RESEARCH ARTICLE: Exploring and evaluating Vertically Integrated Teaching in Ethical Decision-Making (VIT-EDM) in pharmacy




Education, Ethical Dilemma, Ethics, Moral reasoning, PEP, Pharmacy Ethics Teaching


Background: With increased patient-centred care, pharmacists are often faced with ethical dilemmas and expected to provide solutions for practice dilemmas, relying on ethical judgment, principles of professional ethics, standards of practice, and moral reasoning capabilities. Pharmacists need to be competent in ethical decision-making which will enable them to act in a morally preferable and justifiable manner with patients. Literature has shown that moral reasoning skills are teachable and measurable competencies in healthcare. 

Objective: To evaluate the impact of implementing a vertically integrated teaching approach in ethical decision-making (VIT-EDM), on moral reasoning capabilities of pharmacy students as they progressed from year-one (pre-exposure to teaching intervention) to final year (post-intervention) of pharmacy studies, using the Professional Ethics in Pharmacy test (PEP) as a surrogate measure of moral reasoning capabilities. 

Methods: Cross-sectional, parallel cohort, comparison study, using PEP. A de-identified electronic survey link was emailed to enrolled students in each targeted cohort. Descriptive and inferential statistics were conducted using SPSS. 

Results: Fourth-year students’ confidence measures were significantly higher in decision-making. Furthermore, students’ decision-making and moral reasoning measures were higher in fourth-year students. They generally demonstrated moral reasoning capabilities belonging to stage four of moral reasoning levels, which is related to benefitting patients while respecting authorities and legal requirements. However, the difference in the P-scores (fourth-year and first-year) was not found statistically significant. 

Conclusion: Findings of this study underlined the positive impact of the (VIT-EDM) approach, a relatively novel mixed-method pedagogy in teaching pharmacy ethics. It highlighted the enhanced confidence of students in ethical decision-making when facing an ethical dilemma.

Author Biographies

Leen Fino, University of Sydney, Australia & Applied Science Private University, Jordan

Faculty of Medicine and Health & Faculty of Pharmacy

Iman A. Basheti , University of Sydney, Australia & Applied Science Private University, Jordan

Faculty of Medicine and Health & Faculty of Pharmacy

Bandana Saini, University of Sydney, Sydney, Australia

School of Pharmacy, Faculty of Medicine and Health

Rebekah Moles, University of Sydney, Sydney, Australia

School of Pharmacy, Faculty of Medicine and Health

Betty B. Chaar, University of Sydney, Sydney, Australia

School of Pharmacy, Faculty of Medicine and Health


ACPE. (2016). Accreditation Standards and Key Elements for the Professional Programme in Pharmacy Leading to the Doctor of Pharmacy Degree: The Accreditation Council for Pharmacy Education. Standards 2016. Available at:

Al-Aqeel, S.A. (2013). Pharmacy Students Feedback on the use of Role-play in Teaching Ethics. Pharmacy Education, 13

APC. (2020). Accreditation Standards for Pharmacy Programmes in Australia and New Zealand 2020: Australian Pharmacy Council. Available at

Arslan, M., Tarhan, N., Kalender, S., & ŞAr, S. (2018). Investigation of factors affecting ethical decision-making process of community pharmacists in professional life. Journal of Research in Pharmacy, 23, 140-145.

Austin, Z., & Gregory, P.A. (2007). Evaluating the accuracy of pharmacy students' self-assessment skills. American journal of pharmaceutical education, 71(5)

Bebeau, M.J., Rest, J.R., & Yamoor, C.M. (1985). Measuring dental students' ethical sensitivity. Journal of Dental Education, 49(4), 225-235

Benson, A., Cribb, A., & Barber, N. (2009). Understanding pharmacists' values: A qualitative study of ideals and dilemmas in UK pharmacy practice. Social Science & Medicine, 68(12), 2223-2230.

Beshara, S., Herron, D., Moles, R.J., & Chaar, B. (2020). Status of Pharmacy Ethics Education in Australia and New Zealand. American Journal of Pharmaceutical Education, 84(3).

Chaar, B., Brien, J.A., & Krass, I. (2005). Professional ethics in pharmacy: The Australian experience. International Journal of Pharmacy Practice, 13(3), 195-204.

Chaar, B.B. (2009). Professional ethics in pharmacy practice: Developing a psychometric measure of moral reasoning. Pharmacy World and Science, 31(4), 439-449.

DeMella, C., Donohoe, K., Morgan, L., Phipps, L., Drisaldi, A., & Forder, M. (2017). Implementation of an online ethics course into a pharmacy curriculum. Currents in Pharmacy Teaching and Learning, 9(5), 835-840.

DeSimone, J.A., Harms, P.D., & DeSimone, A.J. (2015). Best practice recommendations for data screening. Journal of Organizational Behavior, 36(2), 171-181.

Fejzic, J., & Barker, M. (2015). Implementing simulated learning modules to improve students’ pharmacy practice skills and professionalism. Pharmacy Practice, 13(3). https://10.18549/PharmPract.2015.03.583

Fino, L.B., Basheti, I.A., & Chaar, B.B. (2020). Exploring Ethical Pharmacy Practice in Jordan. Science and Engineering Ethics. https://10.1007/s11948-020-00231-3

Fino, L.B., Basheti, I.A., Saini, B., Moles, R., & Chaar, B.B. (2020). Exploring pharmacy ethics in developing countries: a scoping review. International Journal of Clinical Pharmacy, 42(2), 418-435.

Gallagher, C.T. (2011). Building on Bloom: A paradigm for teaching pharmacy law and ethics from the UK. Currents in Pharmacy Teaching and Learning, 3(1), 71-76. https://10.1016/j.cptl.2010.10.002

Hasan, S. (2015). Teaching ethics to pharmacy students using a team-based learning approach. Pharmacy Education, 11

Horton, E.R., Morin, A., Pervanas, H.C., Mukherjee, S.M., & Belliveau, P. (2014). A Novel Structured Format for Engaging Pharmacy Students in Bioethics Discussions. American Journal of Pharmaceutical Education, 78(9), 171.

Kohlberg, L., & Goslin, D.A. (1969). Handbook of socialisation theory and research

Kruijtbosch, M., Göttgens-Jansen, W., Floor-Schreudering, A., van Leeuwen, E., & Bouvy, M.L. (2019). Moral reasoning among Dutch community pharmacists: testing the applicability of the Australian Professional Ethics in Pharmacy test. International journal of clinical pharmacy, 41(5), 1323.

Latif, D.A. (1999). Using Ethical Dilemma Case Studies to Develop Pharmacy Students' Moral Reasoning. Journal of Pharmacy Teaching, 7(2), 51-66.

Mikhael, E.M., & Al-Tukmagi, H.F. (2016). The compliance of iraqi pharmacists with ethical principles in applying the pharmaceutical care for diabetic patients. Clinical Ethics, 11(4), 159-165. doi:10.1177/1477750916657659

Pearson, M. L., & Hubball, H. T. (2012). Curricular integration in pharmacy education. American journal of pharmaceutical education, 76(10), 204-204. httpa://

PSA. (2017). Code of Ethics for Pharmacists (2017) Pharmaceutical Society of Australia. Available at

Rajiah, K., & Venaktaraman, R. (2019). The effect of demographic and social factors on the decision-making of community pharmacists in ethical dilemmas. Journal of Research in Pharmacy Practice, 8(3), 174-177.

Rest, J., Narvaez, D., Bebeau, M., & Thoma, S. (1999). A Neo-Kohlbergian Approach: The DIT and Schema Theory. Educational Psychology Review, 11(4), 291-324. httpa://

Rest, J.R., Narvaez, D., Thoma, S.J., & Bebeau, M.J. (1999). DIT2: Devising and testing a revised instrument of moral judgment. Journal of Educational Psychology, 91(4), 644-659.

Saw, P.S., Chuah, L.H., & Lee, S.W.H. (2018). A practical approach toward teaching ethics to community pharmacists. International Journal of Clinical Pharmacy, 40(5), 1131-1136. https://10.1007/s11096-018-0707-8

Schlesselman, L.S. (2014). A cross-sectional study of applied bioethical reasoning in pharmacy students and preceptors. Pharmacy practice, 12(2), 401-401

Self, J.D., Baldwin, C.D., & Olivarez, C.M. (1993). Teaching medical ethics to first-year students by using film discussion to develop their moral reasoning. Academic Medicine, 68(5), 383-385.

Self, J.D., Olivarez, C.M., & Baldwin, C.D. (1998). The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students. Academic Medicine, 73(5), 521-523.

Sim, T.F., Sunderland, B., & Hattingh, H.L. (2019). Exploring influences on pharmacists’ and students’ ethical reasoning in a changing practice landscape in Australia. International Journal of Clinical Pharmacy, 41(1), 280-288.

Tham, J. (2017). Applied Ethics. In H. ten Have (Ed.), Encyclopedia of Global Bioethics (pp. 1-12). Cham: Springer International Publishing

Wilby, K.J., & Nasr, Z.G. (2016). Bridging theory and practice: Mixed methods approach to instruction of law and ethics within the pharmaceutical sciences. Saudi Pharmaceutical Journal, 24(6), 669-673.





Research Article