Legal and ethical decision-making skills are essential for many healthcare professions, including pharmacists. Every day, pharmacists need to make decisions about whether prescriptions meet legal and ethical standards and can be dispensed. This ensures safe and appropriate patient care and helps to uphold the public’s trust in our profession.
University accreditation standards in Australia and globally emphasise the importance of legal and ethical decision-making. Trainee pharmacists complete extensive training in legal and ethical practice, both as students and during a year of supervised practice after completing their university pre-registration pharmacy degree. However, many still report difficulties recognising scripts that don’t meet legal requirements and justifying decisions not to supply medicines. This illustrates the need to further strengthen legal and ethical decision-making skills, particularly in the context of dispensing medicines. In this post, we describe two new innovative educational activities aimed at better supporting trainee pharmacists to become more confident in making sound dispensing decisions.
Why pharmacy trainees struggle with real-world decisions
In Australia, registration as a pharmacist involves completing a university pre-registration degree followed by a year of supervised practice as a trainee pharmacist/pharmacy intern. During this year, they complete a structured training program, such as the National Alliance for Pharmacy Education (NAPE) Intern Training Program (ITP). This aims to prepare them for their future practice and the oral and written exams (including law and ethics content) they must pass to be registered as a pharmacist. The NAPE program embeds legal and ethical decision-making activities in online discussion assessments, in-person seminars, exams, and daily practice in supervised settings.
During this intern year, trainee pharmacists are faced with progressively greater responsibility, including making decisions about dispensing prescriptions. Despite extensive training, many struggle to apply their classroom knowledge on legal requirements, ethical principles and patient-centred care to real-life dispensing decisions. When we reflected on this disconnect, we realised that we had made assumptions about the skills students had coming into the program. Given the amount of law and ethics training they have completed so far, we assumed that they would be able to just jump into solving dispensing problems faced in their workplace without further structured guidance. Instead, our learners’ experiences suggest they need more scaffolded and strategically placed learning activities to help them master these key skills.
Building legal and ethical decision-making skills – our two-part approach
To help address this gap, we designed and delivered two learning activities to further develop trainee pharmacists’ legal and ethical decision-making skills. These incorporated case-based and team-based learning. These activities are strategically placed at key points within the ITP to scaffold learning throughout their intern year. Small group sessions included opportunities to apply legal and ethical principles to real-life dispensing scenarios, self-reflection, and peer learning. Padlet and an anonymous online discussion board were used to monitor student engagement and understanding, encourage active participation and anonymous contributions, and provide a space for interns to share and discuss legal and ethical dilemmas encountered in practice.
Activity 1: Structuring a legal and ethical response lecture
The first activity – a lecture on how to structure a legal and ethical response – was delivered at the start of the ITP, before other learning activities and assessments on this topic. A law and ethics scenario was included as an icebreaker and opportunity for interns to recap their law and ethics knowledge from their pre-registration degree. The learning outcomes for this activity were: 1) Recognise the importance of legal and ethical reasoning for the intern year and future practice, 2) Identify key sources of legal and ethical obligations, and 3) Apply a structured framework when responding to legal and ethical problems.
Activity 2: To dispense or not to dispense lectorial
The second activity was a lectorial called “To dispense or not to dispense”. This was strategically placed as a capstone at the end of the program and was timed to support interns as they prepared for their written and oral exams. It provided learners with opportunities to practice making legally and ethically defensible decisions about dispensing prescriptions and apply legal and ethical frameworks to realistic pharmacy scenarios. Interns worked in small groups to discuss dispensing dilemmas, followed by a whole group debrief to consolidate learning.
What worked well and what could be improved?
The activities were delivered to 84 trainee pharmacists in 2024 by an academic experienced in teaching law and ethics to pharmacy students. The timing of these activities was aligned with interns’ clinical development and workplace application and designed to support ITP and registration exam preparation.
So what did interns think of these activities? 48 interns completed a feedback survey and provided overwhelmingly positive feedback, with 100% agreement with the statement that “I developed the ability to practically apply knowledge in the field(s) I am studying”. Interns identified the following positives in the approach:
- Greater confidence in legal decision-making at work
- The lecture is extremely well-planned
- Educators were supportive and patient as they (the students) mastered the content and skills
- Work was stimulating and prepared them well for exams and to become a practising pharmacists
- Relevance and quality of content and exams were really good
Additionally, as educators, we observed robust discussion both during the sessions and on the online discussion board, enhanced critical thinking about workplace practices (e.g. interns would ask questions of staff about the ethical and legal acceptability of what they saw in their workplace), and greater integration of legal and ethical decision-making and improved confidence in students’ learning activities and assessment responses.
There were some limitations. Two 60-minute sessions are not enough to fully develop complex decision-making skills (although these were revisited at several points throughout the program). A lecture is also not ideal for teaching legal and ethical deliberation, which is better suited to more interactive formats. Our evaluation was largely opportunistic and relied on self-report, and a more formal evaluation of skills acquisition is needed. Finally, there was no post-registration follow-up, so the long-term impact of this intervention on practice remains unknown.
Looking to develop critical professional skills in your own teaching?
If you’re thinking about scaffolding professional decision-making in your teaching, here are some tips to get you started:
- Don’t make assumptions about your learners and their skills when they get to you. Just because you are building on a topic that students have encountered before doesn’t mean they can just jump into solving problems without guidance and support.
- Identify the skills that are essential for success in your teaching context and provide safe, structured opportunities for students to master these.
- Timing is key! Closely consider the timing and placement of skill development activities so that these are most useful for you and your students, and assist other learning and assessment activities in your unit.
- People are our best resource. Create opportunities for students to make connections, learn with and from each other, and apply their learnings to their own unique context.
Key takeaways and future directions
The outcomes of this intervention were promising, and we plan to improve these activities in future. We hope to use a “train the trainer” model to shift towards small-group, case-based learning. We are also looking at ways to support intern pharmacists as peer teachers to lead discussions.
Training of pre-registration pharmacists to make legally and ethically defensible dispensing decisions is essential for professional development and education providers to meet accreditation requirements. The approach presented here had positive impacts on skills development and student satisfaction. We look forward to further developing, refining and evaluating this approach to best meet the needs of trainee pharmacists and the patients they care for.
