INTRODUCTION

Evaluating a new education activity to develop students’ understanding of ethical dilemmas and the choices they make was the main aim of this study. Debates are often reported in the literature as an effective way to explore ethics.^1-3 Understanding the professional environment of pharmacy helps explain why ethics for pharmacy technicians is an emerging area to be developed. The Pharmacy Act was introduced in Ireland in 2007 signalling a new era for Irish pharmacy.⁴ The Act was a major development that overhauled the regulation of pharmacy and set new standards of governance, fitness to practice, and registration of pharmacies and pharmacists. However, the Act did not address difficulties faced by pharmacy technicians such as varying entry level qualifications, the need for professional development, and regulation and registration issues.⁵ Simultaneously, pharmacists were developing their role in the delivery of patient-centered services, which was affecting the role of pharmacy technicians and raising implications for their professional education and training. Pharmacy technicians in Ireland have two routes to qualification: a full-time, college-based course and a work-based-only course delivered in a modular format by distance learning. Neither of these routes leads to registration. The issues of regulation and registration of pharmacy technicians as a profession have not been exclusive to Ireland; internationally, there has been much debate and discussion.^6-10 Discussion of professionalization brings the issue of ethics to the forefront. Ethics is defined as “moral principles that govern a person’s behaviour or the conducting of an activity.”¹¹ Health care ethics education has become a basic requirement for any health profession training program, and should span the continuum of undergraduate, postgraduate, and continuing education.¹² One of the standards listed in the Accreditation Council for Pharmacy Education’s (ACPE) Standards for Pharmacy Technician Education and Training Programs addresses technicians’ abilities to demonstrate ethical conduct in all job-related activities.⁷ Ethical responsibilities are formally expanding throughout health care with nursing staff and allied health professionals producing their own ethical guidelines.¹³ According to the International Pharmaceutical Federation (FIP), codes of ethics should be developed across health care professions.¹⁴ FIP recommends that institutions offering pharmacy education and continuing professional development (CPD) should include the Code of Ethics and its underlying principles of respect for the autonomy of persons, beneficence, non-maleficence and justice, in their offerings for all students and professionals.¹⁵

Codes of ethics have been developed for pharmacy technicians in other countries. For example, both the American Association of Pharmacy Technicians (AAPT) and the General Pharmaceutical Council of Great Britain (GPhC) have developed core competencies that incorporate ethical dimensions that are used to illustrate and guide expected behaviours of technicians in both training and practice.^16-20

In Canada, pharmacy technicians are required to practice within legal requirements, demonstrate professionalism and uphold professional standards of practice, codes of ethics and policies, and apply ethical principles in the decision-making process.²⁰ In Great Britain, technicians must follow the standards of conduct, ethics and performance as dictated by the GPhC. Every registered pharmacy technician is responsible for their own actions.¹⁷ In the US, ethical principles apply to technicians working in all settings, are based on the application and support of the moral obligations that guide the pharmacy profession in relationships with patients, other health care professionals, and society.¹⁶ In light of these requirements, it is incumbent upon pharmacy technician educators to incorporate ethical development into their educational programs.

Considering the role of pharmacy technician training programs in relation to the professional formation of technicians, the issue of ethics was identified as an area for development. Hindmarch and colleagues reviewed various methods of teaching ethics, including the role of undergraduate peer-based health care ethics teaching.¹³ Their study appraised interventions in which peers play a significant role in the development of fellow students and included peer discussions that were guided by clinical faculty members trained in ethics facilitation.¹³ Their findings suggest peer-based ethics education is an effective and valued educational methodology in training health care professionals.¹³ Numerous ways for incorporating ethics lessons into courses have been reported, and include regular class discussions, dedicated lectures, shared personal reflections, reading assignments, paper assignments, case study ethics presentations and debates.²¹

In-class debates involve peer-learning and can provide an excellent opportunity for active learning and may also support oral communication skills and critical thinking in students.²² Lampkin and colleagues found that a debate series in a first-year pharmacy self-care course was useful as an active-learning classroom tool to use in conjunction with didactic instruction to improve overall education.²³ A study by Randolph found that survey results of student perceptions of the use of debates as a teaching strategy in the allied health professions showed that debates encouraged active student participation in class and outside-of-class research experiences, provided students an opportunity to discuss issues and develop conclusions, and promoted the ability for students to advocate for themselves.²⁴ Reubin and colleagues reported that debates can be used as an adjunct educational methodology that complements other course content.²⁵ Hannah and colleagues also found that debates offer a useful strategy for teaching ethics in pharmacy courses.³

The aim of this study was to evaluate the implementation of a cross-curricular intervention in the form of a debate on an ethical dilemma to integrate ethics into pharmacy technician professional formation and investigate if establishing such an intervention would improve student ethical reasoning skills. Literature focusing on pharmacy technician education is limited and this study attempts to redress this issue. A shared assignment to integrate pharmaceutics and pharmacy practice course concepts was used as a guide in the development of this curriculum intervention.²⁶

METHODS

After a preliminary pilot investigative cycle in 2014-2015 indicated a positive outcome through an informal discussion with the class, a more robust mixed methods approach including both qualitative and quantitative methods was used in this study. Qualitative methods used included reflective writing pieces on the exercise or blogs recorded in the students’ electronic portfolios, a survey for students to express their view and opinions on the exercise, and a questionnaire for an international visiting lecturer who was observing the activity. Qualitative data included students’ ePortfolio reports, the visiting lecturer’s questionnaire, and section 2 of the students’ sentiment survey. Quantitative methods included t-test analysis of pre- and post-5-minute papers and section 1 of the sentiment survey. This broad mixed method approach allowed for triangulation of findings and addressed issues of validity. Twenty-five second-year pharmacy technician students in a two-year program participated in this study. The study participants included male students, female students, mature students, access or non-traditional students, and students of European and non-European origin. The debate was situated within the pharmacy work placement and pharmacy practice II modules and attended by students and lecturers from these modules along with visiting international students and their lecturer. Students of the course are required to complete a 6-month work placement in a pharmacy. This component is known as their work placement module. The pharmacy practice II module includes instruction related to pharmacy law and the role(s) of technicians. The contemporary and expanding role of the pharmacy technician is also covered. The pharmacy work placement module delivers an introduction to the reflective blog assessment, used by students throughout their work placements.²⁷ These modules are part of a comprehensive college course, which also includes modules in pharmacology, toxicology and therapeutics, health and safety, pharmaceutical formulations, microbiology, foundational chemistry, and nutrition.

Prior to developing the intervention, the pharmacy practice and work placement module lecturers met and set a time for the debate within both modules that would be ideal for students. They decided to hold the debate at the end of the pharmacy practice II module and immediately prior to the start of the pharmacy experiential work placement. This ensured that the students had been educated in the practice of pharmacy, their role and responsibilities within it, and that they had been introduced to the college code of conduct for students on work placement and that they would be trained in using blogs as a reflective assessment for placement.²⁷

Several scenarios with ethical dimensions were written. Each of the scenarios allowed for a range of behavioral responses and provided an opportunity for students to exercise their reasoning skills. Although only three scenarios were used in the intervention, the remaining unused scenarios may be used in future debates (Appendix 1), allowing for year-to-year variability in the topics chosen.

Students were asked to complete 5-minute papers in class immediately before and after the debate. A “5-minute paper” is an in-class writing activity (taking 5 minutes or less to complete) in answer to an instructor-created question.²⁸ The pre- and post-debate papers posed different ethical scenarios for students to consider and comment upon. They were designed to establish a baseline of a student’s critical thinking and the impact of the debate on this thinking.

Following completion of the pre-debate 5-minute paper, students received a PowerPoint presentation (Microsoft, Redmond, WA) that provided the learning objectives of the exercise, a brief overview of ethics and ethical dilemmas, the difference between a moral and legal standard, codes of ethics for a profession, an outline of how the debate can help them approach the problem, and a definition of what a good debater embodies. A formal class debate was new to the students and the presentation was an important step in contextualizing the layout and objectives of the exercise.

Upon completion of the presentation, the debate scenario was posed and a modified think-pair-share strategy was adopted for the conduct of the debate.²² This strategy was adopted as the students were new to debating and it offered them a stepwise approach to formulating their positions. It eventually allowed the entire class to come together to share and challenge positions they have formulated about the case presented. Initially, in this format, students were given 10 minutes to plan and make notes individually on the debate scenario and then each student was randomly paired with another student. The pairs were given 10 minutes to share their ideas, combine their notes and think more deeply about the topic. On completion of this task, each pair outlined their thinking to the debate facilitators. Each unique strategy suggested was recorded on the board (five in all) and then groups of students (five students per group) were randomly assigned to argue for one of the strategies. The practice of using debates where the debaters must take the view or act out a role that is not necessarily their own is an effective way to teach ethics.²⁹ Each group was given 15 minutes to prepare their case and then present to the class. Questions and class discussion were allowed at the end of each presentation. Facilitator involvement ensured strict timekeeping and avoided drifting off topic. An assessment rubric (Appendix 2) was developed and used to highlight to the students what was expected of a good debater. The rubric was also used to provide students with feedback on their performance following the debate.

A short round-up talk was given to guide students through issues raised and to give them useful reference sources. After the post-debate, students completed their 5-minute papers and an anonymous online survey. In the subsequent afternoon session, students were asked to reflect on the debate as a way of exploring ethics and used this topic as their initial reflective blog entry. The visiting lecturer was given a questionnaire for later completion.

The next issue that arose was whether the students would be assessed on the intervention and if so, whether the marks assigned would contribute to their overall grade for the work placement module. It was decided that the debate would not influence students’ grades. This was because the debate was an exploratory intervention designed primarily to assess its impact on students’ ethical thinking skills not to grade them on their participation. The 5-minute papers were used only for analysis to determine any change in student learning. This methodology compares well with that of Stewart and colleagues’ who used pre- and post-minute papers to measure the impact of an integrated assignment on their pharmacy course. The minute papers completed in that study before and after the assignment showed improvement in student learning.²⁶

Survey completion was on a voluntary and anonymous basis. In relation to the students’ reflective blog entries, they were requested to reflect on what they had learned from the debate. No marks were assigned to these entries. The study received approval from the Dublin Institute of Technology (DIT) ethics committee.

A constructivist ontological position was taken, which allowed for concepts about how ethics are perceived and developed by students to be produced through social dialogue and reflection.³⁰ An interpretivist epistemological position was assumed because an interpretation of the students’ reflection on ethical reasoning was required. This was appropriate because research into how each student perceives the outcome of an ethical dilemma must consider the differences in individuals, and the nature of an ethical dilemma by definition has no one correct outcome.

The methodology chosen for the study was an instrumental case study.³¹ This was appropriate because it was anticipated that the intervention would be easily adaptable more generally. A mixture of qualitative and quantitative methods was adopted; however, the focus