Contents
Peer-Reviewed Articles
Items of Interest
Nigerian Pharmacy Students' Attitudes Toward Pharmaceutical Care
Abstract
Objectives: The objectives of this study were to investigate and describe the attitudes of students in a Nigerian school of pharmacy toward pharmaceutical care.
Methods: A cross-sectional (first-fourth year, n=250) survey of pharmacy students was conducted. Using anonymous responses based on a Likert-type scale, the students completed a self-administered questionnaire designed to test the research objectives. Descriptive statistics on the sample characteristics and questionnaire items including means, standard deviations, and frequency distributions were computed. A Varimax factor analysis with Kaiser normalization was employed. Student's t-test and a one-way analysis of variance (ANOVA) were utilized for inferential statistics.
Results: A Cronbach's alpha reliability coefficient for the survey instrument was found to be 0.78. Of the respondents, 88% agreed that all pharmacists and pharmacy students should perform pharmaceutical care. About half (48%) also indicated that providing pharmaceutical care takes too much time and effort. Attitude rating was 46.33 ± 9.90 (range, 11 to 55; midpoint, 33). Females had significantly higher positive attitudes than their male counterparts (p < 0.0001). Positive attitudes were also associated with age (p < 0.0001), exposure to pharmacy curriculum p = 0.048), and work experience (p = 0.007).
Conclusion: Nigerian pharmacy students in the cross-sectional survey indicated moderately positive attitudes toward pharmaceutical care. Positive attitude ratings were associated with age, sex, curricular exposure, and work experience in a pharmacy setting.
Key words: attitudes, Nigeria, pharmaceutical care, pharmacy students, rating scale
Introduction
The world-wide acceptance of pharmaceutical care as the mission of the pharmacy profession is shaping pharmaceutical education and practice. As a result, pharmaceutical care is adopted as the focus of good pharmacy education.[1] Obstacles that differ in practice settings and places have hampered efforts geared toward the implementation of pharmaceutical care world wide. Some obstacles identified include deficient clinical knowledge and communication skills, insufficient time, and negative attitudes of pharmacy practitioners.[2-5] Attitude factors may represent key obstacles in realizing pharmacists' contribution to society.[6] Chisholm and Wade have indicated the importance of the need to foster positive attitudes regarding pharmaceutical care among practitioners and, more importantly, among future practitioners.[7] Pharmaceutical care philosophy of practice is enabling pharmacy students to visualize how the profession is evolving, irrespective of the future practice settings the students select.[8]
Several approaches have been reported to improve students' attitudes toward pharmaceutical care. One method to foster enhanced attitudes toward pharmaceutical care is exposure to the principles and practice of pharmaceutical care as part of early pharmacy education.[7] There are reports indicating the need to teach pharmacy students the concept of pharmaceutical care and the importance of applying this philosophy of practice to the benefits of patients.[9-12] Another method that may produce positive attitudes for future practitioners is to encourage pharmacy practice experience early in students' pharmacy education. In fact, obtaining pharmacy practice experience before the pharmacy professional curriculum has begun may result in more positive attitudes toward pharmaceutical care.[7] In addition, the effectiveness of using actual patients in the classroom to develop positive students' attitudes toward pharmaceutical care has been demonstrated.[13] A patient-centered intervention programme has also been described and demonstrated to improve students' attitude toward providing care for HIV/AIDS patients.[14]
McDonough et al strongly recommended that students interact with patients early in their academic careers to improve interpersonal communication and empathy skills.[4] The opportunity for students to interact with patients and develop practical concepts about the importance of performing pharmaceutical care occurs traditionally in the latter stages of the pharmacy curriculum during the experiential component. However, introducing students to patients early in the pharmacy curriculum demonstrates the importance of performing pharmaceutical care. Additionally, these early experiences may help students develop positive attitudes regarding pharmaceutical care activities. Such attitudes will hopefully motivate students to incorporate these concepts into practice.[13] The purpose of the pharmaceutical care shadowing experience was to improve the pharmacy students' attitudes toward good professional practices. During the pharmaceutical care shadowing experience, the students gain exposure to relevant ethical and practical issues of pharmacy practice and are expected to share their experiences with fellow classmates and faculty members in a formalized setting.[15] The establishment of student-driven, faculty-observed pharmaceutical care clinics within schools and colleges of pharmacy can help to effectively prepare students for the challenges of an active patient care practice.[16] Another study has determined whether completion of a patient counseling course improved pharmacy students' perceptions of the importance of pharmaceutical care and whether there was a difference in students' perceptions of pharmaceutical care provided in retail settings compared with that provided in clinical settings. This report indicates that teaching the concept of pharmaceutical care and incorporating it into a patient counseling course is more instructive when a clinical setting is used.[17]
Most of the reports concerning future pharmacy practitioners' attitudes toward pharmaceutical care are based on experience in developed countries. As the philosophy of pharmaceutical care spreads to other parts of the world, there is a need to build on professional literature by incorporating evidence from the developing countries. Nigeria is one such country, where pharmaceutical care is gradually dominating the picture of professional philosophy. This most populous country in Africa has an estimated population of over 120 million inhabitants. The number of universities in Nigeria is growing, with 45 currently operating. The federal government owns 23 of these universities, state governments own 18, and the remaining 4 are privately owned. Only 9 of the 45 universities have pharmacy programmes, but plans are underway to establish new schools of pharmacy in Nigeria. The Pharmacists Council of Nigeria regulates pharmaceutical education in the country. All the pharmacy faculties have a 5-year bachelor of pharmacy unclassified (i.e., not classified into first, second, or third class) degree programme. Only the University of Benin received the Council's approval and commenced a 6-year doctor of pharmacy programme in 2001, with a gradual phasing out of its bachelor of pharmacy degree programme. Since the commencement of the doctor of pharmacy degree, this university has been at the centre of pharmaceutical care advocacy in Nigeria. Whereas, the students are exposed to the philosophy and practice of pharmaceutical care, there has been no study on the attitudes of students in the faculty toward pharmaceutical care; therefore, such a study would be necessary. The findings would be a useful baseline data to monitor progress in the training of future pharmacy practitioners.
The objectives of this study were therefore, to investigate and describe the attitudes of the Nigerian pharmacy students toward pharmaceutical care using an existing pharmaceutical care assessment instrument.
Methods
The investigation was performed at the Faculty of Pharmacy, University of Benin, Nigeria. Students participating in the survey represent a random sample of 250 pharmacy students in their professional years. The pharmacy students were selected using a table of random numbers. The respondents completed a self-administered questionnaire designed to test the research objectives. The instrument was developed and re-validated in the United States of America.[18,19] This 13-item standard Pharmaceutical Care Attitudes Survey (PCAS) has been widely employed to assess students' attitudes. Two of the 13 item constructs were negatively worded. The 5-point (Likert-type) response scale was: strongly agree = 5; agree = 4; neutral = 3; disagree = 2; and strongly disagree = 1. Respondents were asked to state the degree to which they agreed or disagreed with the attitude items posed to them. We also added a section to gather data on some demographic characteristics of the respondents. These were sex, age, marital status, professional year, and work experience in a pharmacy.
Returned questionnaires were entered into Microsoft Excel software and checked for accuracy. Data were then loaded into SPSS (version 11.0) for descriptive statistical analysis or GraphPad Instat (version 2.05a) for inferential statistical analysis. Negatively worded attitude items were reversed to enable summation of scores; a logical midpoint between the agree-to-disagree axis was assumed. Mean scores with standard deviations and percentage frequencies were determined. Factor loading was computed to determine items contributing to group summary scores, and 2 items with factor loading of less than 0.4 were excluded. The factor analysis also evaluated the construct validity of the instrument. Cronbach's alpha was calculated to estimate the internal consistency of the responses to questionnaire items. Principal component analysis employed Varimax rotation with Kaiser normalization and list-wise deletion of missing data. This process was accomplished in order to assess the dimensions of students' attitudes toward pharmaceutical care. Rated scores were treated as interval data suited for quantitative analysis. Relationships between the demographic profile and responses were explored using Student's t-test and one-way ANOVA. Inferential statistics were calculated with the aid of GraphPad Instat, which reports exact P values, hence a P value of less than 0.05 was interpreted as significant.
Results
The survey achieved a response rate of 88.0% (220/250). The majority of the respondents were females (57%) and about the same proportion (59%) were aged between 20 and 24 years. About a third of students (31%) were in their second professional year and 44% had work experience in a pharmacy setting. Details of the demographics are presented in Table 1.
Of the respondents, 88% agreed or strongly agreed that all pharmacists and pharmacy students should perform pharmaceutical care. About half (48%) also agreed/strongly agreed that providing pharmaceutical care takes too much time and effort, Table 2.
Chronbach's alpha for the 13 questionnaire items was found to be 0.777. About 50% of the total variance obtained was due to 3 of the 13 items, the first contributing 33.3%, whereas the second and third items had 9.7% and 8.9% respectively. Following determination of communalities, 2 items had factor loading of less than 0.4 and were therefore excluded from the summary score. These items were: "pharmacy students can perform pharmaceutical care during their clerkships," (#4), and "I would like to perform pharmaceutical care as a pharmacist practitioner" (#7). The rated scores and factor loadings, which are used to determine items that belong to the group responses, are presented in Table 3.
Based on the remaining 11 items that loaded above 0.4, the mean total score was computed to be 46.33 ± 9.90 (range, 11 to 55; midpoint, 33). Varimax rotation yielded 3 components. The first component had 10 items and a reliability coefficient of 0.816.The second component comprised 2 items with a reliability coefficient of 0.411, and the third component had only one item and indeterminable reliability coefficient. However, standard grouping of the 13 items as the instrument's developers recommended produced low reliability coefficients as follows: professional benefits (0.635), professional duty (0.562), and return on efforts (0.411). Further inferential statistical analysis indicated that female pharmacy students had significantly higher positive attitudes toward pharmaceutical care than their male counterparts (t = 6.11; p<0.0001). Positive pharmaceutical care attitudes were also associated with age (F=16.47; p<0.0001), exposure to pharmacy curriculum (F=2.67, p=0.048), and work experience in a pharmacy (t=2.74, p=0.007), which are presented in Table 4.
Discussion
Negative attitudes are a barrier to performing pharmaceutical care. The need to foster positive attitudes toward pharmaceutical care among future practitioners of pharmacy is justified. Despite the rapid adoption and widespread acceptance of pharmaceutical care as the focus of pharmacy, the implementation of the philosophy in pharmaceutical education is not widespread. This study represents the first initiative to evaluate students' pharmaceutical care attitudes in Nigeria where pharmaceutical care is being gradually introduced. Though the instrument of data collection was developed in the United States, where pharmacy students have relatively higher level of exposure than their Nigerian counterparts, the instrument's internal consistency in this study was considered satisfactory. Furthermore, we had to use a composite score rather than the subscales, which were considered inappropriate for this study. Overall, the Nigerian students surveyed indicated positive attitudes toward pharmaceutical care in general terms but the dimensions of their attitudes could not match the suggested dimensions of professional benefits, professional duty and returns on efforts[7,14]. We speculate 2 main reasons for this difference. These are differences in the environment of pharmacy practice and pharmacy curricular exposures. The evolution of pharmacy practice models indicates an uneven adoption of a new practice model as opportunities for its existence emerge rather than a series of abrupt changes all over the globe.[20,21] Pharmacy practice and education in Nigeria are still focused primarily on drugs and their distribution with some fragments of clinical pharmacy activities.
Previous data had suggested that female pharmacy students had more positive attitudes toward pharmaceutical care than men. Age and pharmacy work experience were also found to be factors[7,18]. This study provides further evidence supporting previous reports. The findings of this study have implications for pharmacy education in Nigeria. Though the present investigation was conducted in only one of the 9 schools of pharmacy in Nigeria, the results may be an indication of attitudes in other schools as well. Again, the Pharmacists Council regulates pharmacy education in Nigeria. A previous study on attitudes of Nigerian pharmacists toward pharmaceutical care found a preference for a combination of traditional pharmacy practice and pharmaceutical care, as well as gradual introduction of the practice philosophy in Nigeria.[22] There is, therefore, a need for increasing the pharmaceutical care content of the Nigerian pharmaceutical education. Additionally, evidence-based models such as early introduction of pharmaceutical care into pharmacy education, availability of actual patients, and pharmacy students observation of practicing pharmacists should be encouraged.[7,13,14]
Limitations
Though the present investigation was conducted in only one of the 9 schools of pharmacy in Nigeria, the results may be an indication of attitudes in other schools as well. Again, the Pharmacists Council regulates pharmacy education in Nigeria. A previous study on attitudes of Nigerian pharmacists toward pharmaceutical care found a preference for a combination of traditional pharmacy practice and pharmaceutical care, as well as gradual introduction of the practice philosophy in Nigeria.[22] There is, therefore, a need for increasing the pharmaceutical care content of the Nigerian pharmaceutical education.
Not all the students in the survey had been exposed to the concept of pharmaceutical care which could have possibly affected their responses. However, the questionnaire was prefaced with this definition: "pharmaceutical care is a practice philosophy whereby the pharmacist takes responsibility for identifying, preventing, and solving a patient's drug and health related problems." The purpose of prefacing the questionnaire was to give all the respondents the same point of reference to the concept of pharmaceutical care. Furthermore, it may be useful to revalidate the PCAS from the point of view of the students. Since one of the 13 questionnaire items may not be relevant to all pharmacy students, in particular those students who are not familiar with clerkship experiences. Previous research with the PCAS suggested the use of a reduced 12-item (PCAS-reduced) instrument without the clerkship item. The validity of one global score on the PCAS has not been established[13].
Conclusions
This study, as the first of its kind in Nigeria, is considered an important contribution, especially because it provides baseline evidence to monitor changes regarding transitions toward pharmaceutical care education and practice in the country. Nigerian pharmacy students in the cross-sectional survey indicated moderately positive attitudes toward pharmaceutical care. Positive attitude ratings were associated with age, sex, curricular exposure, and work experience in a pharmacy setting. Further research would be necessary to clarify the dimensions of students' pharmaceutical care attitudes. A nation wide survey of students in all the Nigerian pharmacy schools would provide additional evidence. Again, the validity of the widely used Pharmaceutical Care Attitude Scale (PCAS) requires a cross-validation in Nigeria. So far, we have used it to undertake a baseline study to find the direction of students' attitudes, but the dimensions of these attitudes require further clarification.
References
1. International Pharmaceutical Federation (FIP). Statement on Good Pharmacy Education Practice, 1998.
2. American Society of Hospital Pharmacists (ASHP). Statement on pharmaceutical care. Am J Hosp Pharm. 1993;50:1720-1723.
3. May RM. Barriers to pharmaceutical care in acute care setting. Am J Hosp Pharm. 1993;50:1608-1611.
4. McDonough RP, Rovers JP, Currie JD et al. Obstacles to the implementation of pharmaceutical care in the community setting. J Am Pharm Assoc. 1998;38:87-95.
5. Van Mil JWF, De Boer WO, Tromp TFJ. European barriers to the implementation of pharmaceutical care. Int J Pharm Pract. 2001;9:163-168.
6. Knapp DA. Barriers faced by pharmacists when attempting to maximize their contribution to society. Am J Pharm Educ. 1979; 43:357-359.
7. Chisholm MA, Wade WE. Factors influencing students' attitudes toward pharmaceutical care. Am J Health-Syst Pharm. 1999;56:2330-2335.
8. Hepler C, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990; 47:533-543.
9. Admick BA. Teaching pharmaceutical care: removing the fences. Am J Pharm Educ. 1992;56:434-441.
10. Berardo DH. Teaching pharmaceutical care: a methodology for change. Am J Pharm Educ. 1992; 56:430-434.
11. Schommer JC, Cable GL. Current status of pharmaceutical practice: strategies for education. Am J Pharm Educ. 1996;60:36-42. 12. Chisholm MA, Hawkins DW, Taylor AT. Providing pharmaceutical care: are pharmacy students beneficial to patients? Hosp Pharm. 1997;32:370-375.
13. Chisholm MA, Wade WE. Using actual patients in the classroom to develop positive student attitudes toward pharmaceutical care. Am J Pharm Educ. 1999;63:296-299.
14. Chisholm MA Ricci, JF. Development and cross-validation of an instrument to measure first-year pharmacy students' attitudes toward AIDS/HIV patients. Am J Pharm Educ. 1988;62:162-166.
15. Ateequr Rahman A, Tahir R, Brocavich J. Student attitudes and assessment of a first year pharmacy shadowing course. Am J Pharm Educ. 2003; 67(2):article 40. 16. Isetts BJ. Evaluation of pharmacy students' abilities to provide pharmaceutical care. Am J Pharm Educ. 1999;63:11-20.
17. Lawrence L, Sherman J, Adams E, Gandra S. Pharmacy students' perceptions of pharmaceutical care in retail and clinic settings. Am J Pharm Educ. 2004;68(1):4.
18. Chisholm MA, Martin BC. Development of an instrument to measure student attitudes concerning pharmaceutical care. Am J Pharm Educ. 1997;61:374-379.
19. Martin BC, Chisholm MA. Cross-validation of an instrument measuring students attitudes toward pharmaceutical Care. Am J Pharm Educ. 1999;63:46-51.
20. Higby GJ. American pharmacy in the twentieth century. Am J Health-Syst Pharm. 1997;54:1805-1815.
21. Hepler CD. The third wave in pharmaceutical education: the clinical movement. Am J Pharm Educ. 1987;51:369-385.
22. Oparah AC, Eferakeya AE. Attitudes of Nigerian pharmacists towards pharmaceutical care. Pharm World Sci. 2005;27(3):208-214.
Perceptions of Cheating and Self-Reported Cheating Behaviors of First-Year and Third-Year Pharmacy Students
Paul L. Ranelli, PhD, Professor, College of Pharmacy, Duluth, University of Minnesota, Duluth Minnesota
Introduction: Despite the interest in and number of studies examining cheating within the university system, little has appeared in the literature regarding academic dishonesty among professional students, such as pharmacy students. The authors examined the differences between first-year and third-year pharmacy students relating to perceptions of cheating and participation in cheating-related behaviors.
Methods: A nonproportional quota sample of pharmacy students was selected to complete the attitude toward cheating scale (ATC). Statistical analysis was used to model the effects of students and student-related characteristics on perceptions of cheating and participation in cheating-related behaviors.
Results: Statistical differences were found between first- and third-year pharmacy students in both perceptions of cheating and participation in cheating-related behaviors. Additionally, both groups report rates of cheating statistically greater than zero.
Conclusion: First-year and third-year students had dissimilar views about cheating. The professionalization and normative processes of a pharmacy school curriculum appeared to influence students' participation in academic cheating, since third-year students generally reported less cheating than first-year students.
Key words: cheating, professionalization, teaching, learning, curriculum, pharmacy students
Introduction
The literature on academic cheating is replete with statements that include words like "epidemic," "on the rise," and "increasing numbers."[1-3] McCabe, founder of the Center for Academic Integrity at Duke University, has researched the incidence of cheating since the 1960s and has discovered some interesting facts.[2] Of students surveyed in 1993, 87% admitted to cheating on written work and 70% on classroom exams. Fifty-nine percent collaborated with others on assignments, 52% copied from others, and 26% plagiarized.
The incidence and causes of cheating have also been investigated. Reported cheating was more common in men than women, more common with students who possess low grade point averages, more common in younger students than mature ones, and more common in science and technology students than those in other disciplines.[4] Nevertheless, student motivations for cheating vary. Evidence suggests that those with high achievement motivation are more likely to cheat than those with lower levels.[4,5] Research also indicates that moral development is related to cheating.
It has been found that scores on moral reasoning tests correlate negatively with the occurrence of cheating.[6] For example, Kohlberg evaluated cheating behaviors among students at 2 levels of moral reasoning-pre-conventional and post-conventional.[7] Pre-conventional students behave according to socially acceptable norms and obedience is compelled by threat or punishment. This level is characterized by a view that correct behavior means acting in one's best interest.[8] Approximately 70% of the students at this level were found to cheat.[7] Students at the post-conventional level demonstrate an understanding of social mutuality and a genuine interest in the welfare of others. About 15% of students at this level demonstrated cheating-related behaviors.[7]
Despite the interest and number of studies examining cheating within the university system, little has appeared in the literature regarding academic dishonesty among professional students, such as pharmacy students. In a study examining attitudes toward cheating, Hardigan found that pharmacy students guided by intrinsic motivations possess more conservative attitudes toward cheating-related behaviors than those motivated by external considerations.[9] Efforts by academic and professional organizations to promote the professionalization of pharmacy have addressed this issue from a holistic perspective. This approach, while not addressing cheating specifically, details the expected behaviors of pharmacy professionals. Among these prescribed behaviors is the mandate for ethically sound decision- making.[10]
This study helps to broaden and advance the research related to the study of ethical decision-making by pharmacy students. Specifically, the methodology examined the differences between first-year and third-year pharmacy students relating to perceptions of cheating and participation in cheating-related behaviors. Because a close relationship exists between professionalization and cheating, this study adds empirical data to the study of pharmacy students as ethical decision makers.
Methods
In the fall of 2002, a nonproportional quota sample of pharmacy students was selected to complete a questionnaire about cheating (QC). Non-proportional quota sampling allows the researcher to specify the number of sampling units they want in each category (i.e., gender, ethnicity, age, first- and third-year students). This sampling method helps to ensure that smaller groups are adequately represented in the sample. The authors identified 9 colleges of pharmacy that they felt best represented a cross-section of pharmacy education. In choosing the sites, specific attention was placed on whether the college was a public or private institution, whether it was located in an urban or rural setting, and its geographic location. Coordination was initiated with a faculty member at each college to determine if he/she would participate with the data collection process. Once a faculty member agreed to participate, he/she was mailed the requisite number of surveys along with directions for administration. Every attempt was made to standardize the data collection process and maintain student anonymity. The standardization process included a list of instructions that described how students should receive the survey, complete the survey, and submit the completed survey to the faculty member for return mailing. The faculty members who participated in the data collection process were given an honorarium for their participation.
The QC is a self-report instrument consisting of 17 questions regarding situations/actions that could be considered cheating (Figure 1).[10] Questions were presented using a dichotomous (yes/no) format asking the student if they considered the actions to be cheating. An additional statement was attached to each question which asked the students if they had participated in this behavior prior to (first-year students) or during pharmacy school (third-year students). Evidence of the instrument's reliability and validity was established in an earlier study.[10] Demographic data collected from respondents included gender, ethnicity, age, religiousness, educational background, current enrollment year, and grade point average. Religiousness was a self-reported measure (yes/no) of whether or not students considered themselves religious persons.
The independent variables included in the model were student gender, ethnicity, age, religiousness, educational background, current enrollment year, and grade point average. Two nominal variables were used as dependent variables: (1) a yes or no variable that asked students if they considered a behavior to be cheating, and (2) a yes or no variable that asked students if they engaged in this behavior. Chi-square analysis and t-tests were conducted to determine if the demographic characteristics between first- and third-year students were significantly different. Logistic regression models were calculated using the independent variables as covariates and yes or no questions as dependent variables; the a priori level of significance was p < 0.05.
Additionally, we tested the hypothesis that students in each group cheated at a rate greater than zero. We performed this analysis because we wanted to see if pharmacy students cheated at a rate greater than what would be expected by chance (Ho:µ1=0--nil value).
Results
A total of 844 students completed the survey. Of these, 823 were used for analysis; the other 21 surveys were not usable because of missing or incomplete data. Fifty-three percent were first-year students. As shown in Table 1, 67% of respondents were female, 74% considered themselves to be religious and the mean GPA was 3.3. The relevant chi-square or t-test demonstrated no statistical differences across the demographic variables of age, gender, GPA, religiousness, and educational background. The only difference found to be significant was the variable ethnicity; more non-Hispanic and Hispanic whites were found within the first-year student cohort, while more Asian Americans were in the third-year cohort (χ 2=36.82, p < 0.01). This would indicate that other than enrollment year, the groups were comparable.
Table 2 shows the students' perceptions of 17 behaviors as cheating. Using the adjusted logistic model, more first-year students than third-year students believed that not contributing a fair share in a group project (χ 2=18.03, p < 0.01) and allowing someone to copy homework were cheating (χ 2=6.83, p < 0.01). More third-year students believed that using an old test to study without the teacher's knowledge was cheating (χ 2=7.72, p < 0.01). Other than these differences, first-year and third-year students had similar views about cheating. Seventy to 90% of respondents in each class considered the 10 behaviors related to test-taking as cheating. Similarly, 81-88% of respondents in each class believed the 3 behaviors related to writing term papers were cheating.
Using the adjusted logistic model, there were statistical differences between first-year and third-year respondents for self-reported participation in 7 cheating behaviors (Table 2). Six of these pertained to test-taking behaviors. Compared with third-year students, more first-year students reported looking at notes during a test (χ 2=17.31, p < 0.01), arranging to give or receive answers by signal (χ 2=6.23, p < 0.01), giving answers during an exam (χ2=15.96, p < 0.01), allowing a student to copy a test (χ 2=10.52, p < 0.01), and asking for an answer during an exam (χ 2=7.72, p < 0.01). More third-year than first-year respondents reported obtaining a copy of an exam and memorizing answers (χ 2=5.21, p < 0.05) and using an old test to study without the teacher's knowledge (χ 2=36.29, p < 0.01).
Testing the null-hypothesis that students in each group cheated at a rate greater than zero indicated significant findings. For first-year students, 15 out of 17 showed statistical differences (p < 0.05). The questions not statistically different from a zero response were taking a test for someone else and having someone write a term paper for you. For the third-year students, 14 questions were statistically different. The 3 questions not statistically different from a zero response were looking at notes during a test, taking a test for someone else, and having someone write a term paper for you.
Discussion
The cheating behaviors listed in Table 2 were randomly listed in the survey instrument. When they were put into categories, trends concerning respondents' beliefs about cheating became evident. Over 70% of respondents believed that all of the test-related and paper-related behaviors were cheating. For the 4 behaviors in the other category, however, there was less consensus that the behaviors were cheating; agreement ranged only from 27-60%. What is unique about these 4 behaviors is that they tend to fall into what may be considered a gray area. That is, individual variation, cultural norms, and professor expectations, may have played a large role in whether respondents considered allowing someone to copy homework, not contributing a fair share in a group project, using an old test to study without the teacher's knowledge, and using a paper for more than one class to be cheating. According to Wankat and Oreovicz[11] different cultures define the act of sharing answers with a friend differently, so professors need to share their definitions and rationales with the class. Other researchers have found that it is important to discuss the rules of plagiarism and cheating with students, preferably during the first class session.[11-14]
Interestingly, 3 of the 4 behaviors were statistically different between first-year and third-year respondents. Fewer third-year students considered allowing someone to copy homework and not sharing in a group project to be cheating, while fewer first-year students considered studying from an old test without the teacher's knowledge to be cheating. This possibly indicates that the professionalization found within pharmacy schools may play an important role in how students view cheating and other ethical behaviors.
An interesting point to consider is that in comparing the incidence of participating in these other cheating-related behaviors, only the practice of using an older test to study without the teacher's knowledge showed any significant difference between the 2 classes. This may indicate that despite differences between classes in the students' perceptions of what is cheating, their participation in these behaviors is not significantly different.
The question of whether the student engaged in each of the possible cheating behaviors formed the essence of the study, and the results show that there are differences in cheating behavior before and during pharmacy school. While the first-year and third-year students were not necessarily matched groups, trends between the 2 groups can give us an indication of how professionalization, academic rigor, and peer pressure may affect their behavior. It appears as if pharmacy students are not cheating at the extent to which other studies have reported this behavior. For example, McCabe and others reported that about 70% of undergraduate students have cheated on classroom exams. It may not be appropriate to compare cheating among pharmacy students with undergraduate students, since the environment of pharmacy school is different from the undergraduate classroom environment.[2,4,5,9]
If researchers of cheating behaviors take a closer look at the health professions, some parallels in cheating behaviors between pharmacy students and other health professional students can be seen. One study found that 16.5% of medical students reported cheating on classroom exams as undergraduates, but only 4.7% reported cheating in medical school.[15] In this study, cheating decreased for 5 of the seven behaviors showing statistical differences between first-year and third-year respondents. Most differences between first-year and third-year pharmacy students were found with cheating on classroom exams. First-year students were more likely to cheat during the exam. For instance, looking at notes during a test decreased from 5.75% to 0.79%, and giving answers during an exam decreased from 11.72% to 4.22%. Third-year students were more likely to engage in cheating behaviors before the exam, such as obtaining a copy of an exam and memorizing answers or using an old test to study without the teacher's knowledge. The various methods that might be employed to obtain a copy of an exam are best left to other researchers. Thus, it appears that the professionalization and norms of a pharmacy curriculum affect both pharmacy students' cheating behavior and their view of cheating.
A consistent pattern emerges with first- and third-year pharmacy students, in that both groups responded relatively homogenously in regard to overall cheating behavior. The highest percentages of students in both classes cheat in the "gray zone." This area is defined as a gray zone because many respondents do not define the behavior as cheating.
Limitations
This study has several limitations that may lessen the generalizability of the results to all pharmacy students. First, the study uses a non-random sample of pharmacy students. Careful selection of the 9 pharmacy schools, however, helped ensure representation of public, private, urban, rural, and geographically diverse schools.
Second, survey research relies on respondents answering questions honestly. To help students feel comfortable admitting to cheating, the authors worked with the faculty member at each school to assure anonymity. Even so, students may not have provided honest answers. In addition, the results do not describe the scope of cheating among pharmacy students, since they were simply asked whether they ever engaged in the behavior before or during pharmacy school, not the frequency of the behavior.
Third, the survey provides cross-sectional data of the behaviors of first-year and third-year pharmacy students. From this data, the authors are inferring that behavior changed from the first year of pharmacy school to the third year of pharmacy school. The 2 groups are relatively similar in background characteristics, making this inference plausible.
Conclusion
Despite its limitations, this study provides insight into academic dishonesty among pharmacy students. First-year and third-year students at 9 schools of pharmacy indicated similar views about cheating, especially related to test-taking and paper-writing behaviors. Pharmacy students tended to report more cheating for behaviors for which they did not have consensus about defining the behavior as cheating. The professionalization and normative processes of a pharmacy school curriculum appeared to influence students' participation in academic cheating since third-year students generally reported less cheating than first-year students. Pharmacy educators should include discussions of academic dishonesty in their course curricula so that educators and students can share similar expectations. Similarly, a concerted effort by schools to add a professionalization component within the curriculum may help develop a culture that discourages cheating.
References
1. Altschuler, GC. Battling the cheats. Education Life Supplemental. New York Times 2001 January 7; Sect 4A (col1).
2. McCabe DL. What we know about cheating in college. Change. 1996;28:28-33. 3. Turrens JF, Staik IM, Gilbert DK, Small WC, Burling JW. Undergraduate academic cheating as a risk factor for future professional misconduct. In: Investigating research integrity: proceedings of the first ORI research conference on research integrity. Washington, DC; 2001.
4. Newstead SE, Franklyn-Stokes A, Arnold P. Individual differences in student cheating. J Educ Psychol. 1996;88:229-241.
5. Friedman M, Rosenman RH. Association of specific overt behavior pattern with blood and cardiovascular findings. JAMA. 1959;169:1289-1296.
6. Malinowski CI, Smith CP. Moral reasoning and moral conduct: an investigation prompted by Kohlberg's theory. J Pers Soc Psychol. 1985;9:1016-1027.
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8. Barger, R.N. A summary of Lawrence Kohlberg's stages of moral development. Available at: http://www.nd.edu/~rbarger/kohlberg.html. Accessed January 10, 2006.
9. Hardigan PC. First- and third-year pharmacy students' attitudes toward cheating behaviors. Am J Pharm Educ. 2004;68:110-11.
10. Graham, MA, Monday, J, O'Brien, K, & Steffen, S. Cheating at small colleges: an examination of student attitudes and behaviors. J Coll Student Dev. 1994;35:255-260.
11. Hendershott A, Drinan PF, Cross M. Gender and academic integrity. J Coll Student Dev. 1999;40:345-354.
12. Wankat PC, Oreovicz FS. A different way of teaching. ASEE Prism. 1994;3(5):16.
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Web Site Review: Patient Medication Counseling
Brooke Berry, Pharm.D. Candidate, McWhorter School of Pharmacy, Samford University, Birmingham, AL
Faculty Facilitator: Michael Kendrach, Pharm.D., Associate Professor, Director, Drug Information Services, Birmingham, AL
Introduction
Counseling patients regarding appropriate medication use is a vital component of a pharmacist's daily responsibilities. Patients receiving verbal instructions from the pharmacist is important, but may not be complete. Patients may not remember all the instructions and information provided to them, which may lead to medication non-compliance as well as medication misadventures. Therefore, in addition to spoken communications, providing written materials containing a medication overview with proper administration techniques, side effects, and dosing, is essential for some patients.
Pharmacies have computer programs that can print patient medication education sheets. These documents can assist the pharmacist in counseling patients. However, patients may obtain medication education from other sources besides the pharmacy. Many Internet sites are available free to the public that furnish medication information presented in terminology comprehensible to non-healthcare professionals.
Pharmacists need to be aware of these Web sites for various reasons. As more patients become reliant on the computer for information, pharmacists can recommend internet sites deemed appropriate for a patient desiring additional information regarding a medication. The patient may be eager to participate in his/her healthcare and have a willingness to learn about new medications, or the patient may have seen an advertisement for a new medication and wishes to learn more. In addition, free medication information Web sites can reduce costs for the pharmacist plus offer remote access to patient oriented information while away from the pharmacy.
The purpose of this review is to assess various Web sites that provide free access to prescription medication information prepared in non-healthcare professional language.
Discussion
A total of 16 Web sites were identified and reviewed (see Table 1). Overall the information provided by all the sites was very comparable, with some exceptions. A comparison of some notable features follows. USA Today Web site offers patients very comprehensive information for their personal medical care. The Web site not only directs the consumer to drug information, but also information addressing blood tests, recent news stories pertaining to their drug search, disease state information, and related information. Some advanced wording and language are also within this site. Drugs.com has consumer information, advanced consumer information, and professional information. The site also offers a search method to locate recommended medications to treat specific medical conditions. One Web site, emedicine.com, is least preferred. This site was difficult to navigate and provided more articles related to corresponding topics than direct drug information. Emedicine.com should be recommended only to consumers who not only seek medication information, but also disease state information. The remaining 13 sites presented the data logically and with bolded sub-headings for easy information retrieval. The Web sites in Table 1 are arranged by the author's preference based upon the most user-friendly and informative sites to the least recommended.
Table 2 presents a few differential features of selected Web Sites, particularity the origins of the information presented for these patient education sites. After reviewing the content of all the Web sites, 7 of the 16 sites (Discovery Health, Drugs.com, FDA, Health A to Z, IQ Health, Mayo Clinic, and Medline Plus) obtained their information from a single source, Micromedex/Cerner Multum. Although the information was identical among these Web sites, the presentation format differed among these sites. For example, Medline Plus and the Mayo Clinic contain a jump box (box located at the top of the Web page that provides a link directly to the topics stated within the box) at the start of the information.
Three Web sites (CVS.com, RiteAid.com, and WebMD) presented the information obtained from FirstDataBank, Inc. All 3 of these sites contain a jump box, facilitating the patient to the information they desire. Wolters Kluwer Heath, Inc. (Facts & Comparisons) was the information resource for Winn Dixie and Walgreens. Winn Dixie's site also contained a jump box. Express Scripts reads information from Clinical Pharmacology. The information presented by emedicine.com is not from a commercial vendor but written by pharmacists and reviewed by physicians.
One particular area of interest with increasing applicability is whether or not the information is available in Spanish. Four of the 16 Web sites offered Spanish: Medline, Winn Dixie, Rite Aid, and Drugs.com. An additional feature provided by Walgreens, WebMD, and Express Scripts is photos of the medications.
The Web sites reviewed have common information sub-headings. In fact, Health A to Z, IQ Health, and Discovery Health's share the exact information and presentation. The following list describes the information sub-headings that all sites have in common:
In conclusion, many free Web sites presenting medication information prepared for consumer use are available. Although all 16 sites present a similar collection of information, a few have multiple differences that distinguish selected sites as more user-friendly than others. Different education levels and computer savvy should be taken into account when recommending specific sites. Preferred Web sites are USA Today, WebMD, and the Mayo Clinic, while emedicine.com is least preferred. These tools provide additional modes of information dispersal that not only help ease the burden on the pharmacist's time, but can also provide valuable information to those who consult the Web sites.
Updated
February 7, 2006