or endure career trajectories despite obstacles that arise over time (Lent e. al, 1996). Illness Experience illness related event within physical, emotional, social, and sp iritual contexts. An (internal or external), effects (long term or short term), and impact (proximal or

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16 distal). For this particular study the Illness Experience is used to explai n Illness Model. A model developed by Suchman (1965) to explain how an individual experiences an illness through a five step process. This process includes a flight into health, the acceptance of the Sick Role, contacting medical authority, becoming a dependent patient, and recovery and rehabilitation. Sick Role A the oretical framework developed by Talcott Parsons (1951) to explain the behavior of individuals and societal response behaviors both while experiencing illnesses and after illnesses have ended through reintegration into social norms. Underpinning this theor y are the two basic premises of sanctioned deviance and a set of rights and responsibilities. Sanctioned Deviance An act of permission given by society to an individual engaged in a Sick Role. The societal permission sanctions the sick individual to be non adherent to social norms and allows the individual to be an unproductive part of society through both sickness and recovery as long as the individual is fulfilling their Sick Role rights and responsibilities. Rights and Responsibilities A set of obli gations an individual in a Sick Role is expected to accept once becoming ill and being given sanctioned deviance by society. These obligations are broken down into two parts, rights and responsibilities. These rights include exemption from social norms an d the recognition that the individual is not to blame for their illness. The responsibilities of the sick individual include the desire and exertion of effort to get well as well as the expectation that the individual is also expected to seek out and comp ly with competent health care provisions. Significance Exploring the factors behind why pharmacists become certified in a specialty area of pharmacy provide s insight in to the behavior of these health care professionals as they make career choices concern ing specialization. Since certification itself further advances the field of pharmacy, discovering the origins of such motivations shapes future action s to encourage other pharmacists to become certified in specialt y areas which in turn, result s in numero us societal benefit s including improved patient care and greater job satisfaction.

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17 Presently, debate ensues about whether there is a nationwide pharmacist shortage and whether the market will soon become flooded with new graduates of pharmacy schools (Tr pharmacists in the United States is becoming increasingly challenging to determine. If the re is an oversupply of pharmacists, board certified pharmacist s would be dominatingly favored over their uncertified counterparts. Investigating the intrapersonal and professional motivational influences of board certified pharmacists also contribute s to understanding why pharmacists choose specific specialties and how to motivate other pharmacists to choose similar professional endeavors. In general, work motivation has been found to be predictive of employee turnover, job satisfaction, commitment, job performance, and overall psychological well being (Liesine & Endriulaitiene, 2008). Once the field of pharmacy understand s and identifies which factors motivate pharmacists to seek career development, they can assimilate such information to create a workforce of professionals that are more knowledgeable and highly qualified With this in mind, exploring the motivational forces behind choice to become board certifi ed is a worth while effort, requiring further investigation. The present imbalance in the distribution of pharmacists across specialties areas is an area of concern for the pharmacy profession. A search of the Board of Pharmac y Specialty website database of certified pharma cists revealed more than 72 % of board certified pharmacists are Board Certified Pharmacotherapy Specialists (BCPS) which represents a continually increasing growth in this specific area of specializa tion (BPS, 2013 ). The practicality and attractiveness of the pharmacotherapy specialty area itself

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18 is of some perplexity since it does not correspond to any specific or unique occupational area within the field of pharmacy. The stated responsibilit y of practic ing BCPS is to ensur e drugs are used in the most efficiently safe, appropriate, and economical manner (Pradel et al., 2004) This responsibility is neither unique nor novel in the present day pharmacy profession and as such, the pharmacotherapy specialization has received some negative criticism (Hepler, 1993). If the study at hand, does indeed find significan t differences in the life experiences, values, self efficacy, and/ or goals be tween board certified pharmacotherapy spe cialists and board certified pharmacists whom have chosen more focused specialties, these differences should be used to inform and create interests in future board certified specialists about other area specialties. If such valuable information is used de corously the disproportion in certification among these specialty groups could be remedied Similarly, if this study finds that differences exist between the different specialty areas in terms of motivational origins or in the cultivation of motivationa l experiences, pharmacy interest groups and professional organizations could find the information useful in identifying possible reasons pharmacists are not choosing to specialize within certain areas and implement adjustments to make the under represented specialties more attractive. Exploring the factors that motivate pharmacists to choose this specific specialty over other specialty areas aids the profession in addressing the shortcomings in desirability of less popular specialties. In turn, such infor mation can be used by training programs and educators to help to bolster the number of pharmacists becoming certified in general and reduce the disparities in certification numbers among other specialty areas.

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19 As this study proposes to investigate, phar macists may be impacted by their previous or present illness experience in many ways. This impact include s the possibility of motivating individuals with illness experiences to choose a certain career path or achieve certain career goals and objectives. T wo studies of interest were located through literature review pertaining to motivations of health care professionals to choose a specific specialty originating from personal health care experiences. One small scale study examined essay portions of applicat ions to nurse midwifery educational in which six themes pertaining to influential factors were identified. The most popular of such themes identified was personal birth experiences (Ulrich, 2009). The second study located examined motivations to choose t he midwifery profession in terms of influences on becoming Certified Nursing Midwives (CNMs). Similarly to the former study, a majority of the survey respondents affirmed that they were motivated to become CNMs as a product of their personal birth experie nces (Ventre et. al, 1995). In both cases, exploring the origins of motivations to enter a specialty field of nursing provided insight into how personal health care experiences can affect health care professionals in terms of career choice and development Likewise, if the illness experiences of pharmacists are found to be indicative of motivational origins to either become specialized or to choose a specific specialty within pharmacy, this information can be quite impactful on the profession. Firstly this information can be used to foster interest for specialization among the generalist pharmacist early on during training by preceptors and educator, or later during the career cycle by pharmacy managers and administrators. Secondly, this information c a n also be used to guide pharmacist s into specifi c specialties. Identifying that personal

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20 illness experiences are valuable and contribute to the growth and well being of the pharmacy profession encourage s pharmacists to expl ore their past or present illnes s experiences and to cultivate them as opportunities for the exploration of career interests and learning experiences lead ing to career success. Furthermore, the perception of an illness experience itself may have significant impacts on how a child models their future career path or on how adults may choose to specialize within a chosen field of practice. In addition to investigating the impact of illness experiences on pharmacists, this study also seeks to investigate how constructs within Social Cognitive Career Theory can be used to explain how illness experiences impact motivation. Results of the tivate pharmacists with a history of or those in a current illness state. If it is found that self efficacy in selecting a specialty area is positively related to having an illnesses experience in that area, then our research could be used to inform caree r counselors, trainers, and health care practitioners about this relationship. Since no relevant literature within the field of pharmacy specialties explor ing the connection of the illness experience with career motivation could be located, the proposed st udy could offer s enormous value to the field through its contribution of investigating this under studied phenomenon. Assumptions In this study the following assumptions have been made: 1. The survey was 2. T he target population has access to the email address provided to the Board of Pharmaceutical Specialties at the time of test registration. 3. adequate level of internet proficiency required to complete the onli ne survey. 4. Each of t he study partic i pants will only complete the survey once.

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21 5. T he online survey will only be completed by members of the target population. Organization of the Dissertation Following this introductory chapter, this dissertation is divided i nto four subsequent chapters. Chapter 2 contains a literature review on the history of pharmacy specialization, the different types of credentials within pharmacy and the processes for obtaining those credentials In addition, Social Cognitive Career Theor y and the Illness Experience concepts are reviewed and discussed in detail due to their impact o n theoretical framework and instrument design. Chapter 3 focuses on the research methods utilized for this study. In this chapter the specific methodology is conducting the study, and statistical analyses. In Chapter 4 statistical findings are described in detail. The last chapter, Chapter 5, provides a esults, the implication of such results, and ends with final conclusions.

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22 CHAPTER 2 LITERATURE REVIEW Specialty Certification Granted to pharmacists who have exhibited a level of competence in a specialty area exceeding the stated minimum requirements for licensure to practice pharmacy, certification in pharmacy specialties ha s been available since the 1970s. Established in 1976 by the American Pharmacists Association (APhA), the Board of Pharmaceutical Specialties (BPS) began offering the first specialty certification within pharmacy, board certified nuclear pharmacist, after petitions from the professionals and professional orga nizations advocated for the designation of pharmacy specialties areas in 1977. Within the past several decades, five additional specialty areas have been recognized including nutrition support pharmacy, pharmacotherapy, psychiatric pharmacy, oncology pharm acy, and ambulatory care pharmacy. Additionally two sub specialties within the field of pharmacotherapy have also been recognized: cardiology and infectious disease. Since its advent, board certification in pharmacy specialty areas has had exceptional grow th what was for decades a slowly adopted and accepted credentialing system has now essentially quadrupled in popularity from 1996 to the present (Pradel et al., 2004). Specialization and certification within different fields in health care has had a progr Ophthalmology, specialization first took hold of medicine almost a century ago and (Sharp et al., 2002). This growth in specialization in the medical field was undoubtedly closely related to advancements in medical science itself and has led to vast improvements in the health care delivery system (ABMS, 2011). The field of nursing

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23 also has its own lis t of respective specialties that have been developed over the last century, although official certification has only existed since the late 1970s after the education of nursing professionals moved into the university setting. Thus, as nurses became viewed as highly educated and valued professionals, the desire for official certification in a specialty area soon followed so that these professionals could nursing, officia l specialty certification in pharm acy had its advent in the 1970s when pharmacists much like physicians and nurses in the past sought to gain additional an systems, pharmacy has t aken a unique direction and began to develop its specialty areas around types of health conditions or disease states (Pradel et al., 2004) in addition to the most popular area of pharmacotherapy which is more of a generalist speci alty area, focusing on efficient and proper drug use in all areas of pharmacy. pharmacy specialty areas, in which board certification is available has a unique and important role in the pharmacy profession. Nuclear pharmacy, the first established specialty in pharmacy was created in 1977 and now represents roughly four percent of all board certified specialty pharmacist s Concerned with public he alth and safe use of drugs, the Board Certified Nuclear Pharmacist (BCNP) is an essential part of the medical team and specializes in the creation and dispensation of radiopharmaceuticals. Additionally, they provide consultation to patients and other profe ssionals about health and safety issues for both radiopharmaceuticals and non radioactive drugs alike. The nutrition support pharmacy specialty was

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24 established during the mid 1980 s and now roughly represents 3.7 % of all board certified pharmacist s The B oard Certified Nutrition Support Pharmacist (BCNSP) primarily is concerned with caring for patients with special nutritional needs, including both enteral and parenteral (intravenous feeding) routes. These pharmacists also design and modify treatment regim ens according to the specific nutritional needs of patients (Pradel et. al., 2004). Psychiatric pharmacy became a designated specialty in 1992 and specifically focus es on the needs of patients with psychiatric illness. The Board Certified Psychiatric Pha rmacist (BCPP) specialty presently represent s 5% of the board certified pharmacist population with duties primarily revolving around performing patient assessments, optimizing drug regimens, and identifying drug induced problems of such by monitoring patie nt responses to treatments. Even more recently, oncology pharmacy was designated as a specialty area of pharmacy by the BPS in 1996. Individuals who become Board Certified Oncology Pharmacists (BCOP) represent roughly 10% of the board certified pharmacist s and primarily focus on caring for patients with malignant diseases. Pharmacists within this designated specialty concentrate on designing and assessing treatment regimens along with monitoring and modifying existing treatments with the goal of optimizing outcomes for patients with cancer. (Pradel et al., 2004) During the late 1980s, the BPS created the designation for its currently most popular specialty, pharmacotherapy, which presently represents roughly 73 % of all board certified pharmacists. The Board Certified Pharmacotherapy Specialist (BCPS) is primarily responsible for ensuring drugs are used in the most efficiently safe, appropriate, and economical manner. The BCPS is typically involved in directing ca re

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25 for patients and are commonly referred to as a source of knowledge about drugs and utilizations for other health care professionals. In 1997, BPS announced the introduction of the pharmacotherapy, in which pharmacists are designated a s professionals with improved levels of experience and training in a sub area of a specialty. Presently, only two of specialties of pharmacotherapy: cardiology and infectious diseases. Although both of th ese sub specialties have been available for certification for over a decade, pharmacists credentialed in these areas represent less than 2% of the total board certified pharmacist population (Connor & Hamilton, 2010, Pradel et al., 2004). Most recently in 2011, the BPS board approved a specialty area i n ambulatory care pharmacy which represents 4% of the board certified population. To date, no information about enrollment in this area has been published. Credentialing in Pharmacy According to the Counci l in Credentialing Pharmacy (CCP) there are currently three primary categories of credentials a pharmacist may seek in the United States: college and university degrees, licensure, and post graduate degrees and certificates. The first of such categories ha s been standardized over the past decade in that d in the form of a four year doctorate of phar macy degree, known as a Pharm.D within the United States (CCP, 2010). This universi ty education includes didactics, small group experiences, laboratories, simulations, and experiential instruction. The second primary category of credentials, licensure, is awarded and regulated at the state level. Pharmacists who wish to practice within the field of pharmacy in the U.S. must seek licensure to practice. In order to gain licensure as a Registered

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26 Pharmacists, R.Ph, a candidate pharmacist must have graduated from a state board approved college or school of pharmacy, completed a minimum num ber of hours of practice experiences in pharmacy, and must satisfactorily pass licensure examinations including the North American Pharmacist Licensure Examination (NA PLEX) and, in most states, the Multistate Pharmacy Jurisprudence Examination (MPJE) (CCP 2010). The NA MPJE functions as a test of legal knowledge at both state and national levels (NABP, 2011). The purpose of these examinations as well as the requisites to take licen sure competence necessary to ensure the public health and welfare will be reasonably well rds of pharmacy require that a pharmacist must maintain their knowledge base through satisfactory completion of continuing education unit s (CCP, 2010). These measures of initial licensures and licensure renewal were purposely put into place as a mean to protect the well being of society in terms of having competent professionals to serve as facilitators between medications and the patients who need them. In this way, licensed pharmacists are placed on the front line in action, serving as an obstruction b etween adverse drug events and preventable drug related morbidities and the patients that may be harmed. These licensure requirements ensure the pharmacists have both the legal and practic al knowledge needed to guarantee the pharmacist is competent in ter ms of providing safe and effective provision of medications to society as a whole, one patient at a time.

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27 Lastly, the third fundamental category of credentialing, academic post graduate education and training programs, focuses on the further development a nd enhancement of both the knowledge and skills of pharmacists. This extra education and training may take place through post graduate master or PhD program enrollment, certificate programs, fellowships, residencies, or certifications. Certificate progra ms, also known as practice based CPE activities, are accredited systematic and structured educational experiences that are smaller in scale and occur over a shorter period than traditional degree programs. This type of extra training requires a minimum of 15 contact hours and consists of relatively focused experiences designed to enhance knowledge and skill sets in specific area s of practice. Fellowships are unaccredited and typically entail one to two years of directed and individualized training in a sp ecific area of pharmacy with the intention of training the pharmacist to eventually become an independent researcher within a chosen sub field of pharmacy. Residencies on the other hand, are usually accredited training programs that offer direct learning experiences for pharmacists. Most pharmacists who chose to pursue residencies complete a post graduate year one pharmacy residencies (PGY1) which offer enhanced knowledge in the general proficiencies of managing medication use systems and reinforce optima l medication therapy outcomes for patients with a wide array of disease states. After completion of a PGY1, some pharmacists choose to complete a second year of residency training (PGY2) which offers more in depth knowledge and training experiences in a s pecialized area of pharmacy. In most cases, this type of training is geared towards preparing pharmacists to become board certified when Board of Pharmaceutical Specialty (BPS) certification is offered in the respective specialty area. C ertification is t he last type of

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28 credentialing offered and is awarded by either the BPS or the Commission for Certification in Geriatric Pharmacy (CCGP). These certifications are offered to individuals that have exceeded the minimum requirement for pharmacist licensure an d those who have demonstrated a high level of competence within a specific field of specialty area. The CCGP currently offers a sole certification in geriatric pharmacy, while the BPS offers certification within six specialty areas of pharmacy (CCP, 2010) Like licensure, specialty certification within pharmacy requires that candidates complete a minimum number of practice experience hours within their specialty area and complete an examination pertaining to knowledge of medication and medication use with in their specialty field. Specialty certification also requires that those who pass the initial exam maintain their specialty credentials through either taking a renewal exam or the satisfactory completion of CEUs approved by the Board of Pharmaceutical S pecialties (BPS). Unlike licensure to practice pharmacy, specialty board certification is a voluntary credential that is awarded to a pharmacist with advanced knowledge in specific areas of pharmacy. For many decades in the U.S., one of the functions of specialty certification has been to distinguish individuals that have exceeded the minimum requirement for pharmacist licensure and have demonstrated a high level of competence within a specific field of specialty area from their generalist pharmacist coun terparts. The main purpose of specialty board certification is similar to that of licensure but focuses more on enhancing patient care in certain specialty areas by o

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29 Motivational Benefits of Specialty Certification in Pharmacy Specialty board certification is thought to be a means to communicat e a erience and skill set within a sub specialty to other health care professionals and to patients. Pharmacy practitioners with these credentials are frequently sought for professional consultations and drug therapy management collaborations. Because of this becoming board certified is considered a way to enhance professional respect and rapport with other health care professionals through the display of advance level of knowledge and skill sets whilst improving patient care. The BPS (2011) reports that as board certification becomes more recognized they anticipate greater recognition from third party payers such as Medicare and Medicaid, along with private insurers and payers. In two states this recognition has already begun to come to fruition; in both Ne w Mexico and North Carolina pharmacists that are board certified specialists may apply for certain prescribing privileges (BPS, 2011). Reimbursement for advanced service provided to patients is the logical next step for board certified specialty pharmacist s to seek. Pharmacists may become motivated to become board certified specialists after considering the wide range of benefits of this type of credential. Becoming board certified impacts and enhances the relationships between pharmacists with patients other health care professionals, and third party payers. Pharmacists who desire to become more involvement in management of drug therapy for their patients may seek certification as a means to display their capabilities and competen ce within their specific area of patient care. As such, they may have greater opportunities to become involved in treatment decisions through added prescribing privileges in some areas, collaboration and consultations with other professionals, or by invitation from patie nts who recognize

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30 their added value (Connor & Hamilton, 2010). This extra autonomy and inter professional collaboration are benefits that pharmacists may value, thus they may be a source of motivation to become certified. M erit and tenure pay raises asso ciated with certification can be a significant financial motivator for pharmacists as well. Private companies often award monetary incentives, promotions, or give hiring preferences to board certified pharmacists. The U.S government, as an employer, has been cited as offering increased pay and bonuses to pharmacists in departments including the U.S Department of Veterans Affairs and the U.S. Public Health Service (BPS, 2011). In addition to the aforementioned prestige and financial motivators, individu al and professional ethics may prove to be likely motivational factors for pharmacists pursuing specialty certification. Personal ethics, or moral responsibilities are the overall expectations of any person within society to meet certain self set standard s of conduct Individuals produce and maintain their own set of person al ethical principles (Colero, 2011). These principles may form a motivating force for pharmacists where they may expect themselves to perform well for society and to prevent harm for s pecific types of patients but instead they may find themselves unable to meet those standards due to an inadequate work position and responsibilities. For these individuals, becoming certified may be a means to exercise a higher degree of personal ethics which in turn provides a greater personal benefit of fulfillment. Contrastingly, professional ethics refer to a code of conduct or standards of behaviors set forth by professional associations (Colero, 2011). Pharmacists, as health care professionals, m ay become motivated to receive ethical benefits by fulfilling professional ethics in the pursu it of

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31 professional ethics requires them to maintain competence. A pharmacist, who works with cancer patients, may feel that studying for and becoming a certified oncology pharmacist is a way to comply with this code of conduct. Studies of both professional associated with their behavioral intentions (Barnett & Vaicys, 2000). All of these external professional benefits mentioned may serve as a motivational starting point for pharmacists to becoming certified, especially those who wish to improve their quality of work life, adher e to personal ethical principles, or those who wish to advance in their professional environment. Pharmaceutical Care and Specialization Specialization within the area of pharmacy has provided pharmacists an opportunity to be recognized for their advance d knowledge and skill in helping patents reach their drug therapy objectives by providing medication information, assessments, monitoring, and promoting safe and effective drug therapy decisions for patients. Hepler & Strand (1990) defined pharmaceutical c is seen as a process where the pharmacist cooperates with both the patient and other health care professionals for the designation, implementation, and monitoring of a plan of therapy specifically designed to produce specific therapeutic outcomes for the patient. As previously mentioned as both a benefit of certification and a possi ble motivation al force, becoming a board certified specialist may afford a pharmacist greater opportunities to become involved in collaborative efforts with other health care professionals. As such, it may be the case that pharmacist s wishing to emerge f rom a transitional period of pharmacy to a patient

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32 centered focus, may find that becoming certified will afford them additional opportunities for professional maturation in terms of developing opportunities to engage in pharmaceutical care activities and b eing invited to work in partnership with other health care providers for the benefit of the patient (Hepler, 1993; Ferro et al., 1998). However, n ot all health care professionals view pharmacists as true clinicians and are thus sometimes excluded from des igning therapeutic plans of treatment for patients (McDonough et al., 1998). With the added credentials that becoming a board certified specialist provides, pharmacists can display the ir advanced knowledge and skill set, which allow s them to gain more tru st and respect from other health care providers and patients alike. Hence, patients will be more likely to openly discuss drug problems or therapeutic questions with these pharmacists during both patient interviews and monitoring sessions, which in turn h elps the pharmacists to provide optimal safe and efficient care to their patients whilst helping to identify and prevent possible drug related morbidities. Specialization within pharmacy has played an important role in promoting the reprofessionalization of pharmacy itself. The need for reprofessionalization in pharmacy was expressed several decades ago when technologies and distribution practices were the primary duty of pharmacists at the time was to simply dispense the correct medication to the correct patient (Birenbaum, 1982; Hepler 1985, Hepler, 1988, Hepler 1990, Hepler 1993). It was at this point in time that reprofessionalization was thought to represent both a p roblem for pharmacy in terms of loss of power and status and an opportunity for pharmacists in terms of gaining new roles and recognition. In 1988,

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33 before his concept of pharmaceutical care was fully accepted Hepler first discussed the role of the specia lization movement in the reprofessionalization of pharmacy. Hepler proposed services (including elements of pharmaceutical care) may become a specialty in order to set itself apa embrac ing profession maturation. As pharmaceutical care gained accept ance rapidly nearly two decades ago, Hepler (1993) began to express the idea that pharmacy specialization was not equivalent to practicing pharmaceutical care by means of clinical pharmacy. Instead, Hepler argued that being a clinical pharmacist and practicing pharmaceutical care should be the respo nsibility of both generalists and specialists as professionals. It was criticized by Hepler (1993), though the emergence and recognition of this specialization may have p layed some role in promoting pharmaceutical care within and outside the pharmacy profession. Part of the reprofessionalization of pharmacy is adhering to and setting a formal code of ethics for APhA (2011) code of ethics for pharmacists is centered on the basis that as professionals, pharmacists should promote the good and welfare of the patient first. Being a professional and helping patients, requires a lifelong commitment to the better ment of society by serving patients and ensuring their wellbeing. These covenants with patients are extremely important since they translate into a lifelong commitment to learning and acquiring new skills. Pharmacy has and still is in a transition of rapid tran sformation

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34 with regard to products and services rendered to the patients who need them. Those in the profession of pharmacy, including those whom have specialized and who are generalists, must therefore continue to re educate and learn new skills as new in formation and technologies becomes available; with the end goal of providing the best care to each patient possible (Traynor & Ferguson, 2002). Theoretical Framework Social Cognitive Career Theory Social Cognitive Career Theory (SSCT) was developed in the 1990s in an attempt to combine and refine current theories on career choice, development, and constructs of self efficacy beliefs, outcome expectations and expectancies, an d goals, this theory purports that all constructs simultaneously and continuously interact throughout the lifespan of an individual to form motivations and reinforcements. SCCT purports interests, intent, and career performance standards are formed after i nitial exposure to ideas and activities after which, pertinent goals associated with such are subsequently developed and maintained through practice, feedback, and nurturing environments (Lent et. al, 1994, Lent & Brown, 1996). Central to SCCT, self effic acy is simply "people's judgments of their capabilities to organize and execute courses of action required to attain designated types of associated with specific activities a nd performance domains; self efficacy beliefs are constantly developed and altered through life experiences. Successful experiences are believed to instill and reinforce higher self efficacy and failures are considered counter acting which force a lowering of self efficacy beliefs. Lent et al. (1996) states these

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35 beliefs are established and adapted through four central forces: vicarious learning through experiences of others, social persuasion, physiological states and reactions, and most impactful persona l performance accomplishments. For illustrative purposes, take the hypothetical example of Pharmacist Joe into account: Pharmacist Joe graduated from pharmacy school within the past year and beg a n working in a hospital. Joe show s great merit and an extensive knowledge base in certain areas and is promoted to an interdisciplinary care team in a geriatric unit. One of his new primary responsibilities is to ensure proper nutritional support for patients in th e unit which requir ing parenteral feeding. Joe has had little exposure to such activities O n his first day of work in the geriatric unit, he feels inadequately prepared for all tasks associated with his new occupational role Thus, Joe experiences low self efficacy relating to these job tasks. However, a s Joe works with another more experienced pharmacist training him, Joe begins to slowly build up his self efficacy by watching his mentor successfully fulfill job tasks aiding the pharmacist in these tasks, and through helping design regimes wit h the other pharmacist. Joe eventually begins to work on his own; organizing and executing tasks such as planning and dispensing nutrition and drug regimens and is successful in terms of providing adequate care to patients, which continues to build his sel f efficacy higher. Over time Joe has developed a high sense of self efficacy and believes he is capable of fulfilling and completing the occupational tasks required. expectations and ou tcome expectancies of specific behaviors and actions. Outcome expectations

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36 certain actions or behaviors. Heavily influencing the impact of these outcomes expectations on the indivi dual, outcome expectancies are the positive and negative appraisals of the outcome of the specific action. These values which are formed before an action resulting in an outcome occurs simultaneously interact with self efficacy beliefs to influence action taken by individuals in their career paths. For example: Once pharmacist Joe receives proper training and thus acquires a high sense of self efficacy regarding his completed job tasks, he also believes the medication regimens he now designs for patients r eceiving parenteral nutrition are beneficial and sufficient without any unforeseen problems. His renewed competence expectancies and favorable outcome expectations rega rding the tasks associated with his occupation. Hence, self efficacy is the primary influencing factor when an individual believes he can satisfactorily and competently perform a certain skill and it will result is a desired positive outcome. Conversely, when an individual does not believe they have the capacity to successfully execute such a skill it is very likely no attempt to perform the task will be made and the outcome will prove negative.. Thus, as illustrated, ance goals are assumed to be a product of and a reinforcing factor for the efficacy beliefs and certain skills and produce specific outcomes. This c onstruct of personal goals is thought to be a means to exercise agency and are nurtured by way of high self efficacy and positive values of certain behaviors, actions, and skills.

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37 For example: Once pharmacist Joe works in his new role for a year and compe tently performs all tasks associated with his job, he builds up high self efficacy which yields positive outcome expectations. He feels his superior performance will result in eventual improved patient outcomes. Since Joe has established self efficacy a nd positive outcome expectations, he now forms goals associated with his tasks and believes they will be successfully completed with positive effects. In addition, Joe develops a personalized professional goal to become a Board Certified Nutrition Support Pharmacist (BCNP) further supporting his desire to aid more patients which in turn reinforces his belief in his abilities to adequately perform job tasks (self efficacy ) and to produce additional positive outcomes (values). SCCT also explains how career pe rformance is interrelated with its underlying theoretical constructs. Career performance is presumed by Lent et. al (1994) to be efficacy, values, and goals. An individual must first have the ability to perform a set of skills They then grow to believe they are capable of executing those tasks successfully. As the individual masters the skills over time skill refinement and higher self efficacy develops (as in the case of pharmacist Joe). The individu al repeats this building cycle experiencing positive value consequences and/ or expected outcomes and forms goals to support the continuation of such outcomes which result s in further successful performance and personal goal attain ment. Lastly, SCCT purport s job satisfaction is an extension of subjective well being in the context of work (Lent & Brown, 2008) and is the eventual result of other constructs. Under this model, several pathways of influence direct and determine job satisfaction

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38 which interplays a s a determinate and a product of overall life satisfaction. The three include self efficacy, outcome expectations, and goals. Self efficacy and outcome expectations are pre determined before entering the work environment. They are thought to have focused, central ways that affect the goal behaviors of participation in and progress of goal directed activities. On the other hand, distal contributors to job satisfaction inc lude environmental factors, resources, and obstacles such as social and material support and previous life experiences which created personal goals. The Illness Experience In addition to SCCT, this study also utilize s S ick R ole concept as the two to form an Illness Experience concept which determines motivational predisposition for becoming board certified via personal life experiences with varying illness states. Through a set of rights S ick R ole explains the experiencing illnesses and a fter illnesses ha s ended through reintegration into social norms. Two basic premises are thought to underpin this theory: sanctioned deviance and a set of rights and responsibilities for the sick. Sanctioned deviance occurs when society pe rmits sick individuals to be non adherent to social norms thus allowing the individual to be an unproductive part of society while sick and recovering as long as the person is fulfilling their S ick R ole obligations. These obligations are part of the secon d underpinning concept responsibilities should be separated between their rights and their responsibilities. Parson asserts that

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39 unlike he althy individuals our sick are given two primary rights by society The first of these rights occurs when the sick person is deemed exempt from everyday social norms because they are sick The second right arises when the sick person is not responsible or blamed for their illness since the illness itself is beyond the control of the sick person. The totality of these primary rights lends itself to the supporting idea that sick people must be taken care of by society and its members, but only when the ind ividual in the sick role fulfill s two additional responsibilities. First, the sick individual must desire to and actively try to get well and second, the sick individual must seek help from competent health care professionals and cooperate with the advice and measures offered by these providers. Th e sick role concept is well known and accepted widely and implies that the passivity of the patient is crucial in terms of care and instruction H ence, th e concept is naturally tailored more towards acute illnes s, rather than chronic illness where the patient may be sick for extended periods of time. brok en down into five key stages every patient should theoretically e ncounter The first stage is when an individual experiences a symptom: the individual will take notice of a particular symptom and will seek a remedy concluding with a flight into health whe r e the patient terminates any delays from accepting the reality of their sickness. In the s econd stage sick individual is excused from normal obligations and is sanctioned to act sick T his stage ends when the individual accepts or denies their sick role rights and

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40 responsibilities. In stage three, the individual becomes a patient through contact with a medical authority who validates the legitimacy of the illness followed by the provision of treatment. The fourth stage revolves around the dependent patient, where the individual rel ies on caregivers and health care professionals to provide care, treatm ent, and emotional support. In the fifth and last step, the patient moves through the recovery and rehabilitation stages where they begin to relinquish their sick role and corresponding sick rights, thus reassuming normal societal obligations. It is here chronically ill patients must make adequate adjustments and partially retain some sick role rights while remerging into society. Integrating these two complimentary theories the concept of the illness experience is formed. Rather than focusing exclusive ly on behavior or intent, the illness related event within physical, emotional, social, and spiritual contexts. This concept has three main assumptions building the foundation f or its motivational influences on an individual. First, the experience itself can be internal or external. An internal experience is when individuals experience firsthand being sick. An external experience is one an individual experiences secondhand thro ugh seeing another person being sick This experience can be from the point of view of a family member, friend, health care professional, or any other societal member that comes into contact w ith an individual while they are ill. The second assumption is that illness experiences can have either short lasting or long term effects on an individual. Effects that are short lasting are thought to typically result from non serious acute illnesses Conversely, i llness experiences with long term effects are usual ly the consequence of a serious/life

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41 threatening acute illness or chronic illnesses, though non serious acute illness may also In t he last assumption for this concept the illness experience may have either proximal or distal impacts on an individual and their motivations. Proximal impacts affect individuals immediately or within a short term period T his is thought to usually occur when the illness is experienced out of childhood and the individual has acc ess to resources to take a specific course of action. On the other hand, distal impacts a ffect individuals after a longer period of time has passed from the initial illness experience thus producing more latent impacts on the individual T his delayed imp act can be attributed to several factors including lack of access to resources immediately following the initial illness, failure to timely recognize the seriousness of illness or the worsening of a chronic illness over time leading the individual to seek treatment at a later point. Individuals, including pharmacists, are impacted by p ast and present illness experience s in many different ways One way individuals deal with an illness experience is through motivation. Often an illness motivates someone to choose a specific career path or achieve a certain career goal or objective. Just the perception of an illness experience may result in a significant impact on how a child models their future career path or on how adults choose to specialize within their chosen field of practice. For illustrative purposes, take the hypothetical example of Alice into account: Alice, at the age of 17, is di agnosed with Major Depressive Disorder (MDD) which lasts through the rest of her teenage years until she turns 20 (internal). On several

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42 her medication and how to avo id unwanted side effects and drug interactions. Alice, having an interest in the pharmacy profession especially with psychopharmacology stemming from her own personal experiences with anti depressants, decides to enroll in pharmacy school after completin term). Finishing her Pharm.D, Alice practices in a hospital pharmacy for some time. When her employer offers incentives for board certification via salary and promotion, Alice decides to look into specialization. Alice choses to become a board certified psychiatric pharmacist (BCPP) based on her own interest which was spurred almost 8 years earlier by her illness experience with MDD (distal). Through this case of Alice, we see how the combination of illness experi ence assumptions may have sizable impacts on career decisions From the information term, and distal according to the theory presented. This however, is not the only combination of assumptions that may have strong impacts on career decision. Take for example, the case of Charles: Charles is in his late thirties and has been studies treatment options for kidney cancers so he may be more involved in the care cured within a m cancer treatment and now desires to help other children having a similar initial diagnosis as his son (proximal). Accordingly, Charles applies for a new job working at the only cancer cent er nearby and decides a specialty board certification designation as a Board

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43 Certified Oncology Pharmacist (BCOP) is his goal. Charles takes the exam and obtains his specialty certification but is not offered the position he applied for. Charles then ret urns to his job as a retail pharmacist for the remainder of his career (short lasting) and assumes his previous career role. lasting, and proximal al, long term and distal. Both illness experiences however, succeeded in motivating individuals to ultimately obtain board certification in their respective chosen specialties. The degree of impact of each illness experience depends on the individual, th e illness, and the circumstances. Self an integral part of the overall impact and intertwine with their personal experiences. Additionally, motivational career impa cts vary and may be directly related to how an outcome i s appraised for internal experiences or to the success of treatment for illness for external experiences. Relevant Research Studies Very few studies have inspected the motivations of health care professionals who seek specialized certifications and their choice of specialty area. As discussed in the first chapter, a small scale study in 2009 examined essay portions of applications to nurse midwifery educat ional program s through content analysis. Six themes pertaining to influential factors were identified and ranked in terms of popularity: personal birth experience, love of maternity nursing, seeing midwifery as a calling, encouragement from others (inclu ding midwives), an epiphany moment, and using nursing as a stepping stone to midwifery. As the most popular theme, personal birth experience was identified as a very powerful motivational force whether the experience itself was

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44 positive or negative for t he birth giving mother (Ulrich, 2009). An earlier study also examined motivations to choose the midwifery profession in terms of its influence on becoming Certified Nursing Midwives (CNMs). Similar to the latter study, a majority of the s urvey respondents affirmed their motivat ion to become CNMs as arising from their own birth experiences and the resulting feeling of needing to assist other women during childbirth experiences (Ventre et. al, 1995). A 2010 study was conducted by Rogers S earle, and Creed in order to explore the determinants of medical specialty choice of 179 final year medical students in Australia. This study divided the specialty areas into three categories: surgical, medical, and primary care. Analyses revealed 29% pref erred a surgical specialty, 25% preferred primary care, and 47% preferred a medical specialty. Step wise logistic regression was used to compare choice of medical and surgical specialty areas choice over practicing in general or primary care setting. Selec ting a surgical specialty over a primary care specialty was significantly associated with being male and having higher professional expectations, while selecting primary care over a surgical specialty was associated with high agreeableness, high lifestyle expectations, and a desire to practice outside of a capital city. Selecting a medical specialty over primary care was associated with having an urban background and higher professional expectations, while preferring primary care over a medical specialty wa s associated with higher lifestyle expectations and the desire to practice away from a capital city. These results indicate outcome expectations may play a large role in specialty choice among medical professionals, hence indicating the possibly expectatio ns play a significant role in choice of practice setting in other types of health care professionals as well.

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45 A review of literature on the topic of why pharmacists choose to become specialized via certification yielded minimal results H owever two recen t studies were located both of which examined motivations to become a board certified pharmacist. Conducted in 2007 after the American Society of Health System Pharmacists (ASHP) Accreditation Standards of Postgraduate Year Two Pharmacy Residency Program s began requiring mandatory board certification of residency program directors in residency specialty areas in 2005, a study was completed assess ing the motivations to become board certified among pharmacy residency program directors. This study found the new accreditation status standard was not an important motivating factor listed by these pharmacists I nstead professional and personal development was the most commonly cited factor for influencing motivations to become board certified (Daugherty, 2007) Additionally another study was conducted in 2008 to compare motivational differences between non board certified pharmacist s and board certified pharmacists. This specific study demonstrated differences between the two groups of professionals were sig nificant in terms of general motivational influences and that valences (value) pertaining to work life and self image at work were higher among certified pharmacists. Specific details in terms of the origins of motivational forces that influenced pharmacis ts to seek initial certification were not revealed and were not adequately examined (Tankersley, 2008). Chapter Summary Over the past several decades, more opportunities for pharmacists offering patients specialized care have become apparent with the grea test opportunities appearing in institutional settings The field of pharmacy actively encourages and supports specialty certifications while pharmacists themselves seek certification in order

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46 to offer patients and other health care professional s advanced knowledge, treatments, and care. Unfortunately, little scholarly attention has been paid to and very few studies have examined what motivates pharmacists to become board certified specialists and to choose a specific specialty area. Using both SC CT and the illness experience this study strives to explain motivational influences in the lives of board certified pharmacists. Accordingly, t his study serve s to bridge a much needed gap in the literature on motivations in this specific and vital group o f health care professions.

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47 CHAPTER 3 RESEARCH METHODOLOGY Study Approach The purpose of this study is to examine the internal and external factors which motivate pharmacists to become board certified in a pharmacy specialty. Additionally, this stu dy has several secondary purposes to help determine the origin of such motivational forces and their impacts on job satisfaction Hence, the goals of this study are as follows : (1) to investigate the relationship between individual and interpersonal motiva tional factors which chosen specialty area, (2) to examine the differences in motivational factors between pharmacists that have selected different specialty areas, (3) to investigate how person al life experiences serve as motivational influences in terms of selecting a specialty area (4) to distinguish whether differences in motivational factors exist in becoming certified and choosing a specialty area between pharmacists who choose to become c ertified voluntarily and those required to become board certified for career purposes, and ( 5 ) to investigate the differences in job satisfaction for all board certified pharmacists and for board certified pharmacists within certain specialty areas. S ampl e Population In this study all currently board certified pharmacists in the Board of Pharmac y Specialties (BPS) database were asked to complete a survey. As of the last examination administered in October of 201 3 contain ed 15,485 board certified pharmacists with approximately 11,608 board certified pharmacotherapy specialists, 1 ,421 board certified oncology pharmacists, 758 board certified psychiatric pharmacists, 5 52 board certified nuclear pharmacists, 523 board

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4 8 certified nutrition support pharmacists, and 653 board certified ambulatory care pharmacists. The database also contains board certified pharmacotherapy pharmacists with added qualifications in cardiology and infectious diseases, numbering 90 and 162 pharmacists res pectively All p harmacists with current board certification as of August 2013 granted by the Board of Pharmaceutical Specialties were asked to participate in this study. These pharmacists were included regardless of practice setting, employment status or specialty area. Sample Size and Power Multiple power analyses were conducted to establish which of the intended statistical analyses in this study would require the largest sample size. The results of such power analyses indicated the logistic regr ession used for analyses in research hypothesis V to detect an OR of 1.7 analyses would require n=1140 ; while detection of an OR of 1.5 analyses would require n=2019, which would require a n 8.83% and a 15.65% response rate respectively. Non response bias was assessed in the study population by comparing demographic information and variables that represent responses on key constructs in the study between temporal groups. Participa submitted their online survey within the first attempt at recruitment by the investigator. Instrument Development Data for this s tudy was collected via online survey instrument. The survey was constructed by the investigator by adapting and combining items from several different

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49 scales and instruments into a single questionnaire. The survey is comprised of six main sections: 1. Inf ormed Consent 2. Basic Demographics Questionnaire 3. Illness Experiences Questionnaire 4. Job Satisfaction 5. Self Efficacy and Outcome Expectations 6. Perceived Experiences with Illness Informed Consent The survey first begins with an informed consent section which explains 1) that participation in the study is voluntary, 2) who the research er is and their university affiliation, 3) what the researcher proposes to do with the study 4) the purpose of the om the study and to review study results after completion of study. Basic Demographics Questionnaire The survey was designed so after informed consent was electronically gained, participants w ere asked to complete several questions on personal and prof essional demographics as well as several basic questions on certi fication. Personal demographic items include d gender, race/ethnic group, marital status, and geographic area. Professional demographic items include d employment status, employment setting, work hours, and the degree of specialty practice in the work setting. Certification items include d board certification status, specialty, year of certification, renewal status, and work requirements to specialize. Illness Experiences Questionnaire After p articipants completed the demo graphic portion of the questionnaire, they were prompted to complete the Illness Experiences Questionnaire. This part of the

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50 survey was designed by the investigator to collect information on past and/ or present experiences wi th illness or pharmacologic agents which specifically correspond with each specialty area. Participants were first prompted to respond in a yes or no format about a personal, family member, or an individual close to them ever having a certain illness experience. Participants respond ed regarding their experiences with radioactive drugs (Nuclear Pharmacy), treatment for serious or life threatening chronic illnesses (Ambulatory Care Pharmacy) psychiatric related illnesses (Psychiatric Pharmacy) maligna nt disease (Oncology Pharmacy) intravenous feeding or special nutritional support (Nutrition Support Pharmacy), and heart attacks or cardiac health problems and infectious diseases (Pharmacotherapy ). If a respondent indicate d were then asked to further specify whether the illness was experienced pers onally, through a family member or through someone close to the participant. P articipants were also asked whether they believe d their experiences with illness led them to choose their specific specialty area. Job Satisfaction Next, participants were asked to complete a section on job satisfaction. This segment of the instrument represented the full version of the Generic Job Satisfaction Scale developed by Macdonald & McIntyre (1997). In the initial development of this scale 885 working professional s in Canada across various occupations were sampled. The resulting factor analysis concluded that a set of ten items defined a single factor of job satisfaction, without significant differ ences in six occupational categories or between males and females. Macdonald & McIntyre (1997) also demonstrated that the scale has an acceptable level of internal consistency Concurrent validity of this scale w as also demonstrated by showing correlations

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51 between the job satisfaction items and scores on the scale with other work place and non work place variables. A review of the current job satisfaction literature did no t yield any studies utiliz ing this specifi c scale in the pharmacy setting at the present time. Rather, job satisfaction studies for pharmacists used a wide range of measures and were typically ones that had been previously validated or scales that were constructed for specific purposes of conduct ing such studies (Hassel, Seston, & Shann, 2010; ASHSP, 2012; Maio, Golfarb & Hartmanm, 2004). Thus, the Generic Job Satisfaction scale was chosen to be employed in this study, due to its previously established reliability and its validity in a wide range of occupations and its brief yet wide construct encompassing human nature. The Generic Job Satisfaction scale is comprised of ten items pertaining to an from manageme relationship with supervisors, and general good feelings about work. Each of the items on the scale offers five response options on a L ikert scale ranging from strongly disagree (1) to st rongly agree (5) Participant responses on the items contained in this job satisfaction construct. Since the scale is general ly accepted across most career fields and measures individual perceptions about job satisfaction in a relatively short fashion no items were excluded or adapted for use in this study. Self Efficacy and Outcome Expectations The fifth main section of the survey co ntains questions adapted from t he i nstrument developed and validated by Rogers, Creed, & Searle (2009, 2010) for use in using Social

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52 Cognitive Career Theory. The original instrument contains four segments : self efficacy outcome expectations professional, outcome expectations lifestyle, and goals Content validity of items in the scale was established by using both SCCT as a framework and through expert review. Construct validity in the instrument was verified through ex ploratory factor analysis and subsequent confirmatory factor analysis using an additional sample of medical students, both of which confirmed factorial independence y indicate the sc ale has acceptable levels of internal reliability, with coefficients ranging from .87 .92 (2009) and .83 to .92 (2010). All i tems in the self efficacy and outcome expectations subsections of the o riginal However, word choices were changed to reflect pharmacy specialties and practice areas General instruct ions for how to consider each question and subsequent response w ere also adjusted, with each participant asked to reflect back on the time before they choose their specialty practice area before choosing their responses. The self efficacy section contain ed seven items pertaining to self efficacy regarding choice of specialty with r esponses rang ing from 1 to 5 on a rating professional section contain ed eight items with responses ranging from 1 to 5 on a L ikert type Participant responses to items within each section were summa ted to form a sub section composite score. Perceived Experiences with Illness In th is portion of the survey, part icipant responses to d whether the participant was directed

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53 to complete the rest of th is specific section. If the participant respond ed positively to the first question they were then directed to complete the rest of the sixth section. Otherwise, the participants were directed to skip this survey area. The remaind e r of the sixth and final section of the instrument included the perceived personal/internal illness experience scale contain ing items adapted from the Revised Perceived Illness Experiences (R PIE) scale developed and validated by Kiernan, Gomley, & Maclach was use by wording certain questions to pertain to adult participants, i.e. changing school and work items to options on a L ikert scale of 1 to 5 to indicate level agreement with each item from was comprised by add ing responses on each item together. An Expert panel review determined whic h instrument would contain from the 20 items across six subscales: Pee r Rejection, Thinking about Illness, Physical Appearance, Interference with Activity, Family Response, and Manipulation from the original R PIE (2004). Each subscale in the R PIE instrument demonstrated a moderate internal consistency reliability, with Cr .76 and an overall high reliability of composite R of participants and score s on subscales or total score of instrument. Type of illness was

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54 significantly associated with scores on the Physical Appearance sub scale, in that participants with cancer were more likely than participants with other types of illnesses to indicate more n Females in general were also more likely to have more negative perceptions of their physical appearance, which was attributed to the general concept of females being more concerned wit h body (2004) believe that the R PIE has a broad applicability across illness and nationality since it was derived from children with a large range of illness across multiple countries. Validation of the Survey Instrument Both focus groups and an expert panel review were conducted for the construction, revision and shortening of the test instrument. Participants in both of these phases were recruited from Shands Hospital at UF Health and the Unive rsity of Florida. After each phase of validation, the study instrument was closely reviewed and scrutinized based on the feedback and data collected. Focus Groups Focus groups were conducted over a several week period. The groups c onsist ed of board certif ied pharmacists in the local Gainesville, Florida area. Multiple f ocus group session s with different participants were held subsequent to the initial instrument construction. Focus groups sessions were divided in to two parts. The first part of each group concentrated on exploring motivational influences on becoming certified and relating illness and health care experiences to the different specialty areas. The second part of each focus group concentrated on the review and validation of the study instrumen t. Participant s were asked to discuss the perceived clarity and relevance of the directions and the items on the study instrument. All focus group sessions were

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55 transcribed and subsequently reviewed by the investigator. After review, the instrument was re vised to be more applicable to the target population and several items, including the directions for completing the study instrument, were changed for clarity purposes. Expert Review An expert panel review was conducted in order to exclude repetitive and Experts for the review were recruited from faculty members within the college of pharmacy at the University of Florida and board certified pharmacists at Shands Hospita l. The majority of these experts were pharmacists that had been impacted by an illness either personally or through a close friend or family member. During the expert review of the instrument, experts were asked to review the items in section six, Perce ived Experiences with Illness. In order to evaluate the content validity of the items, experts were asked how well they thought the items adequately measured experiences with illnesses. Experts were also asked to consider whether each item was redundant, r elevant, pervasive, and was logically worded. After the review was conducted, test items were either removed or altered in order to improve the Pre Test Validation Results Focus group participant s (n=9) attended sessions held over a two week period. Each participant attended one of three sessions held, with each session lasting approximately one hour in length. All participants received and consented to participate in the study after reviewing an the Institutional Review Board (IRB) at the University of Florida. Each focus group session was recorded via digital hand held recorder. After each session, the study

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56 investigator carefully transcri bed each recording and thereafter destroyed the digital copy of each session, as to ensure the anonymity of each participant. During the focus groups, the study investigator moderated the discussion addressing two main themes; general motivation to become a board certified pharmacist and validation of the study instrument. After each focus group session was conducted, they were transcribed into text for analysis by the study investigator. Review of the focus group transcripts revealed reoccurring themes mentioned by participants when describing their motivations to become certified. Four common themes were identified: future ca reer aspirations, peer pressure, differentiation, and personal goals. The most popular theme identified was differentiation (n=5), where participants indicated they wanted to set themselves apart from other pharmacists. Peer pressure was also a common the me mentioned (n=4), in which participants stated they felt direct pressure from peers or role models to become certified. Personal goals was an equally commonly mentioned motivational theme (n=4), where participants stated they had inherent motivation to become certified pharmacists via their own personal aspirations. Lastly, career aspirations were also identified as a common theme (n=3), where participants indicated they felt certification would be a requirement in the future or where participants stated they become certified because they thought they would like to be a residency director in the future. Additionally all focus group participants were also asked to review the preliminary study instrument and identify issues with relevance, importance, and administration of the survey itself. After reviewing the focus group transcripts, several common themes were identified pertaining to the study instrument. The vast majority (n=8) of participants

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57 found job performance variables significant and relevant. S ome of the participants (n=4) also stated the Experiences with Illnesses section of the instrument seemed irrelevant and would like to see a statement of relevance before they, themselves, would fill out this portion of the instrument. Participants (n=4) a lso indicated that the instrument length may be an issue and suggested making it shorter. The perceived illness experience portion of the survey was heavily scrutinized during expert review (n=5). The majority of participants agreed that a large number of items on this sub scale either needed wording adaptations or should be excluded from the final study instrument. After evaluating feedback from these experts, 12 of the original survey items were deleted from the survey due to irrelevancy or repetitivene ss. For the eight original survey items that were kept for the final survey instrument, some target population. The focus groups and expert reviews yielded valuable information, which was carefully examined by the study investigator for possible changes to the instrument. Following the review of the information, the job performance section of the survey was removed. The investigator also added a short statement of rea son supporting the collection of information for the Experiences with Illness section of the survey, which participants could read before proceeding to respond. Lastly, several extraneous sub sections in the instrument were removed from the survey in cons ideration of the feedback on length of the survey. Data Collection This study utilized a prospective research design. All participant data was obtained through an internet survey specifically designed for the purpose of this study.

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58 The survey participan ts were initially contacted via email through BPS servers where the purpose and content of the survey was explained and respondents were prompted was administered through Q survey software The survey was also administered on a secure https:// website address and all surveys were completed anonymously. The collected data was stored on a password protected whole disk encrypted computer. No personal identifying information suc h as name, birthday, and social security numbers were collected in the study instead respondent identification numbers were used to sort item responses and all other data points for each participant. In order to optimize response rate, the target populat ion was contacted and asked to complete the online survey twice over a period of 25 days. On day one of the study, an email was online survey. On day 11, participants were sent a reminder e mail with the URL link. The survey was closed approximately two weeks after the second email was sent out. Analytical Methods All data collected for this study was analyzed using IBM SPSS Statistics 19 software. Frequency analysis and other descriptive s tatistics were run to check for missing values and consistency of responses across participants. Standard descriptive statistical analysis of demographic information was completed in order to examine whether a representative sample of the target populatio n was obtained for this study Specific statistical analyses were including, chi square analyses, logistic regression, linear regressions, and one way analysis of variances (ANOVA)

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59 Response bias was accessed by comparing the responses of early and late responders. The assumption this approach makes is that participants who respond later within study periods may be more similar to non responders within the target population (Smith, 2002). Hence, mean respons es on key study variables were compared between these two groups in order to assess whether bias es may have occurred in terms of participation in this study Hypothesis I: In board certified pharmacists, amount of time per work week spent using their spe cialty area will be positively associated with levels of job satisfaction. Analyses were conducted to determine whether amount of time per week spent working within specialty area is predictive of job satisfaction. After job satisfaction items we re scored, standard descriptive analyses were completed in order to find the mean, median, and range of both job satisfaction and the amount of time spent working in specialty area. A linear regression analysis was conducted using job satisfaction (score on Generic J ob Satisfaction Scale) as the dependent variable and amount of time per week spent working within specialty areas as the single independent variable in the analysis. Hypothesis I I: Pharmacists who have become board certified independent of wor k requirements will report higher levels of job satisfaction compared to those pharmacists who become certified to fulfill job requirements Data responses were coded in order to differentiate pharmacists who indicated they became certified independent of w ork requirements from those who did not, were

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60 completed in order to find the mean, median, and range of scores for job satisfaction of pharmacists in both groups. A o ne way ana lysis of variance ( ANOVA ) was run to compare groups mean scores on the Generic Job Satisfaction Scale used in section four of the study instrument, using job satisfaction as the dependent variable and work certification status as the group factor. Hypothe sis III: In board certified pharmacist s working in a setting where specialty certification is used is positively associated with job satisfaction. Analyses were conducted to determine whether response of working within specialty area is predictive of job satisfaction. After job satisfaction items were scored, standard descriptive analyses were compl eted in order to find the mean of job satisfaction and percentage of respondents working within their specialty area. A linear regression analyses was conducted using job satisfaction (score on Generic J ob Satisfaction Scale) as the dependent variable and working within specialty area as the single independent variable in the analysis. Hypothesi s IV : Hi gh levels of self efficacy outcome expectations and goals will be predictive of higher levels of job satisfaction among board certified pharmacists. An analysis was conducted to determine whether both self efficacy and outcome expectations and working with in specialty area were predictive of job satisfaction. After items were scored, standard descriptive analyses were completed in order to find the mean, median, and range of scores for each of the variables. Regression analyses were conducted using job sat isfaction (score on Generic Job Satisfaction Scale) as the dependent variable and self efficacy and outcome expectations composite score as the two independent variables in the model.

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61 Hypothesis V: Pharmacists who are board certifi ed in specific specialty areas and who have had an illness experience will choose to become certified in a corresponding specialty area. A nalyses were completed in order to determine the impact of illness experiences on choosing a specialty area. For these analyses, participants were coded into groups according to which specialties they held board certification. A dditionally, participant responses to items regarding illness experiences were coded into a dichotomous variable representing exposure status All types of illness expe riences (personal, through a family member, or through a loved one) were included in the variable. For example, a participant that reported having a family member experience a psychiatric illness received the same exposure coding as a participant that repo rted having personally experienced a psychiatric illness. In order to estimate the relationship between board certification area chosen and illness experiences an 8 test conditional multivariate binary response model w as estimated This model estimated odds ratios, confidence intervals, and p values for the likelihood of choosing each board certification specialty area (outcome) if exposure status (illness experience) was indicated by the pharmacists in that area. Eight test s were run in the model, one f or each of the psychiatric, nutrition support, and nuclear pharmacy areas of ambulatory care, pharmacotherapy, pharmacotherapy with cardiology added qualification and pharmac otherapy with infectio us disease added qualification. For each of the tests within the conditional multivariate binary response model eight predictors were used: nuclear illness experience, psychiatric illness experience, oncology illness

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62 experience, nutri tion illness experience, ambulatory care illness experience, cardiology illness experience, infectious disease illness experience, and years since initial certification. For each of the exposures odd ratios for selecting a specialty area were calculated as well as corresponding p values. In order to be conservative when dealing with a rotational control group, each test was r u n twice using the two different reference groups that were available : all pharmacists who were not certified in the outcome variabl e area in the study and all pharmacists who held pharmacotherapy specialty certification in the study without any added qualifications Hypothesis V I : In pharmacists who are board certified in specific specialty areas and who have had a self identified pr evious or present illness experience in their specialty area, self efficacy and outcome expectations will be predictive of having an illness in the specialty area in which they hold certification. After coding responses from participants to determine whe ther they ha d specialized in an area where they had an illness experience (yielding the variable (Illness in Specialty), scores on the self efficacy and outcome expectations portion of the survey were used to predict Illness in Specialty A regression ana lysis w as run to determine the relationship between self efficacy and outcome expectation scores (independent variables) and Illness in Specialty (dependent variable). Data from participants in pharmacotherapy and ambulatory care (general specialties) were analyzed separately. Hypothesis V II : In pharmacists with a past or present personal illness experience, self efficacy, outcome expectations, impact of illness experie nce, and goals will be predictive of job satisfaction.

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63 efficacy, outcome expectations, perceived illness experience scales, and working within their specialty area as independent variables and job satisfaction a s the dependent variable, a linear regression was completed in order to determine whether this model was significant.

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64 CHAPTER 4 RESULTS AND FINDING S Data Collection sent through email in two waves during July and August 2013 by the Board of serve, which is a mailing list of pharmacists that were currently board certified in at least one of the BPS specialty areas. T he first completed survey was received on July 25, 2013 and the last completed survey was received on August 20, 2013. The initial recruitment email was sent by the BPS on July 25 th and the survey was initially left open for 10 days. On the eleventh day, A ugust 5, 2013, the BPS resent a modified version of the original recruitment email, asking potential respondents to participate if they had not done so already. The online survey was closed on August 20, 3013, approximately two weeks after the second email In total, 2,685 pharmacists started the survey. Nine of these surveys were excluded due to responses indicating they were not board certified in a specialty area (n=4) or due to incomplete responses which made it unclear whether they held board certific ation in a specialty area (n=5). Out of the remaining 2 676 participants, approximately 2,577 pharmacists completed the Job Satisfaction portion of the survey, with a completion rate of 96.3%. The Self Efficacy questionnaire portion of the survey was comp leted by 2,525 participants and 2 481 participants completed the Outcome Expectations Questionnaire with completion rates of 94.3% and 92.7% respectively. In total 2,453 of the 2,676 participants completed all three of the surveys indicating an overall co mpletion rate of 91.6%.

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65 Response Rate All participants were recruited via email list serve by the Board of Pharmacy Specialties (BPS). Although the BPS could not provide an exact numbers of recipients, they reported to an attempt to transmit the recruitm ent email to roughly 14,959 response rate (n=2,676) for pharmacists across all specialty areas was 17.88%. The BPS also provided rough estimates of the number of pharmaci sts in each specialty area that received the recruitment email: 11,608 in Pharmacotherapy, 1,421 in Oncology Pharmacy, 758 in Psychiatric Pharmacy, 652 in Ambulatory Care, 552 in Nuclear Pharmacy, and 523 in Nutrition Support Pharmacy. Since pharmacists c an hold multiple specialty certifications, some email recipients may be listed twice in the BPS email list and are thus counted multiple times. Keeping this in mind, the rough response rates for each of the specialty areas were as follows: Pharmacotherap y (n=2 041) 17.58%. Oncology Pharmacy (n=234) 16.46%, Psychiatric Pharmacy (n=123) 16.2%, Ambulatory Care (n=215) 32.97%, Nuclear Pharmacy (n=53) 9.6%, and Nutrition Support Pharmacy (n=75) 14.34%. Non Response Bias During data collection, each survey r espondent was categorized into one of two groups depending on whether the response was received before or after the second recruitment email was sent out. Respondents who replied between the dates of July 25, received on or after August 5, 2013, the day the second recruitment email was sent out, possible non response bias that

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66 data collection, analyses were completed to compare key demographic and study variables between these two groups. In this study, 83.3% of participants (n=2 229) were classified as an Early Responder and 16.7% (n=447) were classified as Late Responders. No statistical differences were found between groups for gender, marital status, children at home, or years since first certification. The percentage of participants responding in the race/ethnic groups significantly differed by respondent group type 2 (7 N = 2 628) = 25.219, p = .001. Additionally, the percentage of participants responding that indicted U.S. residency also significantly differed by respondent group type 2 (1, N = 2 636) = 5.301, p = .021. For the key study variables, analyses were completed to determine if differences existed between the composite scores of Job Satisfaction, Self Efficacy, Outcome Expectations, and Perceived Illness Experience. The mean differences for each of these variabl es were small and ranged from .01 to .21. No statistically significant differences were found for any of these variables between early and late responder groups. Table 4 1 depicts the mean differences between the key study variables for the responder gr oups. Sample Demographics As previously discussed, 2,676 pharmacists both submitted a survey and were board certified in a specialty area. Females were the predominate respondents (n=1819, 68%), males only represented approximately 30.8% (n=825) and a sm all percent (1.2%, n= 32) chose not to indicate their gender. The study population was predominately White/Caucasian, with 81 .5 % (n=2,180) indicating this selection as their

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67 ethnic group. The two other most common ethnic groups indicated were Asian/Pacif ic Islander (n=253, 9.5%) and Black/African American (n=62, 2.3%). Tables 4 2 and 4 3 further depict the gender and ethnic group race variables. In the study, participants were also asked to indicate their marital status, how many had children currently l iving at home, and geographical location. Some participants chose not to indicate any responses to these demographic variables: marital status (n=42), children (n=50), and geographic region (n=193). For marital status, participants were asked to indicate their marital status by selecting one of four predefined categories. The most commonly indicated marital status was Married/Civil Union (n=1 982); the second most common was Single Never Married (n=610) followed by Single Divorced (n=127) and Widowed (n=5 children variable, participants were asked first whether they had children living at home. children living at home or piped through the survey software to the next question respectively. The majority of participants indicated they had no children currently living at home (n=1 544). Participants who indicated that they did have children at home (n=1 082) ranged from having 1 to 7 child ren at home currently: 14.8% (n=397) indicated 1 child, 18.5% (n=494) indicated 2 children, 5.8% (n=154) indicated 3 children, 1.2% (n=32%) indicated 4 children, less than 0.1% (n=2) indicated 5 children, and less than 0.1% (n=2) indicated 7 children. Pa rticipants were asked in a two part question to indicate their geographical locations. First, participants were asked whether they currently resided within the United States. The vast majority of participants reported 504) and less than 4.9% re

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68 yes, they were piped to the next question on the survey and asked to indicate in which state or U.S. territory they currently resided. Likewise, participants that lived outside the United States were present ed with a free response question, asking them to specify what country they currently lived in. Each state or U.S. territory listed was represented by participants in the study, ranging from 2 residents (Wyoming) to 159 residents (California). For partici pants outside the U.S. the most commonly reported countries of residence were Canada (n=31), Spain (n=13), and Saudi Arabia (n=11). Table 4 4 shows the full list of countries in which participants indicated residency. Specialty Certification Demographic Variables Participants were also asked to respond to several specialty certification related questions: specialty certification type, percent of work time each week spent using specialty certification, year of initial specialty certification, number of spe cialty certification renewals, added qualification status and whether receiving specialty certification was voluntary or mandatory for their position. When asked about their area of specialty certification type, participants were asked to indicate board certified specialty or specialties area(s) in which they currently held certification. Participants were allowed to indicate multi ple responses if they held specialty certification in more than one area. As expected, most participants indicated they held s pecialty certification in pharmacotherapy (n=2,041). Additionally, as Table 4 5 specifies, Oncology was indicated by n=234, Ambulatory Care by n=215, Psychiatric by n=123, Nutritional Support by n=75, and Nuclear by n=53. Several participants (n=97) indica ted they currently held board certification in more than one specialty area. The majority of these multiple certification pharmacists held certification in only two areas. In rare cases participants indicated they held 3 or more certifications simultaneous ly (n=2). For

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69 participants that held multiple specialties, pharmacotherapy was the overwhelmingly common choice of specialty with n=96 holding some combination of specialty certifications including pharmacotherapy. A combination of Psychiatric and Pharmac otherapy specialty certifications was reported by 13 participants, Oncology and Pharmacotherapy was reported by 31 participants, Nutrition Support and Pharmacotherapy was reported by 19 participants, and Ambulatory Care and Pharmacotherapy was reported by 31 participants. The most uncommon combinations of specialty areas reported were Ambulatory Care and Psychiatric certification (n=1), the Nutritional Support, Psychiatric, and Pharmacotherapy combination (n=1), and the Ambulatory Care, Nutritional Support Oncology, Psychiatric, and Pharmacotherapy combination (n=1). A visual depiction of the frequency of each multiple specialty types can be found in Table 4 6. All participants that indicated they held current board certification in pharmacotherapy (n=2 041) were piped to a survey item that asked if they had an added qualification. Possible responses to the item consisted of four pre determined responses: No I do not plan to apply, No But I may apply in the future, Yes Cardiology, and Yes Infectious Dis ease. In total n=2 031 participants indicated a response, with most (n=1 327) reporting that they did not have an added qualification and do not plan to apply for one contrasted by the 23% (n=637) who indicated that they may apply for one sometime in the future. Participants that were board certified in pharmacotherapy and held an added qualification were dispersed quite similarly across the two available areas, 1.3% (n=32) held the Cardiology added qualification and 1.2% (n=35) held an Infectious Disease qualification.

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70 Participants, through free text response were asked what year they first became certified. Most commonly, participants reported receiving initial board certification in a specialty area within the last five years from 2009 to present (n= 1464) with responses ranging from 1982 to the present. For the years prior to 2009, participants were broken down into brackets in four year intervals for descriptive purposes: 2004 2008 (n=615), 1999 2003 (n=236), 1994 1998 (n= 185), 1993 1989 (n=98), 198 8 1984 (n=3), and 1983 1982 (n=4). The overall mean of years since certification for the study population, calculated as 2013 Several responses (n=8) were not clearly discernible from the response given and therefore relabeled as not discernible. For example, several responses had more than 4 numbers entered for the year. Since a response of 20012, could indicate that the participant meant to specify either year 2001, 2002, or 2012 a response such as this could not be reliably distinguished by the researcher to indicate a specific response and thus it was relabeled as not discernible. Several participants (n=63) chose not to respond to this item. Participants were also asked about re newal of certification. In a two step question, participants were first asked if they had ever renewed their specialty response item to indicate the number of the times they h ad renewed their certification(s). Approximately 32% of participants (n=858) indicated they had renewed their specialty certification, however only 31% (n=812) of participants responded to the free text response portion of the question. The mean for numb er of times each participant had renewed certification was 1.49 times with a standard deviation of .722. The majority of

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71 participants who had renewed certification, indicated they had done so only once (n=500), twice (241), or three times (n=58), while a few participants indicated they had renewed 4 (n=10), 5 (n=2), or 6 (n=1) times. Less than 1% (n=46) of participants chose not to respond to the portion of the question regarding the number of times they had renewed, although they did indicate that they h ad renewed certification. Participants in the study were also asked questions relating to the use of their specialty certification(s) in the work place. First, participants were asked whether they felt if they worked in a setting where they used their spe cialty certification. Most p articipants (n=2 321) indicated yes while less than 11.2% (n=301) selected no. Participants were also asked to indicate the percent of their work week that was spent using their specialty certification. Responses ranged from 0 100%, with a mean of 68.9% of the work week and a standard deviation of 30.77. Work Place Demographic Variables In addition to personal and certification type demographic variables, participants were also asked to indicate employment status, work place setting, and hours worked per week. The bulk of participants indicated that they were currently employed (99%, n=2 595) and worked more than 35 hours per week (n=2 438). Less than 8% of participants that reported current employment indicated they worked l ess than full time: 1.3% reported working 1 20 hours per week (n=36) and 5.4% reported working 21 34 hours per week (n=145). Participants were also asked to select the setting in which the majority of their practice took place. Nineteen preset options w ere presented. The most common settings reported were in a non military hospital settings (n=1 309), academic institution (n=413), and government/military hospital or institution (n=265). Table 4 7 depicts the

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72 frequencies of all nineteen options selected A small number of participants chose not to indicate employment status (n=55), hours worked per week (n=43), and work place setting (n=50). Descriptive Statistics After participants completed the Informed Consent section and the portion of the survey pe rtaining to basic demographic information, they were asked to complete several sub sections of the survey including information about Illness Experiences, Job Satisfaction, Self Efficacy when selecting a specialty area, and Outcome expectations pertaining to the formation of a career in their chosen specialty. Job Satisfaction Job satisfaction was measured using a form of the Generic Job Satisfaction contained 10 questions with 5 Likert style response options ranging from (1) Strongly Disagr ee to (5) Strongly Agree. All questions contained positive wording, so that a composite score could be calculated by summating responses to all the variables. For each item, as stated, the range of response was from 1 to 5. Item means (M) ranged from 3 .88 to 4.19 and standard deviations (SD) ranged from .739 to 1.102. On average, participants reported the highest levels of satisfaction with regard to getting along with their directors/ supervisors (M=4.19, SD= .739), generally feeling good about their job (M=4.05, SD=.799), and feeling close to people at work (4.03, SD= .832). Items that on average had the lowest reported levels of satisfaction included receiving recognition for a job well done (M=3.88, SD=.920), believing director supervisors were con cerned with employee well being (M=3.84, SD= 1.040), and feeling that all professional talents and skills were used at work (M=3.64, SD=1.102). Skewness

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73 statistics for all items were in acceptable levels for utilizing mean scores as measures of central ten dencies, ranging from .620 to 1.158, all with standard errors of .048. Medians for all of the job satisfaction items were 4.00. The Job Satisfaction Composite score was calculated for each participant by summating the response for each of the 10 items in the job satisfaction section. participants that completed this section of the survey (n=2577) was 39.466 with a standard deviation of 5.995. Variance for the composite scores was 35.943 and skewness was .620 with a standard error of .048. Table 4 8 visually depicts the vital descriptive statistics for each item and the calculated composite scores Illness Experiences In order to adequately answer the research questions proposed for this study, experiences with healthcare and diseases/conditions. Participants were asked a series of seven questions pertaining to health experiences. Each of the seven questions directly corresponded with one of the Board of Pharmacy Specialties specialty areas or added qualifications. For each of the questions, a h ealth care experience, disease state, or health condition was listed and followed by four response options: No I have no experience, Yes I have a personal experience, Yes I have had a family member experience this, or Yes Someone close to me has experi enced this. Participants were allowed to select as many responses to each question as they liked. The first condition participants were asked about was if they had experienced a heart attack or cardiac health problem. The majority of participants cited th ey had an

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74 experience personally (n=28), through a family member (n=1 175), or someone close (n=272). Participants were also asked whether they had experienced a serious health problem resulting from an infectious disease. Although most participants (n=1 790) had no experience, 955 participants cited experiences: personally (n=87), through a family member (n=657) or through someone close (n=211). Participants were then asked if they had experienced being administered radioactive drugs for treatment or diag nosis purposes: n=232 had personal experiences, n=835 had a family member experience and n=227 had an experience through someone close. In order to measure experiences in the ambulatory care setting, participants were asked if they ever had experienced a serious or life threatening chronic disease state: n=135 reported they had personal experience, n=1485 reported family member experiences and n=379 reported someone close to them had experience. Next participants were asked about receiving intravenous fee ding, tube feeding, or nutritional support during treatment for an illness: n=19 had personal experience, n=547 had a family member experience and n=137 had an experience through someone close to them. When participants were asked if they had experienced a psychiatric related illness : n=179 cited personal experience, n=944 cited a family member experience and n=341 cited experience through someone close. Lastly, participants were asked whether they had ever experienced a malignant disease/cancer: n=110 ha d personal experience, n=1752 had a family member experience and n=536 had experience with someone close to them. Table 4 9 visually depicts frequency of responses for each item. In addition to the aforementioned survey items, another portion of the surv ey was dedicated to measuring the impact of personal illness experiences. For this purpose,

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75 the Revised Perceived Illness Experience Scale (R PIE) was specifically adapted for this study. The scale contained 8 questions with 5 Likert style response optio ns ranging from (1) Strongly Disagree to (5) Strongly Agree, with higher scores indicating a higher impact of illness experience. All questions contained positive style wording so that a composite score could be calculated by summating responses to all the In order for participants to be prompted to complete this portion of the study, they had to they were able to complete later questions on the s urvey and skipped this portion. In total, n=556 participants indicated they had a personal illness experience sometim e in their life and completed the adapted R PIE section of the survey. For each item, the range of responses was 1 to 5. Item means ranged from 1.63 to 3.11 and standard deviations ranged from .894 to 1.274. Skewness statistics ranged from .236 to 1.526 with standard errors from .206 to .207 indicating that the mean is an acceptable measure of central tendency. Medians for each of the items ranged from 1.0 to 3.0. On l vels of The perceived illness experience composite scores ranged from 8 (indicating a ll

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76 responses were strongly disagree) to 40 (indicating all responses were strongly agree) with a mean of 18.043, a standard deviation of 6.292, and a skewness of .336. Table 4 10 visually depicts vital descriptive statistics for each of the adapted R PIE i tems and the perceived illness composite scores. Three additional questions were presented to participants at the end of the survey, pertaining to whether they felt their illness experiences still impacted their lives at the present time. For participant s that indicated they had history of a personal illness experience, 64.9% (n=364) cited they felt it still had an impact on their life today. All participants were asked whether they had a family member or someone close that ever had a chronic or serious illness. The majority of participants indicated either yes currently (n=1 113) or yes not currently (n=845). In addition, participants were asked whether they felt that this illness had an impact on their own lives today: 44.4% (n=1079) of these participan ts felt that it had some impact. Self Efficacy Self efficacy in choosing a specialty area was measured by using a Social Cognitive Career Theory instrument developed by Rogers, C reed, & Searle (2009, 2010) that was specifically adapted for this study. Th e self efficacy scale portion of the instrument contained 7 questions with 5 Likert style response options ranging from (1) Not Very Confident to (5) Highly Confident All questions contained positive wording, so a composite score could be calculated by s ummating responses to all the variables Means for each of the 7 items ranged from 3.88 to 4.30, with standard deviations ranging from .667 to .795. The median response for all of the items was 4. The range of skewness of each of the items ranged from .8 75 t o .421 with standard errors of .049, indicating that the mean is an acceptable measure of central tendency for the scale. On

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77 average, participants had the highest levels of self efficacy regarding choosing a practice area that would fit their interest s and abilities (M=4.30, SD=.667), choosing a practice area that would fulfill their expectations and goals (M=4.24, SD=.671), and choosing a practice area that would fit well with their personality type (M=4.22, SD=.703). Again, on average, the lowest in dicated levels of self efficacy were: locating valid and accurate information to help choose between equally desirable practice areas (M=3.97, SD= .772) and deciding what they were and were not ready to sacrifice in order to choose a specialty area (M=3.88 SD=.795). The composite scores for self efficacy composite score had a mean score of 28.78 (SD =4.00) and a skewness of .421. Table 4 11 visually depicts descriptive statistics for each of the items and the composite score. Outcome Expectations The outcome expectations for participants when choosing a specialty area was measured by using the Socia l Cognitive Career Theory instrument developed by Rogers, C purpose. The outcome expectations scale portion of the instrument contained 8 items with 5 Likert style response options r anging from (1) Strongly Disagree to (5) Strongly Agree. All questions contained positive wording, so a composite score could be calculated by summating responses to all the variables For each item, as stated, the range of responses was 1 to 5. Item me ans ranged from 4.04 to 4.40 and standard deviations ranged from .588 to 8.11. Skewness statistics for all items were in acceptable levels for utilizing mean scores as measures of central tendencies, ranging from .1.110 to .676 all with standard errors o f .049. Medians for all

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78 the outcome expectations items were 4.00. On average, participants reported the highest levels of outcome expectations for the specialty area selected with regard to the following expectations: be intellectually stimulating (M=4.4 0, SD= .588), provide them with work satisfaction (M=4.35, SD=.639), and let them practice clinical skills that best suited perceived abilities (M=4.35, SD=.668). Conversely, items that on average had the lowest reported levels of outcome expectations for the specialty area selected were: allow interaction with colleagues (M=4.28, SD=.709), allow the performance of a broad spectrum of skills (M=4.24, SD= .683), and provide them with a good income (M=4.04, SD=8.11). The composite score calculated for the ou tcome expectations portion of the survey had a mean of 34.28 (SD=4.273) with a skewness of .553. The range of scores 12 visually depicts the descriptive statistics for each of the items and the composite score. Test of Hypotheses seven hypotheses were tested with statistical analyses in the I BM SPSS Statistics 19 software suite and SAS statistical analysis software. For each of the wise deletion on a case by case basis. For study hypotheses other than for hypothesis five if any of the data points had a missing value in any of the fields for items included in an analysis analysis. Missing data points within hypothesis five with estimated using restricted multiple imputations methods.

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79 Hypothesis I A li near regression analysis was performed in order to examine the relationship between job satisfaction composite scores (dependent variable) and percent of time per work week spent working using specialty certification area (independent variable). The analys is revealed that percent work week of spent working in specialty certification area (M=69.02, SD=30.71) significantly predicted job satisfaction (M=39.46, SD= 5.97) in pharmacists = 38.01, t (1) = 131.64, p < .001. For every single point increase in job satisfaction, percent of work week using specialty certification increased by .020. Percent of work week spent working in specialty certification area also explained a significant proportion of variance in job satisfaction scores, R 2 = .011, F (1, 2559) = 28.23, p < .001. This analysis revealed there is a positive association between job satisfaction and time spent at work using specialty certification, meaning that pharmacists who spent a greater percentage of the work week working within their specialty area were predicted job satisfaction using this model, the job satisfaction intercept is summed with the beta coefficient of percent of work week spent in specialty multiplied by the reported percent of work week spent using specialty certification (Predicted Job Satisfaction= 38.01+ (.020 % of week spent in specialty)). For example, a board certified psychiatric pharmacist in this model reports spending 90% of their work week using their psychiatric specialty certification and is predicted to have a composite score of 39.81 out of 50 for job satisfaction. Using this same example but with a pharmacist who reports spending on ly 10% of their work week using their psychiatric specialty

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80 certification, job satisfaction level decreases in this model, yielding a lower predicted job satisfaction composite score of 38.21 out of 50 which is relatively small (3.2%) but a statistically a nd practically significant difference in terms of job satisfaction score. Hypothesis II Participants were coded in four groups depending on their responses to a survey item that asked about the voluntary nature of their specialty certification: voluntaril y certified, required to get a new job, required to certify for tenure/promotion, required to become certified as part of a position held at that time. A One Way Analysis of Variance (ANOVA) was performed in order to determine if mean job satisfaction com posite scores differed between the voluntary or required sub groups. The One Way ANOVA revealed that main effect for group was not significant, F(3, 2561) = 1.289, p = .276. The means for job satisfaction composite scores for each of the four groups were v ery simila r and are displayed in table 4 13. The majority of participants indicated that specialty certification was voluntary (n=2 306), thus the required to certify sub groups were small : required to get a new job (n=21), required for tenure or promoti on (n=69), and required as part of a position held at that time (n=169). Because the subgroups for required certification were smaller than expected, the sub groups were combined to create one broader variable with two groups: voluntary certification (n=2 306) or required to certify (n=259). Using this new variable, a new One Way ANOVA was completed in order to determine if group differences exist ed in mean job satisfaction composite scores. The analysis indicated that job satisfaction score for pharmacis ts that voluntarily certified (M=39.45, SD=6.00) were not statistically significantly different from

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81 scores for pharmacists that were required to become certified (M=39.35, SD=5.87) F(3, 2 563 ) = .060 p = 807. Hypothesis III A linear regression analysis w as completed in order to determine if job satisfaction could be predicted for pharmacists who work in their specialty area. The analysis revealed a strong positive relationship = 36.45, t (1) = 105.010, p < .001 and working with in specialty area accounte d for a significant amount of the variance in job satisfaction composite scores R 2 = .031, F (1, 2564) = 81.618, p < .00 1 Through the analysis, it was revealed that on average, a pharmacist who works in their board certified specialty area ( 3.33, p< .001 ) has a 6.5% higher job satisfaction composite score than their counterparts not working in their specialty area, calculated by: predicted job satisfaction=36.495 + 3.333 (Yes to working in specialty=1, No=0). Hypothesi s IV A linear regression analysis was completed in order to determine whether self efficacy outcome expectations were predictive of job satisfaction in pharmacists that are board certified in a specialty area. The analyses was conducted u sing job satisfaction composite score (M=39.48, SD=5.99) as the dependent variable and with the self efficacy compo site score (M=28.78, SD=3.99), o utcome expe ctation composite score (M=34.30 SD=4.27) and working in specialty area results (88.5% Yes, 11.5 % No) as the independent variables. The regression analysis revealed that the model s ignificantly predicted job satisfaction in pharmacists = 21.185, t (3) = 20.252, p = .001 The self efficacy composite scores, outcome expectations composite scores, a nd working in specialty area results also

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82 explained a significant proportion of variance in job satisfaction composite scores, R 2 = .118, F (3, 2440) = 108.56, p = .001 Through this analysis, a strong positive relationship between job satisfaction and self efficacy and outcome expectations was discovered, meaning that pharmacis ts with higher job satisfaction scores also reported higher scores for self efficacy ( .240, p<= 00 0 ) and outcome expectations ( .258, p = .001 ). Working within specialty area was al predicted job satisfaction ( 2.896, p = .001 ) in this model can by interpreted that average pharmacist s who report working in their specialty area scores 2.896 points higher on their job satisfaction composite score. Using this model, the job satisfaction intercept ( = 21.185) is summed with the beta coefficients of outcome expectations, self efficacy, and working i n specialty area to predict job satisfaction of an individual pharmacist (Predicted Job Satisfaction= 21.185+ (.240 self efficacy score) + (.258 outcome expectations score) + (2.896* working in specialty Yes=1/No=0). For example, a board certified pha rmacist in this model that works in their specialty area and scores a 28 on the self efficacy scale and a 34 on the outcome expectations scale and is predicted to have a composite score of 40 out of 50 for job satisfaction. Using this same model but with 20 on the self efficacy scale and a 26 on the outcome expectations scale yields a lower predicted job satisfaction composite score of 32.7 out of 50. This shows a 15% predicted difference i n job satisfaction composite score from their earlier counterpart which reveals statistical and practically significant differences in terms of job satisfaction scores.

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83 Hypothesis V A nalyses for a n eight test conditional multivariate binary response model were completed in order to examine the association between types of illness experiences and choosing a specialty area. For these analyses participants were coded into groups es to items regarding illness experiences were coded into a dichotomous variable. All types of illness experiences (personal, through a family member, or through a loved one) were included. For each of the specialty areas (Oncology, Psychiatric, Nutrition Support, Nuclear, Ambulatory Care, Pharmacotherapy, Pharmacotherapy Cardiology, and Pharmacotherapy Infectious Disease) eight exposures (nuclear illness experience, psychiatric illness experience, oncology illness experience, nutrition illness experience, ambulatory care illness experience, cardiology illness experience, infectious disease illness experience, and years since initial certification) were used as predictors within each test. Each test within the model was run twice, once for each of the ref erence groups (all pharmacists without that specialty certification and board certified pharmacothe r apists) when applicable. The conditional multivariate binary response model revealed that for each of the ychiatric, oncology, and nutrition support pharmacy) pharmacists had a higher likelihood of having an illness experience in that area when compared to either of the reference groups. Additionally, for each of the eight models tests the control variable of years since certification yielded statistically significant odds ratios. The test within the model that examined nuclear pharmacy revealed that nuclear illness experience exposure was associated with higher odds of becoming certified in nuclear pharmacy w hen compared against board certified that did

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84 not cho o se nuclear pharmacy certification (OR: 9.23, 95% CI: 3.54, 24.07, p < .01 1) and pharmacists board certified pharmacotherapy (OR: 9.16, 95% CI: 4.00, 20.95, p <.001). The test within the model for the psyc hiatric pharmacy specialty revealed that having a psychiatric illness experience exposure was significantly associated with higher odds of choosing the psychiatric pharmacy specialty compared against board certified that did not cho o se psychiatric pharmacy certification (OR: 4.09, 95% CI: 2.32, 7.22, p <.00 1) and pharmacists board certified pharmacotherapy (OR: 2.36, 95% CI: 1.56, 3.57, p <.00 1). illness experience exposure of onc ology was significantly associated with increased odds of selecting oncology pharmacy board certification when compared against board certified that did not cho o se oncology pharmacy certification (OR: 3.08, 95% CI: 1.63, 5.82, p <.00 5) and pharmacists that were board certified in pharmacotherapy (OR: 2. 89 95% CI: 1.90 4.40 p <. 0 01). revealed that having a corresponding illness experience exposure in nutritional support was statistically asso ciated with higher odds of choosing nutritional support pharmacy when compared against board certified that did not cho o se that pharmacy certification (OR: 2.02, 95% CI: 1.07, 3.80, p = .0292) and pharmacists board certified pharmacotherapy (OR: 1.80, 95% CI : 1.03, 3.14, p =.0390). For the nuclear, psychiatric, and oncology specialty areas, tests also revealed that ambulatory care illness experience exposure was associated with decreased odds of choosing that particular specialty area with odds ratios ranging from 0.36 to 0.58 with p values less than 0.05

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85 when compared to board certified pharmacists in other specialty areas The full results 4 14 differed in terms of ambulatory care illness experience exposure was not statistically associated with becoming a board certified ambulatory care specialist (OR=1.12, 95% CI: 0.78, 1.62, p = .5375 ) when compared with the pharmacotherapy reference group. However, psychiatric illness experience exposure was significantly asso ciated with choosing the ambulatory care pharmacy specialty when compared to the pharmacotherapy reference group (OR=1.40, 95% CI: 1.02, 1.93, p = .0376). In order to examine the impacts of illness on specialty certification type, the pharmacotherapy specia lty was broken down into three parts: pharmacotherapists with an added qualification in cardiology, pharmacotherapists with an added qualification in infectious disease, and pharmacotherapists without any added qualification. Similar to the results for ambulatory care pharmacy, for the pharmacotherapy specialty area the only significant predictor in terms of exposures was psychiatric illness experience, which was associated with an increase in odd s of selecting pharmacotherapy (OR=1.73, 95% CI: 1.11, 2.72, p = .0161) when compared to all other pharmacists that did not have certification in pharmacotherapy. Within pharmacotherapy added qualifications of cardiology and infectious d isease no statisticall y significant associations with exposures of illness experiences w ere detected within the model. The full results of the model for 15.

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86 Hypothesis VI Using the previously coded variable of Illness in Specialty, regression analyses were completed in order to determine the relationship between self efficacy, outcome expectations, and choosing to become board certified in a specialty area after having an illness experience in that specialty area. The logistic regression analysis for the specific type board certified specialties revealed that self efficacy composite scores (M=29.13, SD=3.88) and outcome expectations composite scores (M=34.44, SD=4.22) significantly predicted Illness in Specialty among pharmacists (n=564) that were board certified in oncology, nutrition support, nuclear, and psychiatric pharmacy specialties in our model 2 ( df =2 ) = 8.64, p=.013 R 2 =.015, 2Log=773.205). See Table 4 15 for values for each variable in the statistical analys is. As shown in table 4 15, holding outcome expectations composite score constant, self efficacy composite score is negatively and significantly related to Illness in Specialty. Self self efficacy composite the odds, (Exp(B) 1 )*100, that pharmacists having been certified in the same area as their illness experience decreases by 6.2%. Contrastingly, o utcome expectations composite score had a strong positive relationship with Illness i n S pecialty holding self efficacy composite score constant. The odd ratio of 1.056 indicated that for every single point increase in outcome expectations composite score, the pharmacist has a 5.6% increase in the odds of being certified in the same special ty area as their illness experience. Identical regression analyses were conducted for pharmacists that were board pharmacotherapy cardiology, and pharmacotherapy infectious diseas e). For

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87 pharmacist s in the ambulatory care pharmacy specialty, the logistic regression analysis, 2 ( df =2 ) = 16.168, p< .001 R 2 =.007, 2Log=1007.210, revealed that self efficacy composite scores had a strong positive relationship with Illness in S pecialty ( .095, efficacy indicates that for every point increase in self efficacy composite score, the ambulatory care pharmacists had a 10% increase in odds of having an illness exp erience in their specialty. The outcome expectations composite score estimates were extremely small and not significantly related to illness in specialty ( .001, p=.979). For board certified pharmacotherapists with added qualifications, logistic regres sion analyses were completed separately for cardiology and infectious disease groups. The analysis for pharmacists with the cardiology added qualification revealed no significant relationship between Illness in Specialty, outcome expectations, and self ef ficacy composite scores, 2 ( df =2 ) = 5.602, p=.061, R 2 =.002, 2Log=226.736. The analysis for pharmacists with the infectious disease added qualification revealed relationships between variables contrasting to those in ambulatory care pharmacy ( df =2 ) = 12.249, p=.002, R 2 =.005, 2Log=190.787. Holding self efficacy composite score constant, outcome expectations ( .257, p=.003) had a significant positive relationship with Illness in S pecialty. The odd ratio of 1.294 indicates that for every single poi nt increase in outcome expectations composite score, the odds of being certified in pharmacotherapy with an added qualification of infectious disease increased by 29%. Contrastingly, self efficacy composite scores holding outcome expectations constant, had a small negative non significant relationship with illness in specialty ( .042, p=.541)

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88 Hypothesis VII A regression analysis was completed in order to determine whether self efficacy composite score, outcome expectations composite score, perceived illne ss experience composite score, and working in specialty area were predictive of job satisfaction. The analyses w ere conducted using job satis faction composite score (M=39.00, SD=6.534 ) as the dependent variable and with the self efficacy compo site score ( M=28.62, SD=4.02) o utcome expe ctation composite score (M=34.61 SD=4. 06 ) perceived illness composite score (M=18.03 SD= 6.32 ) and working in specialty area (87.5% Yes, 12.5% No) as the independent variables. The linear regression model was significant = 22.978, t (4) = 8.053, p < .001 at predicting job satisfaction and the dependent variables explained a significant amount of variance in job satisfaction, R 2 = .154, F (4, 529) = 24.01, p < .001 Job satisfaction composite scores had a positive signifi cant relationship with self efficacy composite scores ( .158, p =.035), outcome expectations composite scores ( .370 p<.0 0 1 ), and working in specialty area ( 1.985, p<.013). Contrastingly, perceived illness experience composite scores had a negative significant relationship ( .168, p <.00 1 ) with job satisfaction composite scores in the model. Summary The purpose of this chapter was to review data collection procedures, describe sample demographics, provide descriptive statistics of key variables, a nd to test study hypotheses. Sample demographics were presented in sections: general demographics, specialty certification demographic variables, and work related demographics. Descriptive statistics for key study variables were broken down into four mai n sections: illness experience variables, job satisfaction, self efficacy, and outcome expectations.

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89 each of the hypothesis, extensive data analyses were conducted in order to provide of the findings presented in this chapter will be presented.

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90 Table 4 1 Mean difference in responder g roups Key Study Var iables M1* M2* T Sig. Mean Difference Std. Error 95% CI Job Satisfaction Composite 39.45 39.46 .050 .961 .01 .31 .62, .59 Self Efficacy Composite 28.78 28.85 .368 .713 .07 .20 .48, .33 Outcome Expectations Composite 34.33 34.11 .958 .338 .21 .22 .22, .66 Perceived Illness Experience Composite 18.06 17.95 .163 .871 .11 .71 1.29, 1.52 *M1=Early Responder Group, M2= Late Responder Group Table 4 2 Sample population g ender Gender N Percent Male 825 30.8 Female 1 819 68.0 Did Not Indicate 32 1.2 Total 2676 100.0 Table 4 3 Sample population ethnic group c lassification Race/ Ethnic Group N Percent American Indian/Alaskan Native 11 .4 Black/African American 62 2.3 Asian/Pacific Islander 253 9.5 Mexican American 19 .7 Puerto Rican (Mainland) 13 .5 Other Hispanic 40 1.5 White/Caucasian 2 180 81.5 Other 50 1.9 Did Not Wish to Indicate 48 1.8 Total 2 676 100.0

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91 Table 4 4 Sample population c ountries of r esidence Country N United States 2 504 Australia 5 Belize 1 Bermuda 1 Canada 31 Egypt 7 France 1 Germany 2 Hong Kong 4 Japan 1 Lebanon 3 Malaysia 5 Qatar 1 Saudi Arabia 11 Scotland 1 Singapore 9 South Korea 3 Spain 13 Sudan 2 Switzerland 2 Taiwan 1 Thailand 5 United Arab Emirates 3

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92 Table 4 5 Study population specialty c ertifications Specialty Certification Raw Frequency Percent Pharmacotherapy 2,041 76.3 Nuclear 53 2.0 Psychiatric 123 4.6 Oncology 234 8.7 Nutrition Support 75 2.8 Ambulatory 215 8.0 Nuclear 53 2.0 Infectious Disease AQ 35 1.3 Cardiology AQ 32 1.2 Total 2738

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93 Table 4 6 Study p opulation m ultiple specialty t ypes Multi Specialty Types Frequency Psych Pharm 13 Onc Pharm 31 Nutrition Pharm 19 Nutrition Psych Pharm 1 Amb Pharm 31 Amb Psych 1 Amb Nutrition Onc Psych Pharm 1 Total 97 Key: Psych=Psychiatric, Pharm=Pharmacotherapy, Onc =Oncology, Nutrition=Nutritional Support, Amb=Ambulatory Care Table 4 7 S ample population work place settings Setting Frequency Percent Academic Institution 413 15.4 Ambulatory Care Clinic 194 7.2 Cancer Center 70 2.6 Community Pharmacy, Chain 26 1.0 Community Pharmacy, Independent 17 .6 Correctional Facility 1 .0 Drug Information Center 14 .5 Government/Military Hospital/Institution 265 9.9 Hospital, Community for Profit 108 4.0 Hospital, Community Not for profit 671 25.1 Hospital, University 227 8.5 Hospital, University Affiliated 303 11.3 Home Health Care 18 .7 Intermediate Care Facility 3 .1 Long Term Care 14 .5 Managed Health Care 97 3.6 Pharmaceutical Industry 54 2.0 Psychiatric Hospital/Facility 16 .6 Other 115 4.3 Did Not Indicate 50 1.9 Total 2 676 100.0

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94 Table 4 8 Job s atisfact ion d escriptive s tatistics Survey Item Mean Standard. Deviation Variance Skewness I receive recognition for a job well done 3.88 .920 .846 1.158 I feel close to people at work 4.03 .832 .692 1.083 I feel good about working for my employer 3.98 .895 .801 1.105 I feel secure about my job 3.97 .934 .872 1.056 I believe my direct supervisor is concerned about my well being 3.84 1.040 1.082 .975 On the whole, I believe work is good for my physical health 3.93 .920 .847 .979 I feel that my financial compensation is good 3.93 .893 .797 1.174 All of my professional talents and skills are used at work 3.64 1.102 1.213 .729 I get along with my director/supervisors 4.19 .739 .546 1.238 I feel good about my job 4.05 .799 .638 1.097 Job Satisfaction Composite 39.446 5.9952 35.943 .620 Item scores possible range is 1 5, composite score possible range is 10 50.

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95 Table 4 9 Frequency of health experiences in s ample p opulation Health Condition Raw Frequency Heart Attack/Cardiac Health Problem No 1 316 Yes Personally 28 Yes A family member 1 175 Yes Someone close 272 Serious Infectious Disease No 1 790 Yes Personally 87 Yes A family member 657 Yes Someone close 211 Been Administered Radioactive Drugs No 1 565 Yes Personally 232 Yes A family member 835 Yes Someone close 227 Serious/Life Threatening Chronic Disease State No 961 Yes Personally 135 Yes A family member 1 485 Yes Someone close 379 Intravenous/ Tube Feeding/Nutritional Support No 1 947 Yes Personally 19 Yes A family member 547 Yes Someone close 137 Psychiatric Related Illness No 1 426 Yes Personally 179 Yes A family member 944 Ye Someone close 341 Malignant Disease/Cancer No 644 Yes Personally 110 Yes A family member 1 752 Yes Someone close 536

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96 Table 4 10 Descriptive statistics for R PIE adaptation in sample p opulation Item Mean Std. Deviation Variance Skewness Median I feel/felt left out of things at work 2.10 1.077 1.161 .701 2.0 me because of my illness 1.63 .894 .800 1.526 1.0 like to be reminded of my illness 2.59 1.257 1.579 .133 3.0 I only tell people about my illness if I really have to 3.11 1.274 1.624 .236 3.0 My illness stops/stopped me from doing activities I like 2.49 1.342 1.801 .340 2.0 I am not always able to join in with what my peers are doing 2.12 1.212 1.469 .778 2.0 My family makes/made a fuss of me because of my illness 1.92 1.045 1.092 .995 2.0 My illness makes/made many problems in my personal life 2.10 1.129 1.275 .802 2.0 Perceived Illness Experience Composite 18.043 6.292 39.591 .336 18.0 Item scores possible range is 1 5, composite score possible range is 8 40.

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97 Table 4 11 Descriptive statistics for s elf efficacy in s ample p opulation Survey Item Mean Std. Deviation Variance Skewness Choose a practice area that would fulfill your expectations and goals 4.24 .671 .450 .849 Choose a practice area that would fit well with your personality (e.g. extrovert introvert) 4.22 .703 .495 .798 Choose a practice area that would enable you to live the type of lifestyle you desire 4.09 .766 .587 .875 Choose a practice area that would fit your interests and abilities 4.30 .667 .444 .915 Decide what you are and are not ready to sacrifice in order to choose a practice area 3.88 .795 .632 .485 Decide what you value most in your pharmacy career 4.09 .748 .560 .771 Locate valid and accurate information to help you choose between equally desirable practice areas 3.97 .772 .596 .628 Self Efficacy Composite 28.78 4.003 16.026 .421 Item scores possible range is 1 5, composite score possible range is 7 35.

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98 Table 4 12 Descriptive statistics for outcome e xpectations in s ample p opulation Survey Item Mean Std. Deviation Variance Skewness Be intellectually stimulating 4.40 .588 .346 .676 Provide you with work satisfaction 4.35 .639 .409 .920 Allow you interaction with your colleagues 4.28 .709 .503 1.110 Let you practice clinical skills that best suit your perceived abilities 4.35 .668 .447 1.083 Provide you with a good income 4.04 .811 .658 1.032 Allow you to perform a broad spectrum of skills 4.24 .683 .466 .977 Be compatible with your interests 4.33 .636 .404 .872 Allow you to achieve your desired professional success 4.29 .677 .458 .956 Outcome Expectations Composite 34.28 4.273 18.265 .553 Item scores possible range is 1 5, composite score possible range is 8 40.

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99 Table 4 13 Job satisfaction composite scores by voluntary certification status group N Mean Std. Deviation Std. Error Voluntary 2 306 39.4549 6.00780 .12511 Required to certify for tenure/promotion 69 38.2029 6.23458 .75056 Required to get a new job 21 39.0952 6.51847 1.42245 Required as part of a position held at that time 169 39.8639 5.60074 .43083 Total 2 565 39.4452 5.99329 .11834

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100 Table 4 14 Conditional multivariate binary response model for specific type specialty areas Reference Group: All Others Who Did Not Take Test Reference Group: Those Who Took PHA Test Test Exposure OR 95% CI p value OR 95% CI p value nuc xnuc 9.23 (3.54, 24.07) < .000 1 9.16 (4.00, 20.95) <.0001 nuc xpsy 1.33 (0.61, 2.92) 0.4725 0.77 (0.41, 1.46) 0.4193 nuc xonc 0.68 (0.24, 1.91) 0.4604 0.64 (0.27, 1.51) 0.3034 nuc xnut 1.87 (0.82, 4.27) 0.1370 1.67 (0.86, 3.23) 0.1295 nuc xamb 0.39 (0.15, 1.01) 0.0523 0.59 (0.27, 1.31) 0.1960 nuc xcar 0.85 (0.38, 1.93) 0.7047 0.75 (0.39, 1.47) 0.4066 nuc xinf 0.96 (0.40, 2.27) 0.9182 1.07 (0.54, 2.15) 0.8434 nuc nyrs 1.32 (1.25, 1.40) <.0001 ----------------------psy xnuc 1.61 (0.90, 2.90) 0.1077 1.60 (1.05, 2.45) 0.0298 psy xpsy 4.09 (2.32,7.22) <.0001 2.36 (1.56, 3.57) 0.0001 psy xonc 1.34 (0.66,2.72) 0.4230 1.26 (0.74, 2.12) 0.3933 psy xnut 0.72 (0.38,1.34) 0.2966 0.64 (0.40, 1.03) 0.0647 psy xamb 0.36 (0.19, 0.67) 0.0013 0.54 (0.34, 0.85) 0.0087 psy xcar 1.25 (0.70, 2.21) 0.4464 1.10 (0.72, 1.68) 0.6530 psy xinf 0.84 (0.45, 1.55) 0.5733 0.94 (0.60, 1.47) 0.7837 psy nyrs 1.18 (1.13, 1.24) <.0001 ----------------------onc xnuc 0.65 (0.39, 1.08) 0.0979 0.64 (0.46, 0.89) 0.0080 onc xpsy 1.51 (0.93, 2.45) 0.0937 0.87 (0.64, 1.18) 0.3706 onc xonc 3.08 (1.63, 5.82) 0.0005 2.89 (1.90, 4.40) < .0001 onc xnut 1.60 (0.95, 2.69) 0.0782 1.42 (1.03, 1.97) 0.0349 onc xamb 0.58 (0.34, 0.99) 0.0479 0.88 (0.63, 1.23) 0.4483 onc xcar 0.76 (0.47, 1.25) 0.2838 0.67 (0.49, 0.92) 0.0128 onc xinf 0.55 (0.31, 0.96) 0.0369 0.62 (0.43, 0.89) 0.0098 onc nyrs 1.13 (1.08, 1.17) <.0001 ----------------------nut xnuc 0.73 (0.38, 1.39) 0.3331 0.72 (0.40, 1.28) 0.2663 nut xpsy 1.25 (0.69, 2.28) 0.4643 0.72 (0.42, 1.23) 0.2333 nut xonc 0.96 (0.47, 1.97) 0.9113 0.90 (0.48, 1.68) 0.7451 nut xnut 2.02 (1.07, 3.80) 0.0292 1.80 (1.03, 3.14) 0.0390 nut xamb 0.59 (0.30, 1.17) 0.1329 0.89 (0.49, 1.64) 0.7171 nut xcar 0.83 (0.45, 1.55) 0.5611 0.73 (0.42, 1.28) 0.2719 nut xinf 1.09 (0.56, 2.14) 0.7941 1.23 (0.68, 2.22) 0.4983 nut nyrs 1.22 (1.17, 1.28) < .0001 ----------------------Key: Tests =types of specialty certification : nuc= nuclear, psy=psychiatric, onc=oncology, nutr=nutrition ; Exposures =types of illness experiences : xnuc= nuclear, xpsy=psychiatric, xonc=oncology, xnutr=nutrition xamb =ambulatory care, xcar=cardiology, xinf=infectious disease nyrs= number of years since initial certification; PHA=pharmacotherapy specialty area

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101 Table 4 15 specialty areas Reference Group: All Others Who Did Not Take Test Reference Group: Those Who Took PHA Test Test Exposure OR 95% CI p value OR 95% CI p value pha xnuc 1.01 (0.63, 1.62) 0.9733 ----------------------pha xpsy 1.73 (1.11, 2.72) 0.0161 ----------------------pha xonc 1.06 (0.61, 1.87) 0.8286 ----------------------pha xnut 1.12 (0.69, 1.82) 0.6408 ----------------------pha xamb 0.66 (0.40, 1.09) 0.1061 ----------------------pha xcar 1.13 (0.72, 1.79) 0.5899 ----------------------pha xinf 0.89 (0.54, 1.48) 0.6542 ----------------------pha nyrs 1.08 (1.04, 1.12) 0.0001 ----------------------amb xnuc 0.96 (0.58, 1.59) 0.8673 0.95 (0.68, 1.33) 0.7651 amb xpsy 2.43 (1.50, 3.95) 0.0003 1.40 (1.02, 1.93) 0.0376 amb xonc 1.08 (0.60, 1.97) 0.7940 1.02 (0.69, 1.50) 0.9293 amb xnut 0.94 (0.55, 1.60) 0.8177 0.84 (0.58, 1.21) 0.3451 amb xamb 0.75 (0.43, 1.28) 0.2859 1.12 (0.78, 1.62) 0.5375 amb xcar 1.05 (0.64, 1.72) 0.8485 0.93 (0.67, 1.29) 0.6444 amb xinf 0.84 (0.49, 1.44) 0.5223 0.94 (0.66, 1.34) 0.7362 amb nyrs 0.83 (0.77, 0.89) <.0001 ----------------------car xnuc 1.51 (0.59, 3.81) 0.3876 1.49 (0.67, 3.32) 0.3248 car xpsy 1.36 (0.57, 3.27) 0.4917 0.78 (0.37, 1.66) 0.5263 car xonc 0.54 (0.18, 1.62) 0.2742 0.51 (0.20, 1.31) 0.1602 car xnut 1.23 (0.49, 3.12) 0.6562 1.10 (0.50, 2.42) 0.8135 car xamb 1.21 (0.38, 3.83) 0.7482 1.82 (0.64, 5.15) 0.2603 car xcar 1.71 (0.66, 4.45) 0.2713 1.51 (0.65, 3.50) 0.3376 car xinf 1.60 (0.62, 4.09) 0.3285 1.79 (0.81, 3.96) 0.1491 car nyrs 1.19 (1.11, 1.27) <.0001 ----------------------inf xnuc 0.65 (0.26, 1.59) 0.3438 0.64 (0.30, 1.39) 0.2606 inf xpsy 1.43 (0.61, 3.31) 0.4091 0.82 (0.40, 1.69) 0.5947 inf xonc 1.48 (0.51, 4.33) 0.4716 1.39 (0.56, 3.50) 0.4802 inf xnut 0.86 (0.33, 2.26) 0.7659 0.77 (0.33, 1.78) 0.5399 inf xamb 0.97 (0.36, 2.58) 0.9457 1.46 (0.62, 3.43) 0.3907 inf xcar 0.88 (0.37, 2.08) 0.7647 0.77 (0.37, 1.62) 0.4949 inf xinf 1.37 (0.55, 3.38) 0.5010 1.53 (0.72, 3.28) 0.2724 inf nyrs 1.17 (1.10, 1.26) <.0001 ----------------------Key: Tests =types of specialty certification : pha=pharmacotherapy, amb=ambulatory care, car=cardiology, inf=infectious disease; Exposures =types of illness experiences : xnuc= nuclear, xpsy=psychiatric, xonc=oncology, xnutr=nutrition xamb=ambulatory care, xcar=cardiology, xinf=infectious disease nyrs= number of years since initial certification; PHA=pharmacotherapy specialty area

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102 Table 4 16. Logistic regression a nalysis for p redicting i llness in s pecialty Variable B S.E. Wald df Sig. Exp(B) Self Efficacy Composite .064 .025 6.648 1 .010 .938 Outcome Expectations Composite .055 .023 5.533 1 .019 1.056 Constant .010 .792 .000 1 .989 1.011

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103 CHAPTER 5 STUDY DISCUSSION AND CONCLUSIONS Overview The purpose of this study was to identify and explore the relationship between internal and external motivational factors that may influence pharmacists to obtain board certification in a specialty area. The main research objectives for this study were to (1) explore the relationships between motivational factors (2) investigate the differences in motivational factors between pharmacists in generalist specialty areas an d pharmacists in more concentrated specialty areas and (3) examine whether personal life experiences serve as motivational influences in terms of selecting a specialty area Additional study objectives were to (4) differentiate motivational factors and c hosen specialties for those required to become certified for career purposes and tho se who voluntarily specialize and (5) determine whether differences exist in job satisfaction for pharmacists in the different specialty areas. In this chapter, an overvi ew of the data analyses are discussed in terms of the study hypotheses. After addressing each study hypothesis, the theoretical impacts of these findings are examined. Lastly, the study limitations and the study conclusion close this chapter. Discussion of Research Findings In this study, seven hypotheses were tested in order to investigate the motivational influences for obtaining specialty certification in board certified pharmacists. The first four hypotheses in this study pertained to constructs and a spects of Social Cognitive Career Theory ( Lent et. al, 1994 ). The analyses performed for hypothesis V pertained to intrapersonal or shared illne ss experiences and how they

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104 were associated with ses proposed and tested the convergence between the two underlying motivational theories of the study: Social Cognitive Career Theory and the illness experience construct. For six of the seven study hypotheses, analyses provided enough information to rejec t the null hypotheses in at least one of the groups of pharmacists analyzed. Social Cognitive Career Theory In order to investigate the impact of motivational influences in the career lives of pharmacists that are board certified in a specialty area, Soci al Cognitive Career Theory (Lent et. al, 1994, Lent & Brown, 1996 Lent & Brown, 2008) was utilized to theorize how several factors may interplay and impact each other. For this purpose, each of the key constructs in Social Cogn itive Career Theory (SCCT) w as operationalized so that it could be assessed in our study population. In this study, job satisfaction was examined in terms of its relationships with self efficacy, outcome expectations, and goal seeking and goal participation activities. Both self e fficacy and outcome expectations in the study population were measured through scales originally developed and validated by Rogers, Creed & and adapted for this specific study through focus groups and expert review. Both of these sca les provided summated scores which indicate each of self efficacy and outcome expectations pertaining to their future career at the time they decided to become board certified in a specialty area. Job satisfaction was measured by using the full version of the Generic Job Satisfaction Scale developed by Macdonald & McIntyre (1997) with specific wording adaptations for this study. Goal seeking and goal participation behaviors were operationalized into three possible domains: percent of wor k week spent using specialty certification,

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105 voluntary or required reason for seeking certification, and whether pharmacist s report they work in their specialty area. In SCCT, it is theorized that participation in and progression of goal directed activiti persistence, and participation in goal setting and goal making behaviors ideally lead to having a higher level of job satisfaction. Contrastingly, weak commitment, goal absence, and f ailure at goal achievement theoretically result in lower levels of job satisfaction operationalizing goal behaviors since it is thought to have such a large impact on job satisfaction and therefore also motivational forces. Under fairly conservative reasoning, it is assumed that most pharmacists in this study either currently have or at one point had a goal to function as a board certified pharmacist in their specialty ar ea of choice. Under this assumption, the operationalization of goal participation would be any behavior that is either part of a choice pertaining to using their specialty certification on a regular basis (i.e. selection of a work setting where the specia lty certification is utilized) or choice of work/practice setting that is consistent with specialty certification area (i.e. selecting to work in a specialty setting that corresponds with specialty certification). Likewise progress for goal directed activi ty would be operationalized as any behavior that promotes goal reaching in the future (i.e. voluntarily becoming a board certified specialist rather than being required to be certified for any reason other than a personal or professional goal). Two hypot heses in this study were aimed at operationalizing goal participation

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106 reported p ercent of work week using their specialty certification. Using a linear regression, data analysis revealed the relationship between these two variables was both positive ( .20) and statistically significant ( p < .001 ), so the null hypothesis was participation. In this hypothesis it was theorized that job satisfaction would be positively associated with board certified pharmacists reporting that they worked within their spe cialty area. A linear regression analysis revealed the relationship between these two constructs was both positive ( =3.33) and statistically significant ( p < 00 1 ), thus providing enough evidence to reject the null hypothesis. Both findings are importan t because percent of work week spent using specialty produce the significant results of goal participation behaviors in the sample population. For both of the models for goal part icipation that were estimated a significant proportion of the variance in job satisfaction was explained, however percent of work week spent using specialty certification ( R 2 = .011, F (1, 2559) = 28.23, p = .001.) explained a smaller amount of variance th an working within specialty area ( R 2 = .031, F (1, 2564) = 81.618, p < .001 ). Ideally, if both of these variables were independent of one another, both variables could be added into a model to represent different facets of goal behaviors. However, it co uld be postulated that percent of work week spent using specialty In order to explore this idea, a model was constructed using both of these variables to predict job satisfaction. While this model did have adequate fit, F (2, 2548)

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107 = 39.59, p <.001 the adjusted R 2 value which penalizes models based on addition of variab percent of work week using specialty certification into the model where working in specialty area predicted job satisfaction. Additionally, the model revealed that controlling for working in specialty area, percent of work week spent in specialty area was no longer a statistically significant predictor of job satisfaction ( .008, p =.06). Considering these findings, working within specialty area is a statistically superior repr esentation of goal participation in its relationship to job satisfaction. During data collection, pharmacists were asked to indicate whether becoming board certified in a specialty area was voluntary, required for promotion or tenure, required to obtain a new job, or required as part of the position they held at that time. In this study, goal setting and goal progression measurements were attempted through this variable of voluntary certification status. In hypothesis II, it was postulated that pharmacists who become board certified independent of work requirements would report higher levels of job satisfaction than pharmacists who certified to fulfill job requirements. The one way Analysis of Variance (ANOVA) that was conducted to examine differences in j ob satisfaction score between the voluntary and required sub classifications found no significant differences in mean scores among the four groups F(3, 2561) = 1.289, p = .276. As was previously mentioned in Chapter 4, the means for each of the subgroups were very similar with the mean differences ranging from .41 to 1.65. Considering the close mean scores for each of the groups and the finding that the required sub classifications contained only a small percentage of the total participants in the study, an additional one way ANOVA was completed using the same variables, but

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108 combining all the required subgroups into a single group. This second one way ANOVA compared mean job satisfaction scores between voluntary and required groups and again found no sign ificant mean differences, F(3, 2 563 ) = .060 p = 807. The inability of these two analyses to provide evidence of statistically significant differences indicates that several things may have occurred. Firstly, a possible explanation for retaining the nul l hypothesis is that this survey item may not be actually representative of the construct of goal setting and goal progression that it was attempting to operationalize. Secondly, the inability to detect mean difference s could possibly be attributed to sur vey question structure. P articipants were only allowed to indicate one response for this item which may have encouraged pharmacists who had multiple influences (i.e. latent personal desire and a new career opportunity requiring specialty certification) to misclassify themselves as voluntary certifiers, leading to mis classification of exposure (voluntary or required) group status. If this misclassification exposure did occur, it would dilute the group means, making the groups seem more similar than they re ally are in reality, which in turn would lead to bias towards the null hypothesis of no group differences existing. The final hypothesis pertaining strictly to motivational influences under SCCT was an overall model for predicting job satisfaction using Lent & Brown (2008) theorized that job satisfaction, a domain of subjective well being, is the eventual product of self efficacy expectations, outcome expectations, and participation/progression in goal directed activities. Acco rding to this theory, positive construct forces (i.e. high levels of self efficacy, outcome expectations, and progressive

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109 goal behaviors) lead to high levels of subjective well being in the context of work (i.e. job satisfaction). Under Hypothesis IV it w as theorized that job satisfaction would be predicted and positively associated with outcome expectations, self efficacy, and goals. Self efficacy, outcome expectations and job satisfaction in this model were operationalized using their composite scores on their respective survey scales as measures of the constructs. dichotomous variable of working within area of specialty certification. The linear regression analysis that was comp leted for this hypothesis revealed a significant overall model for predicting job satisfaction ( R 2 = .118, F (3, 2440) = 108.56, p < .001 .). In addition, each of the variables in the model were positively related to and statistically significant predictors of job satisfaction, which indicated that the null hypothesis should be rejected. A step wise liner regression model was completed post hoc to ensure that each variable added additional valuable information to the model for job satisfaction. Using the original model of working in specialty certification area proposed in hypothesis III ( R 2 = .030) as the baseline model, adding self efficacy to the model increased the proportion of variance accounted for by .062 ( Adjusted R 2 = .092). Additionally, adding the third variable of outcome expectations to the model also led to an increase in the proportion of variance in job satisfaction accounted for in the by .026 ( Adjusted R 2 = .117). ed in the study population of pharmacists with board certification in a specialty area. Using

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110 the constructs and theories presented in SCCT, this study was able to predict both relationship and direction of association between the main constructs of job satisfaction, outcome expectations, self efficacy and goals. The total amount of variance in job satisfaction composite scores in this overall model was approximately 12%. It is of important note that each variable added some modest predictable value to the model, in that each of the constructs improved overall model fit. Illness Experiences In addition to utilizing Social Cognitive Career Theory, this study also utilized sick role el as a theoretical basis for forming an Illness Experience concept. Instead of focusing on personal behavior and intentions like SCCT does, the illness experience is a perception of and actions throughout an illness related event within physical emotional, social, and spiritual contexts This illness experience concept functioned in this study to explain theoretically motivational predispositions for becoming a pharmacist who is board certified in a specialty area via subjective life experiences with diseases, illnesses, and health care events. Combining this theoretical construct of illness experience with the results of a number of other research studies found significant motivational relationships between illness experiences and choice of hea lth care specialty (Ventre et. al, 1995, Ulrich, 2009 ). It is of importan ce to note that for all specialty groups, all types of illness experiences were treated equally in terms of analysis of exposure status In all the tests within the proposed model f or hypothesis five any illness experience reported in a specialty area w as include d in the illness experience variable construction, meaning that regardless of whether the origin of the experience was personal or experienced by a

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111 family member or someone close, the pharmacists were coded as having an illness illness experience construct underlying theoretical assumptions that illness experiences can be internal (per sonal) or they can be external (second hand experiences). The first hypothesis tested related to ill ness experience was hypothesis five which pre dicted that pharmacists that were board certified in a specialty area that had an illness experience cho se to become certified in a specialty area corresponding with their illness. In order to adequately test this prediction, an 8 test conditional multivariate binary response model were estimated. This model estimated odds ratios, confidence intervals, and p values for the likelihood of the outcome occurring (choosing each board certification specialty area) when positive exposure status (illness experience) was indicated by the pharmacist. Eight tests were run in the model, one for pharmacotherapy, pharmacotherapy with cardiology added qualification and pharmacotherapy with infectious di sease added qualification. Each of the eight tests contained nine predictor variables: the exposure statuses of nuclear illness experience, psychiatric illness experience, oncology illness experience, nutrition illness experience, ambulatory care illness e xperience, cardiology illness experience, infectious disease illness experience, and as well as the control variable of years since initial certification. The 8 test conditional multivariate binary response model revealed significant associations between illness experience s and corresponding specialty areas for each Oncology ( OR: 2.89, 95% CI: 1.90, 4.40,

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112 p <.0 01), Nuclear ( OR: 9.16, 95% CI: 4.00, 20.95, p <.0 01) P sychiatric ( OR: 2.36, 95% CI: 1.56, 3.57, p <.0 01) and Nutritional Support pharmacy specialties ( OR: 1.80, 95% CI: 1.03, 3.14, p =.0390 ). Since each of these tests within the model revealed that having an illness experience exposure in a certain area statistically increased the odds of being certified in a corresponding specialty the null hypotheses were rejected in each of the was also revealed that having an exposure to an ambulat ory care related illness experience was modestly associated with decreased odds of choosing that particular specialty area with odds ratios ranging from 0.36 to 0.58 with p values less than 0.05 when compared to board certified pharmacists in other special ty areas. These results or life threatening health condition reduced the likelihood of holding specialty certification within nuclear, psychiatric, and oncology specialty areas. One possible explanatio n for these results is that pharmacists who specialty areas. Another possible reason for this association is that the exposure status of ambulatory care may be indicative of ou tside factors that would prevent pharmacists health status and lack of capability to work in a more demanding work environment. pharmaco therapy without added qualifications, pharmacotherapy with an added qualification in cardiology and pharmacotherapy with an added qualification in infectious disease

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113 illness experie nces and choosing a specific certification. Thus, the null hypotheses in these tests were retained, indicating that the evidence provided in this was not sufficient in demonstrating relationships between the exposures and outcome variables for these al As expected a priori, the impact and measurement of specific illness states in very broad areas of specialties was ambiguous. Although exhaustive focus group discussion was dedicated to operationalizing specific illnesses that per tained to each specialty area, the illnesses that were indicated were still somewhat vague in nature. For Ambulatory Care pharmacy, illness experience in Have you personally, a family member or an individual close to you ever received treatment for a serious or life While this definition of measurement may partly cover the Ambulatory Care pharmacy specialty area, it mostly was not all encompassing to every aspect of the specialty area. Likewise, the Pharmacotherapy specialization proposed similar issues with measur ing and defining a corresponding illness state or health care experience that was specific and comprehensive to the specialty area. Pharmacotherapy is indisputably the discuss experiencing any adverse drug related events or morbidities, citing that it was by large not directly related to what they felt the pharmacotherapy specialty area encompassed. After copious discussion in the focus groups, it was determined that no single set of illnesses or experiences could cover the broad range of what areas Pharmacotherapy

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114 entails. Instead it was decided that Pharmacotherapy would be broken down into two small gro ups within the specialty population according to added qualification status. The statistically insignificant findings in the general type specialty groups may be the result of one of two possibilities. The first and most likely explanation is that the stud y failed to operationalize the illness in specialty variable for these groups. Although special attention was paid to constructing and validating these illness experience areas for the general type specialty group, the study failed to adequately operationa lize the illness in specialty variable for these groups thus resulting in a violation of construct validity. Another possible explanation for these results, assuming that the construct validity of illness in specialty area was not violated, is that there may be no actual relationship between having an illness experience and choosing to certify in the corresponding areas of pharma cotherapy and ambulatory care. The paper by Hepler (1993) on pharmacy specialty areas and pharmaceutical care openly criticized t he Pharmacotherapy specialty in dicating that Pharmacotherapy as a specialty entailed the general pharmaceutical care principles that should be practiced in all clinical pharmacy specialties not only in one specialty area Using this same line of reasoning, it could be suggested that a possible explanation for the lack of relationship in this analysis is that Pharmacotherapy and Ambulatory Care may not actually be specialty areas in terms of clinical practice therefore motivational forces, especially those pertaining to illness Convergence of Theoretical Models The last two hypotheses in this study tested the convergence of the underlying theoretical frameworks of the illness experiences and Social Cognitive Career Theory

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115 (SCCT) as motivational influences. In SCCT, ( Lent et. al, 1994, Lent & Brown, 1996 Lent & Brown, 2008) SCCT subjective well being, including job satisfaction, at work i s ultimately a product of motivational forces and influences through the work life span. satisfaction include self efficacy, outcome expectations, goal directed activity, all which interplay and influence one another. As a precedent to these direct pathways, the occurrence of environmental supports, resources, and obstacles impact all of the other theoretical constructs and provide another central pathway of influence for job illnesses may have both short term and long term effects in terms impacting individuals and also may have immediate and/or latent effects on an individual in accor dance with perceptions of the experience. These effects of illness experience were theorized and tested in hypothesis V in order to determine whether these occurrences may have served as motivational forces in the lives of pharmacists that were board cer tified in a specialty area where their illness occurred. Accordingly, the final two hypotheses in this supports, resources, and obstacles and also how they may impact other key constructs. Hypothesis VI predicted that in pharmacists that were board certified in specific specialty areas that also have had a self identified previous or present illness experience in their specialty area self efficacy and outcome expectations would be predictive of having an illness in the specialty area in which they hold certification Four logistic regression analyses were completed; one for each of the three general type specialty areas (Ambulatory Care, Pharmacotherapy Infectious Disease, and

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116 P harmacotherapy Cardiology) and one for all of the specific type specialty areas combined. The analyses revealed that the model for predicting illness in specialty area with self efficacy composite scores and outcome expectations composite scores was signi ficant for ( 2 ( df =2 ) = 8.64, p=.013 R 2 =.015, Care ( 2 ( df =2 ) = 16.168, p<.00 1 R 2 =.007, 2Log=1007.210). For board certified pharmacother apists with added qualifications, two separate logistic regression analyses were performed for the Cardiology and Infectious Disease groups. The model of prediction for pharmacists with the infectious disease added qualification revealed a statistically s ( df =2 ) = 12.249, p=.002, R 2 =.005, 2Log=190.787). Contrastingly, the model for pharmacists with the cardiology added qualification revealed no statistically significant relationship, ( 2 ( df =2 ) = 5.602, p=.061, R 2 =.002, 2Log=226.736). For 3 of the 4 models, having had an illness experience in the same area as board certified specialty was significantly associated with self efficacy and outcome expectations, thus the null hypothesis for these groups was rejected. These results indicted the illness experiences may be a motivational force that influences both self Ambulatory Care pharmacy and those in Pharmacotherapy wi th an added qualification in Infectious Disease. The lack of statistical significance in the model for pharmacists certified Pharmacotherapy with an added qualification in Cardiology, may once again signify failure to adequately operationalize specific il lness experience for this specialty area.

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117 encompassing model was tested in order to outcome expectations, self efficacy, goals, and impact of illness experience. Just as in the earlier examined hypothesis V, the variables used for job satisfaction, self efficacy, and outcome expectations were composite scores for items on each of their respective survey sections. Goals were operation alized in this model by using the survey item that best fit into the theoretical model (as indicated by the results of Hypotheses I through III) of working in specialty certification area. In regards to operationalizing illness experience, this study use composite scores on the perceived illness experiences portion of the survey that was adapted for this specific study from Revised Perceived Illness Experiences (R PIE) During survey administration, par ticipants were Do you now or have you ever had a responded yes to this question, they were asked to complete the perceived illness experience portion of the survey. Contrastingly, if participants respon ded that they experience portion of the survey and were led to the next set of survey questions. Because of this, participants included in this analysis are only included if they indicated that they had a past or present illness experience. The regression analysis for this model revealed that for all board certified pharmacists with a present or past illness experience (n=534), outcome expectations ( .370 p<.00), self effic acy ( .158, p=.035), working within a specialty certification area ( 1.985, p<.013), and perceived illness experience ( .168, p < .001 ) were

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118 statistically significant predictors of job satisfaction ( = 22.978, t (4) = 8.053, p < .001 ,). Additionally, i t was discovered that these four variables as a model explained a significant proportion of variance in job satisfaction for these pharmacists ( R 2 = .154, F (4, 529) = 24.01, p < .001 ). Each predictor in this model was statistically significant in terms of their respective association with the outcome variables of job satisfaction, and effect sizes (i.e. beta coefficients) remained some what consistent with other completed analyses. ficant and positive relationships with the job satisfaction variable. For every point job satisfaction increased in pharmacists with illness experience, the average outcome expectations composite score increased by a .370, self efficacy composite score i ncreased by .158 and the likelihood of working within specialty certification area increased by 1.985. The only variables in the model that was negatively associated with changes in job satisfaction scores were the illness experience variables of perceived illness experience composite score. This composite score for perceived illness scores indicating greater negative appraisal of the impacts of illness experiences. The negative direction of prediction in job satisfaction from this variable essentially indicates pertaining to their own illness experiences becomes more positive in nature (i.e. their composite score decreases) by .168 points in perceived illness experience. Variables in this regression analysis were added in the model in a step wise fashion in order to examine if any important changes in the R 2 statistic occurred. The

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119 first simple model of job satisfaction being predicted by self efficacy had an R 2 of .063 ( Adjusted R 2 =.062 ). Next outcome expectations were added into the model, which resulted in an R 2 change of .53 ( Adjusted R 2 =.117). Joining self efficacy and outcome expectations, working in specialty certification area was added into the model which further increased R 2 by 13 ( Adjusted R 2 =.129). Finally perceived illness experience composite score was added into the final model, resulting in a change in R 2 of .25 ( A djusted R 2 =.154). This overall model indicates that self efficacy, outcome expectations, goals, and impact of illness experience collectively account ed for approximately 15% of the variance in job satisfaction composite scores in the study population. Be cause of the over all model data analysis results and because each of these variables added unique explanation in the proportion of variance in job satisfaction, the null hypothesis was rejected. Overall, the data analysis for the overarching model of jo b satisfaction in pharmacists who reported an illness experience supported a convergence in models for how self efficacy, outcome expectations, working in specialty area, and perceived illness experience work together to predict the outcome variable of job satisfaction. The general intent of the last study hypothesis was to determine how and if SCCT and illness experience constructs affected job satisfaction. The analysis revealed that for pharmacists that have board certification in a specialty area and h ave had a personal illness, adding illness experience into the original model of prediction added a modest yet statistically significant amount of explanation in terms of predicting the outcome variables of job satisfaction and explained an additional amou nt of the variance of job satisfaction scores for this population. Using these results from the data analysis in

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120 hypothesis VI, it could be assumed that both the underlying models can converge to predict the ultimate career related motivational forces of s ubjective well being in the context of work. Study Limitations When evaluating the findings presented within this study, several study limitations should be considered: 1. This study is observational in nature. Data analyses could not assess causality of any variables in study, instead they focused on predicting the observed relationships 2. Results from this study cannot be generalized to non board certified pharmacists or pharmacists with specialty certifications through organizations other than the Board of Pharmacy Specialties (BPS) since only pharmacists with certification through the BPS were included into the study population. 3. Information that was collected through focus groups meetings was transcribed and analyzed by the principle investigator without t he use of a validated content analysis methodology 4. dated in previous studies, wording changes and shortening of items occurred. Since these changes were very minor and since the ins discussed in focus groups and during expert review, t he reliability of the scales that were altered were not a ss 5. In the self efficacy and outcome expect instrument participants were asked to think back to the time when they were selecting a specialty area. This may have possibly result ed in some recall bias within these study sections Since any biases of this nature would have caused non differential misclassification, it is not of great concern in this study. 6. Since no precise number of pharmacists with each specialty certification area could be provided, the response rates for the s tudy survey were not exact. 7. The association between illness experiences and the decisions to pursue certification should be inte rpreted prudently since the temporality of their relationship was not assessed. 8. The operationalization of specific illnesses specialty areas of Ambulatory Care pharmacy and Pharmacotherapy may have been over specified to the extent that it may not have captured all pertaining illness experience in the population.

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121 Final Conclusions and Futu re Research Direction In this study, factors affecting motivation through Social Cognitive Career Theory (SCCT) and illness experienced were examined. S ignificant relationships were found between job satisfaction, goals, outcome expectations and self effic acy in the study proposed that job satisfaction among all board certified efficacy, and goal participation at statistically significant levels. Alth ough this over all model was shown to fit well with theoretical constructs and explained a statistically significant amount of the proportion of variance in job satisfaction, R 2 =.118, more relevant variables could be added into the model to increase the R 2 statistic. Future research studies may want to explore what other relevant variables may be impactful, and test their overall The first several hypotheses were aimed at finding the best way to m easure satisfaction scores. It was assumed in this study that most pharmacists with board certification either currently or at one point had a goal to function as a board certified speculated that participation in and progression at goal directed activities directly for parted. First, this study sought to operationalize the construct goal participation, by measuring if and how much work time to operationalize goal progress behaviors by asking participants whether they certified because it was required or for voluntary reasons. Since the latter could not clearly

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122 establish a relationship with the outcome variable and key construct of job satis faction, goal progress was not measured in this study. Future studies could focus on operationalizing this domain of goal progression within the goal construct, through either validating a scale or validating survey items through focus groups and expert re view. The eight test conditional multivariate binary response model for testing whether a significant relationship existed between having an illness in a specialty area and t type specialty statistically significant associations were detected between exposure to illness experiences and the selection and of a corresponding specialty area revealing increased odds of becoming certified ranging from 1.08 to 9.16 The difference in results for these two types of specialty areas (general vs. specific types) may be attributed to differences in motivational forces for specialty types and/or misclassification of exposure s tatus in this study. The logistic regression analyses completed in order to test the convergence of efficacy and outcome expectations through predicting illness in specialty area were significantly statisti areas. Overall, it was determined the theoretical models did have some points convergence The statistically non significant findings in the chi square analyses and logistic validity in the operationalization of illness experiences corresponding with the broad specialty areas of Pharmacotherapy and Ambulatory Care pharmacy. Although focus

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123 groups and expert opinions gave some idea of what types of illnesses or health care experiences may have been representative, it was of consensus from these sources that the study would most likely not produce a single variable which could adequately measure such broad specialty areas. Future studies wishing to investigate the relationship between specialty area and corresponding illness experiences may want to spend an exten ded amount of time idea of what illnesses may directly relate with their specialty certification. It may also be possible for future studies to include multiple illne ss states into the illness experience indication variables for these groups, keeping in mind that each illness or health care experience should be unique to its specialty area in nature to avoid diluting the groups. Future r esearchers may also want to expl experiences with patients dealing with specific types of illness may also effect selection of specialty area and the decision to pursue specialty certification. The final model of the study also aimed to evaluat e a model of prediction for subjective well being at work using both SCCT and illness experiences. In this final model, job satisfaction was proved to be successfully predicted by outcome expectations, self efficacy, goals, and perceived personal illness experience in pharmacists that were board certified in a specialty area and had experienced a both theories provides a platform for future researchers interested in what types of personal life experiences may influence work life behaviors and thus job satisfaction.

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124 what other types of personal experiences may be key factors in professional motivation and job satisfaction. Lent & Brown (2008) theorized that other possible personal variables of influence that may also be associated with or predictive of subjective well being in the context of work are an ity type traits (i.e. introversion or extroversion) and affective traits (i.e. emotional pre dispositions). For future studies investigating motivational influences, it may also be beneficial to examine if any career setting differences exist and how rat ionale for seeking certification may differ across employment areas. phenomena for other types of health care professionals outside of pharmacy such as physicians, physician assistants, and nurses, as there is very little literature available that has explored these motivational relationships in key health care providers.

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125 APPENDIX A INFORMED CONSENT FOR FOCUS G ROUPS Informed Consent Protocol Title: Performance, & Job Satisfaction Please read this consent document carefully before you decide to participate in this study. Purpose of the research study: The purpose of this study is to examine the impact of motivational influences and work related influences on board certified pharmacists. What you will be asked to do in the study: Attend focus groups and share opinions and experiences related to b ecoming board certified. Time required: Approximately 1 hour Risks and Benefits: It is not anticipated that you will experience any risks or benefits by directly participating in this study. Compensation: Refreshments will be provided during focus gro ups. You will receive a $10 Target gift card for participating in this research. Confidentiality: Your identity will be kept confidential to the extent provided by law. Information shared in the groups will be audio recorded. The recordings will be kept in a locked cabinet at the University of Florida, College of Pharmacy, Department of Pharmaceutical Outcomes and Policy. After the information has been transcribed, the recordings will be destroyed. Your name will not be used in any reports. The entire discussion will be treated as confidential by the research staff and the focus group members will be asked to also treat the discussion as confidential, but the research staff cannot guarantee that all group members will do so.

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126 Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at any time without consequence. Whom to contact if you have questions about the study: XXXXXXXXXXXXXXXXXXXXXXX Whom to contact about your rights as a research participant in the study: IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611 2250; phone 392 0433. Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description. Participant: ___________________________________________ Date: _________________ Principal Investigator: ______ _____________________________ Date: _________________

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127 APPENDIX B RECRUITMENT EMAIL FOR DATA COLLECTION Subject Line: Request to Complete a Brief Survey for a Research Study I am seeking participants to complete a brief online survey as part of a resear ch study to investigate the factors that motivate pharmacists to obtain specialty certification. This project is being conducted with the cooperation and support of the Board of Pharmacy Specialties (BPS). You are receiving this email because you are a Bo ard Certified Pharmacist. To be able to take part in this study, you must have current board certification or have formerly been board certified. Your participation will help us understand what motivates pharmacists to become board certified and how this c ertification contributes to job satisfaction. Your participation is this study will help advance the field of pharmacy by providing rich insight into the motivational influences of the pharmacists in specialty areas and how such can be used to understand and evaluate future pharmacy specialties. To get started, click the link below: https:// If have any questions about the study, please contact Rachel Rosenthal, MPH (Princ ipal Investigator), Ph.D. candidate at the University of Florida via email at xxxx@xxx.xx or by phone at xxx xxx xxx The faculty supervisor for this study is xxxxx and he can be reached via email at xxxxx@xxxx.xx T hank you in advance!

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128 APPENDIX C INFORMED CONSENT FOR PRIMARY DATA COLLECTION Informed Consent Please read this consent document carefully before you decide to participate in this study. Job Satisfaction Principal Investigator: Rachel L. Rosenthal Xxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxx Advisor: xxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxx You are invited to participate in a study that is investigating th e internal and external factors that motivate pharmacists to obtain specialty certification. You are invited as a possible participant in this study because you are a pharmacist that holds specialty certification through the Board of Pharmacy Specialtie s (BPS). To be able to take part in this study, you must currently hold specialty certifications through the BPS or have formerly held certification. If you decide to participate, you will be asked to complete an online survey. This online survey will co ntain questions relating to your certification, job satisfaction, and motivational factors related to Social Cognitive Career Theory and Illness experiences and how such motivates, impacts, and influences becoming board certified in a specific specialty ar ea. It will take you only approximately 10 15 minutes to complete the survey. During the survey, you may skip any questions that you do not wish to answer. It is not anticipated that you will experience any risks or benefits by directly participating in t his study. There is no compensation to you for participating in this study. Your responses in this survey will be kept completely confidential We will NOT know your IP address when you respond to the on line survey. Any information that is obtained in co nnection with this study and that can be identified with you will remain confidential. All data collected in the survey will be anonymous. Your decision whether or not to participate will not prejudice your future relation with the Board of Pharmacy Spec ialties (BPS) or with the University of Florida. If you decide to participate, you are free to discontinue participation at any time without prejudice.

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129 If you have any questions, please do not hesitate to contact us. If you have any additional questions l ater about the study, please contact Rachel L. Rosenthal at xxxx@xxx.xx If you have further administrative questions, you may contact the University of Florida IRB02 Office, at Box 112250, University of Florida, Gainesville, FL 32611 2250 or by phone at 1 352 392 0433. Please print this form for your records. You are making a decision whether or not to participate. Clicking the Next button indicates that you have read the information provided above and have decided to participate You may withdraw at any time without penalty or loss of any benefits to which you may be entitled should you choose to discontinue participation in this study. You must be 18 years of age or older to consent to take part in this research study. Completion of the survey implies y our consent to participate in this research study. NEXT

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130 APPENDIX D MOTIVATIONS IN PHARMACY SPECIALTIES INSTRUMENT Section : Basic Demographics Questionnaire (Personal Variables) Are you a male or female? (1) Male (2) Female Indicate your race/ethnic group: (1)American Indian/Alaskan Native, (2) Black/African American, (3)Asian/Pacific Islander, (4)Mexican American, (5)Puerto Rican (Mainland), (6) Other Hispanic, (7)White/Caucasian, (8)Other _______ What is your current marital status? (1) Single Never Married, (2) Single Divorc ed, (3) Married/Civil Union, (4) Widowed Do you have children? (1) Yes (2) No If yes, how many children do you have? __________ Do you currently live in the United States? If yes please (Indicate State) If no please specify where__________ Are you a board certified pharmacist? (1) Yes (2) No In which specialties are you CURRENTLY certified? (Please select all that apply) (1) Pharmacotherapy (2) Nuclear Pharmacy (3) Psychiatric Pharmacy, (4) Oncology Pharmacy, (5) Nutrition Support (6) Ambulatory Care Pharmacy (7) PCT Cardiology (8) PCT Infectious Disease If Pharmacotherapy, Do you have an Added Qualification? (1) Yes, Cardiology, (2) Yes, Infectious Disease, (3) No But I may apply in the future, (4) No I do not plan to apply In what year were yo u first certified? _______ Have you ever renewed your board certification? (1) Yes (2) No, If yes, how many times __________ Are you a member of any specialty organizations that correspond with the area in which you hold specialty certification? (1)No (2) Yes, Please list ______________ When you first became certified was it voluntary or did your work require certification for any reason? (1) Voluntary, (2) required to certify for tenure/promotion (3) required to certify to get a job (4) required to certify as part of the position I held at the time I applied for certification.

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131 Are you currently employed? (1) Yes (2) No Select the ONE area from those listed below, in which the MAJORITY of your practice takes place. 4.A. Academic Institution 5.A. Hospital, University 4.B. Ambulatory Care Clinic 5.B. Hospital, University Affiliated 4.C. Cancer Center 5.C. Home Health Care 4.D. Community Pharmacy, Chain 5.D. Intermediate Care Facility 4.E. Community Pharmacy, Independent 5.E. Lon g Term Care 4.F. Correctional Facility 5.F. Managed Health Care 4.G. Drug Information Center 5.G. Pharmaceutical Industry 4.H. Governmen t/Military Hospital/Institution 5.H.Psychiatric Hospital/Facility 4.I. Hospital, Community For Profit 5.I. Other 4.J. Hospital, Community Not for profit How many hours do you work in a typical work week? ____ Do you work in a setting where you use your specialty certification? (1) Yes (2) No What percent of your work week is spent using your specialty cer tification? _________ Section 3: Have you personally, a family member or an individual close to you ever experienced a heart attack or other serious cardiac health problem? (1) Yes (2) No If yes (1) personally, (2) family member (3) someone close t o you Have you personally, a family member or an individual close to you ever experienced a serious health problem resulting from an infectious disease? (1) Yes (2) No If yes (1) personally, (2) family member (3) someone close to you Have you personally, a family member or an individual close to you ever used radioactive drugs for diagnosis or therapy? (1) Yes (2) No If yes (1) personally, (2) family member (3) someone close to you Have you personally, a family member or an individual close to you ever received treat ment for a serious or life threatening chronic disease? (1) Yes (2) No If yes (1) personally, (2) family member (3) someone close to you Have you personally, a family member or an individu al close to you ever received intravenous feeding or needed special nutritional support while being treated for an illness? (1) Yes (2) No If yes (1) personally, (2) family member (3) someone close to you

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132 Have you personally, a family member or an individual close to you ever experienced a psychiatric related illness? If yes (1) personally, (2) family member (3) someone close to you Have you personally, a family member or an individual close to you ever experienced a malignant disease? (1) Yes (2) No If yes (1) personally, (2) family member (3) someone close to you Do you feel or think your experiences with personal illness may have led to choose a specific specialty area? (1) Yes (2) No Do you feel or think your experiences with family members or loved ones experiencing illnesses may have led to choose a specific specialty area? (1) Yes (2) No Section 4: For each statement, please select the number that indicates your degree of agreement. Strongly Ag ree Strongly Disagree Know Agree I receive recognition for a job well done 1 2 3 4 5 I feel close to people at work 1 2 3 4 5 I feel good about working for my employer 1 2 3 4 5 I feel secure about my job 1 2 3 4 5 I believe my director or supervisor is concerned about my well being 1 2 3 4 5 On the whole, I believe work is good for my physical health 1 2 3 4 5 I feel that my financial compensation is good 1 2 3 4 5 All of my professional talents and skills are used at work 1 2 3 4 5 I get along with my director/ supervisors 1 2 3 4 5 I feel good about my job 1 2 3 4 5

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133 Section 5: Self Efficacy, Outcome Expectations and Goals (Rogers et. al) Befor e you chose to become a board certified pharmacist, you had to choose a practice area. AT THE TIME you were choosing your practice area, how confident were you that you could: Not Highly Confident Confident Know Confident Not Confident Confident Know Confident Confiden t Choose a practice area that w ould fulfill your expectations and goals 1 2 3 4 5 Choose a practice area that w ould fit well with your personality (e.g extrovert introvert) 1 2 3 4 5 Choose a practice area that w ould enable you to live the type of lifestyle you desire 1 2 3 4 5 Choose a practice area that w ou l d fit your interest s and abilities 1 2 3 4 5 Decide what you are and are not ready to s acrifice in order to choose a practice area 1 2 3 4 5 Decide what you value most in your pharmacy Career (relationships with patients, prestige, technical skills, etc.) 1 2 3 4 5 Locate valid and accurate information to help you choose between equally desirable practice areas 1 2 3 4 5 Before you chose to become a board certified pharmacist, you had to choose a practice area. AT THE TIME you were choosing your practice area, how much did you expect that your choice of practice area would be: Strongly Disagree Disagree Know Agree Be intellectually stimulating 1 2 3 4 5 Provide you with work satisfaction 1 2 3 4 5 Allow you interaction with your colleagues 1 2 3 4 5

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134 Let you practice clinical skills that best sui t y our perceived abilities 1 2 3 4 5 Provide you with a good income 1 2 3 4 5 Allow you to perform a broad spectrum of skills 1 2 3 4 5 Be compatible with your interests 1 2 3 4 5 Allow you to achieve your desired professional s uccess 1 2 3 4 5 Disclaimer Before Section 6: The study at hand is looking at possible influences that lead you to cho ose a specific practice area, including past health care experience. Although some of following questions may seem unrelated they have been specially chosen in according to the theoretical approach of the researcher. Please try to answer of the following questions as honestly as possible. Section 6: Do you now or have you ever had a chronic or serious illness? (1) Yes (2) No 1A .If yes, do you currently have a chronic or serious illness (1) Yes (2) No 1B. If yes, do you consider your illness to still have impacts on your life today? (1) Yes (2) No If yes to either 2A or 2B then proceed. If no then skip the sub scale

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135 F or each statement, please select the number that indicates your degree of agreement Strongly Agree Strongly Disagree Know Agree I feel left out of things at work 1 2 3 4 5 I am afraid 1 2 3 4 5 of my illness reminded of my illness 1 2 3 4 5 I only tell pe ople about my illness if I really have to 1 2 3 4 5 My illness stops me from doing activities I like 1 2 3 4 5 I am not always able to join in with what my peers are doing 1 2 3 4 5 My family makes a fus s of m e because of my illness 1 2 3 4 5 My illness makes many problems in my 1 2 3 4 5 personal life Has a family member or someone very close to you ever had a chronic or serious illness? (1) Yes Currently ( 2) Yes Not Currently ( 3) No If yes, do you consider their illness to still have an impact on your life today? (1) Yes (2) No

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136 APPENDIX E 2011 BPS CER TIFICATION EXAMINATION RESULTS Ambulatory Care Pharmacy Certification Pass; 518 Fail; 143 Total; 661 (77% Pass Rate) Total Certified: 518 as of October 2011* Nuclear Pharmacy Certification 23 Pass; 24 Fail; 47 Total; (49% Pass Rate) Recertification 1 Pass; 2 Fail; 3 Total (33% Pass Rate) New Total Certified: 524 as of October 2011* Nutrition Support Pharmacy Certification 37 Pass; 31 Fail; 68 Total; (54 % Pass Rate) Recertification 24 Pass; 3 Fail; 27 Total (89% Pass Rate) New Total Certified: 482 as of October 2011* Oncology Pharmacy Certification 175 Pass; 146 Fail; 321 Total; (54% Pass Rate)

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137 Recertification 19 Pass; 1 Fail; 20 Total (95% Pass Rate) New Total Certified: 1247 as of October 2011* Pharmacotherapy Certification 1743 Pass; 676 Fail; 2419 Total; (71% Pass Rate) Recertification 85 Pass; 10 Fail; 95 Total; (89% Pass Rate) New Total Certified: 9445 as of October 2011* Psychiatric Pharmacy Certification 67 Pass; 18 Fail; 85 Total; (79% Pass Rate) Recertification 32 Pass; 1 Fail; 33 Total; (97 % Pass Rate) New Total Certified: 684 as of October 2011* Total newly certified in 2011: 2563 Total Certificants as of December 1, 2011: 12,900 Subject to verification by ongoing audit.

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138 LIST OF REFERENCES APhA. (2011). Code of Ethics for Pharmacists. American Pharmacists Association. Retrieved December 23, 2011 from http://www.pharmacist.com/AM/Template.cfm?Section=Code_of_Ethics_for_Pha rmacists&Template=/CM/HTMLDisplay.cfm&ContentID=5420 ASHSP. (2012) Exploring facets of job sat isfaction amoung U.S. hospital pharmacists. American Society of Health Systems Pharmacists. Retrieved April 12, 2012. http://www.ashp.org/DocLibrary/Me mberCenter/InpatientCare/Job Satisfaction Survey.aspx Bandura, A. (1986). Social foundations of though and action: A social cognitive theory Upper Saddle River, NJ: Prentice Hall. eptions of ethical work climate on ethical judgment and behavioral intentions. Journal of Business Ethics, 27 (4): 351 362. Birenbaum, A. (1982). Reprofessionalization in pharmacy. Social Science & Medicine, 16(8):871 878. Borkowski, N. (2009). Organizatio n Behavior, Theory, and Design in Health Care Jones and Bartlett Publishers: Mississauga, Ontario. BPS (2013). Find a Board Certified Pharmacist. Retrieved September 29, 2013 From http://www. bpsweb.org/resources/find_bcp.cfm Colero, L. (2011). A Framework for universal principle of ethics. Crossroads Program Inc. Retrieved December 23, 2011 from : http://www.ethics.ubc.ca/papers/invited/colero.html Connor, K. A. & Hamilton, L. A. (2010). Purs u ing Board of Pharmacy Specialties certification. American Journal of Health System Pharmacy 67: 1146 1151. The Council on Credentialing in Pharmacy. White Paper. Credentialing in pharmacy. Retrieved November 12, 2011. http://www.pharmacycredentialing.org/ccp/Files/CCPWhitePap er2010.pdf Daugherty, N. E., Ryan, M., Romanelli, F., & Smith, K. M. (2007). Board certification of pharmacy residency program directors. American Journal of Health System Pharmacy, 64 : 1415 1421. Dugan, B. D. (2006). Enhancing community pharmacy through advanced pharmacy practice experiences. American Journal of Pharmaceutical Education. 15 ; 70(1): 21.

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139 Ebiasah, R. P., Schneider, P. J., Pedersen, C. A., Mirtallo, J. M. (2002). Evaluation of board certification in nutrition support pharmacy. Journal of Parenteral and Enteral Nutrition 26 (4): 239 247. Extended History of ABMS. (2011) Retrieved September 6, 2011. http://abms.org/About_ABMS/ABMS_History/Extended_History/ Ferro, L. A. (1998). Collaborative practice agreements between pharmacists and physicians. Journal of the American Pharmaceutical Association, 38 (6):655 64 Ga i ther, C.A., Kahaleh, A. A., Doucette, W. R., Mott, D.A., Perdersen, C. A., Schommer, J. C. (2008). A modif organizational, extra role, and individual factors on work related outcomes. Research in Social and Administrative Pharmacy, 4 : 231 243. Job Outloook for Pharmacist. (2011) Retrieved August 5, 2011, from http://www.aacp.org/resources/student/pharmacyforyou/Pages/joboutlook.aspx Glanz, K., Rimer, B. K. & Lewis, F. M. (2002) Health Behavior and Health Education: Theor y, Research, and Practice 3 rd ed. Joessey Bass: Hoboken, New Jersey. Gyurko, C. C. (2011). A synthesis of Vroom's model with other social theories: an application to nursing education. Nurse Education Today, 31 (5):506 10. Hassel, K., Seston, E., & Shann P. (2010 ) Measuring job satisfaction of UK pharmacists: a pilot study. International Journal of Pharmacy Practice, 15(4): 259 264. Hepler, C. D. (1985) Pharmacy as a clinical profession. American Journal of Hospital Pharmacy, 42 :1298 306. Hepler, C. D. ( 1993) Pharmaceutical care and specialty practice. Pharmacotherapy 13(2 Pt 2):64S 69S Hepler, C. D. (1988) Unresolved issues in the future of pharmacy. American Journal of Hospital Pharmacy, 45 (5):1071 1081. Hepler, C. D. (1990).The future of pharmacy: pha rmaceutical care. American Journal of Hospital Pharmacy, N30 (10):23 29. Hepler, C. D. (2002). Critically examining pharmaceutical care. Journal of the American Pharmaceutical Association 42 (5 Suppl 1):S18 9. Hepler, C. D. & Strand, L. M. (1990). Opportu nities and responsibilities in pharmaceutical care. American Journal of Hospital Pharmacy, 47 (3):533 43.

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140 Highby, G. J. (2006). Evolution of Pharmacy. In D. B. Troy(Ed.), The Science and Practice of Pharmacy. 21 st ed. (pp. 7 19). Baltimore: Lippincoot Williams & Wilkins. Kennedy, C. W., Fossum, J. A. & White B. J. (1983). An empirical comparison of within sujects and between subjects expectancy theory models. Organizational Behaviors and Human Performance, 32 : 124 143. Kiernan, G., Gormley, M., & Ma clachla, M. (2004). The Revised Perceived Illness Experience Scale (R PIE) Data from the Barrettown Studies. Behavioral Medicine, 30 23 34. Kuiper, R. L., Painter Cowan, D. L.,& Pacitti, R.(2011). Job satisfaction in hospital pharmacists. American Jour nal of Health System Pharmacy 68: 115. L ent, R. W., & Brown, S. D. (2008). Social cognitive career theory and subjective well being in the context of work The Journal of Career Assessment, 16(6) 6 21. Lent, R. W., & Brown, S. D. (1996). Social cognitive approach to career development: An overview. The Career Development Quarterly, 44, 310 321. Lent, R. W., Brown, S. D. & Hackett, G. (1994). Toward a unifying social cognitive theory of career and academic interest, choice, and performance. Journal of Voc ational Behavior, 45 79 122. motivation International Journal of Psychology: A Biopsychosocial Approach (1): 15 28. Macdonald, S. & MacIntyre, P. (1997). The Generic Job Satis faction Scale: Scale development and its correlates. Employee Assistance Quarterly, 13(2). variation by practice setting. Pharmacy & Therapeutics 29(3): 184 190. McClella n, M. B. (2005).. Medicare Part D: Opportunities and challenges for pharmacy. Journal of the American Pharmacists Association, 45 (3): 328 335. McDonough, R. P. Rovers, J. P., Currie, J. D., Hagel, H., Vallandingham, J. & Sobotka J. (1998). Obstacles to the implementation of pharmaceutical care in the community setting. Journal of the American Pharmaceutical Association 38 : 87 95. NABP. (2011). National Association of Boards of Pharmacy. Retrieved December 22, 2011 from http://www.nabp.net Nurse Certification. (2011) Retrieved October 10, 2011 from http://www.nursecertificationhelp.com/

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141 Parsons, T. (1951). The Social system Glencoe Il: Free Press. Pradel, F. G., Palumbo, F. b., Flowers, L., Mullins, C. D., Haines, S. T. & Roffman, D. S. (2004). White paper: Value of specialty certification in pharmacy. Journal of the American Pharmacists Association 44 (5): 612 620. Rogers, M. E., of social cognitive career theory instruments to measure choice of medical Journal of Career Assessment, 17 (3): 324 337. Rogers, M. E., Creed, P. A. & Searle, J. (20 10 ) A multivariate analysis of personality, values and expectations as correlates of career aspirations of final year medical students. Educational and Vocational Guidance, 10(3):177 189. Rosenthal, M. M., Breault, R. R., Austin, Z. & T perception of their professional role: Insights into community pharmacy culture. Journal of the American Pharmaceutical Association, 51 (3): 363 367. Sharp, L. K., Bashook P. G., Lipsky, M. S., Horowtiz, S. D. & Mil ler, S. H. (2002) Specialty board certification and clinical outcomes: the missing link. Academic Medicine 77: 434 442. Smith, F. (2002). Research methods in pharmacy practice. London : Pharmaceutical Press. Suchman E. A. (1965) Stages of illness and medical care. Journal of Health Human Behavior 6(3):114 128. Tankersley, M. A. (2008). Why pharmacists choose to see or not seek board certification in pharmacy practice: A comparison of motivation and motivating facto rs. (doctoral dissertation). Retrieved from ProQuest Dissertations & Theses Database. (UMI# 3291139). http://drugtopics.modernmedicine.com/drugtopics/article/articleDetail.jsp?id=6519 22 Trayer, A. P. & Ferguson, H. R. (2002). Professionalism is a lifelong commitment. Pharmacy Studen t, Sept/Oct: 12 14. http://www.pharmacist.com/AM/Template.cfm?Section=Professionalism_is_a_Lif elong_Committment_Septembe r_October_2002&Template=/CM/ContentDisplay. cfm&ContentID=5427 Ulrich, S. (2009). Applicants to a nurse midwifery education program disclose factors that influence their career choice 54(2): 127 132

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142 Ventra, F., Spind el, P. G., & Bowland, K. (1995). The transition from lay midwife to certified nurse midwife in the United States. Journal of Nurse Midwifery 40(5): 428 437. Willink D. P. & Isetts B. J. (2003). Becoming 'indispensable': developing innovative community pharmacy practices. Journal of the American Pharmaceutical Association, 45 (3): 376 86.

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143 BIOGRAPHICAL SKETCH Rachel L Rosenthal was born and raised in the low country of southeastern Georgia. She received her Bachelor of Arts d egree and Master of Public Health degree at Armstrong Atlantic State University in Savannah, GA. Her most recent academic accomplishmen t was receiving her Doctor of Philosophy in pharmaceutical s ciences at the University of Florida in 2013.


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