Giving “ Best Advice ” : Proposing a Framework of Community Pharmacist Professional Judgement Formation

Community pharmacy is often portrayed as a marriage of professional and business roles in a commercial domain, thereby creating a need for, and value in, pursuing the development of professional competencies for use in the community pharmacy business. In context, professional judgement is the application of knowledge, skills and attitudes (competencies) which, when applied to situations where there is no one or obvious right or wrong way to proceed, gives a patient a better likelihood of a favourable outcome than if a lay-person had made the decision. The challenge for community pharmacists is that professional judgement formation is influenced by professional, commercial and personal criteria with inherent interconnected challenges. In community pharmacy practice in the Republic of Ireland (ROI), this challenge is compounded by the fact that advice is normally provided in an environment where the pharmacist provides professional advice “for free” and then may offer to sell the patient a product or service based on that advice, an activity which amounts to a commercial transaction. While there is currently no evidence to confirm whether or not these professional judgement influences are resolved successfully, their very existence poses a risk that their resolution “in the wrong way” could compromise patient outcomes or professional standing following the delivery of pharmacy services. It is therefore apparent that a community pharmacist requires skills in identifying and analysing professional/commercial/personal influences in order to appreciate the criteria which may affect both parties’ (patient and pharmacist) decision making. By contemplating the interaction between the pharmacist’s professional competencies and the individual influences OPEN ACCESS


Introduction
Community pharmacy businesses (CPB) exist in a "dual market" industry combining retail services and professional services [1] and are often portrayed as a marriage of professional and business roles in a commercial domain [2][3][4].As an overwhelming majority of CPBs in the Republic of Ireland (ROI) fall into the category of small to medium-sized enterprise [5][6][7] particularly in a rural/regional domain, community pharmacists have both business role and professional role orientation [3] and are therefore motivated by both service and income values.Regardless of the range of pharmacy services attracting remuneration based on a pharmacy's contract with the Irish State, these dual challenges may force the community pharmacist as business owner to "choose between their professional obligations to counsel patients and [their] business objectives" [8] (p.179).This reality often touches on the pharmacist's personal influences [9], moral reasoning skills and professional ethos.The inherent judgement formation challenge is compounded by the fact that in a CPB, the pharmacist generally provides professional advice "for free" and then may offer to sell the patient a product or provide a service based on that advice, an activity which amounts to a commercial transaction [4].Herein lies a dilemma, how is the pharmacist to simultaneously earn a living as a business owner, successfully meet their obligations as a healthcare professional and fulfil a balance between professional and personal strata?
The resolution of such dilemmas often require the application of specific knowledge, skills and attitudes-collectively labelled competencies [10,11], to ensure such decisions are made in the "right" way [12].Contemplation of these competencies requires a further on going action on the part of the community pharmacist, that of critical reflection in order to facilitate knowledge enhancement and skill integration, and to meet the regulatory requirement to "demonstrate the ability to critically reflect on [the pharmacist's] own practice" [11] (p. 7).Of note is that the cultivation of these distinctive competencies can provide a basis for competitive commercial advantage in the community pharmacy setting [1,13], allowing for mutual improvement within and between the professional, commercial and personal criteria evident in the CPB setting.While "research cannot tell practitioners…what to do" particularly in the professional judgement domain as an "ill-defined factor" [14] (p.17), it is disheartening to consider that the majority of community pharmacists enter business without much guidance as to how to address the ethical and moral dilemmas they will face when providing professional advice in a commercial setting [2,4].Therefore, the authors propose a framework of professional judgement formation to support community pharmacists' application of knowledge, skills and attitudes which, when applied to situations where there is no one or obvious right or wrong way to proceed, gives a patient a better likelihood of a favourable outcome than if a lay-person had made the decision [11].For the purposes of clarity, a framework is defined as "a set of assumptions, concepts, values, and practices that constitutes a way of viewing reality" [15].In this context, the proposed framework is an "arrangement of parts" to help the community pharmacist consider, contemplate and comprehend professional judgement formation.
The article begins by exploring professional competence before pursuing an understanding of the professional, commercial and personal (PCP) influences involved in forming a professional judgement in the ROI context, in order to increase understanding of how community pharmacists form these judgements.While there is currently no evidence to confirm whether or not these professional judgement influences are resolved successfully, their very existence poses a risk that their resolution "in the wrong way" [16] could compromise patient outcomes following the delivery of pharmacy services in a retail setting.It is therefore apparent that a community pharmacist requires competence in identifying and analysing professional influences in order to appreciate the criteria which may affect both parties' (patient and pharmacist) decision making [17].By contemplating the interaction between individual influences and their impact on the formation of the community pharmacist's professional judgement in a commercial setting, we can consider the enhancement of professional competencies that underpin the "best" advice being offered to the patient culminating in a framework of professional judgement formation.

Professional Competence in a Community Pharmacy Business
While the principles of profession and professionalism have often been a topic of debate [10,18,19], there is no clear definition of professionalism as applied to pharmacy [20], and it is only recently that the formation of professional judgement has been specifically referenced in Ireland's primary legislation governing the practice of pharmacy [21] or defined in professional guidelines in Great Britain [22].A profession is deemed to be a vocation with a body of knowledge and skills put into service for the good of others [23] while the attitudes that a pharmacist demonstrates in interaction with patients and their families, and with professional colleagues are the foundations on which professionalism rests [10,24].Collectively, these criteria-knowledge and skills (profession) and attitudes (professionalism)-amount to the competencies engaged by the pharmacist when forming a professional judgment.
From a professional perspective, community pharmacists are expected to have: a systematic body of knowledge, authority recognised by patients, broad community sanction of this authority, adherence to the regulative code of ethics/conduct and a professional culture sustained by professional associations [18].When seeking to fulfil these professional requirements, community pharmacists need to be competent to handle uncertainty and apply well-reasoned, ethical and logical judgement when considering the best advice to give to a patient [2,24,25].Therefore the meanings that a pharmacist assigns to competence and competencies merit clarification.The International Pharmaceutical Federation [26] (p.4) proposes that competence be defined as: "The capacity to improve therapeutic outcomes, patients' quality of life, scientific advancement and enhancement of our public health imperatives" while "competencies", it proposes "...refer to the knowledge, skills, attitudes … that an individual develops through education, training, development and experience.Taken together, these competencies can be formulated into a framework that can contribute towards supporting practitioner development, within an individual, for effective and sustained performance".These competencies are explored from a community pharmacist perspective in Table 1.

Knowledge
Acquisition of fact, truths, principles acquired through experience or education; the theoretical or practical understanding of a subject, a particular field or a decision-making framework.
Pharmacists consider (and conceptualise) the consideration of a drug molecule, together with its formulation and delivery in pursuit of the "safe, effective and rational use of medicines" [27] (p.391).They have an in-depth knowledge of pharmacology and therapeutics, physicochemical properties of drugs and excipients, bio pharmacy, and pharmacokinetics, adverse drug reactions and drug interactions.It is this complex, varied and integrated expert knowledge that qualifies them, and them alone, to make professional judgements relating to medicines [12] (p.146).

Skills
The ability, coming from one's knowledge, practice, aptitude to do something well-referred to as "the artistry of practice" [28] (p.403).
The (tacit) skill of a community pharmacist can be demonstrated in the communication process required to respond to symptoms and deciphering whether the presented symptoms are self-limiting or require a referral to another healthcare professional [29].

Attitudes
The "readiness of the psyche to act or react in a certain way...
Pharmacists have a certain moral professional identity as they are the gatekeepers to safe drug usage and (are) required to use their knowledge responsibly in the healthcare system [29] (p. 6).
Table 1 explores the professional competencies [31], inherent moral/ethical considerations [29] and assumed reflective practice engaged by the community pharmacist when forming a professional judgement and highlights the dynamic these create in a pharmacist-patient relationship.Of relevance to the potential impact professional influences may have is the question "who decides?" when an appropriate competence level is evident.Fitness-to-practice committees are typically required to adjudicate on allegations of "professional misconduct" made against registered pharmacists or pharmacy owners, usually by reference to Codes of Conduct/Codes of Ethics.However, despite the publication of a core competency framework for Irish Pharmacists in August 2013, "the exact nature of professional, cultural and technical competencies required to satisfy these new fitness-to-practice requirements remain undecided" [32] (p.71), and commentators believe "if there was to be an impact on pharmacy practice, desirable objectives require detail regarding competencies and how they were to be achieved" [33] (p.693).Thus, despite the fact that fitness-to-practice legislation already in place could impose sanctions on Irish pharmacists [11,21]; there remains a gap between the guidance explicitly directed by these Codes, and the challenges to the formation of professional judgement experienced in the practice environment [34].Much is left to the "subjective interpretation" [35] of the professional judgement influences and their impact on the formation process.The authors believe this gap can be addressed through the exploration of these influences and propose that this approach offers professional guidance in context.

How Professional Judgement Is Formed
Although mentioned in primary legislation governing pharmacy in Ireland [21] ([No.20.] PART 6 Complaints, Inquiries and Discipline 33) professional judgement is not specifically defined.As an intangible and undefined element of the professional interaction between the pharmacist and a patient in the Irish context, it is employed by the pharmacist to enable commitment to the patient's "best interests" when making a decision whether to, and what to advise regarding the patient's health.Notably, the ROI Pharmacy Act [21] specifically refers to professional judgement and it alludes to the possibility that such judgement might be "wrongly but honestly formed" (No. 20, Part 6, 33, a-d).This has the potential to result in an allegation of "professional misconduct", although this general discussion is outside the domain of this paper.Of note from a business ethics perspective is that community pharmacists are "required to use their knowledge responsibly in the healthcare system" [29] (p. 6) and are assumed to have a moral professional identity as gatekeepers to safe drug usage (Table 1).
When forming a professional judgement, the community pharmacist seeks to produce a final choice where the output can be an action or an opinion of choice that has the highest probability of success or effectiveness, and best fits with the values and preferences of the decision maker [3].The more acute the dilemma presented to the pharmacist, such as where an immediate response is required and opportunity to consult with other care-givers is not an option, the higher the degree of uncertainty regarding potential action options.As few decisions are made with absolute certainty, because complete knowledge about all potential alternatives is seldom possible, reasoned decision making is a process of sufficiently reducing uncertainty about alternatives to allow a reasonable choice to be made from among them [17,36].Wingfield and Badcott [37] propose a "pragmatic and utilitarian" four-stage approach to decision making when forming a professional judgement: (1) gather relevant facts, (2) prioritise and ascribe values, (3) generate options and (4) choose an option.This approach presupposes that any professional tension inherent in the situation is recognised in the first instance, creating an assumption that there is a systematic structure to the process which may not necessarily be the case [38].It also assumes that the community pharmacist employs both rational and ethical reasoning [24] engaging a value-based approach with explicit justification as to the background to the decision.From a community pharmacist perspective, this reasoning is core to the formation of a professional judgement as it represents the management of the inevitable tensions that exist when a pharmacist seeks to prioritise a patient's "best interests" in presenting options [39].As such, this process engages both the pharmacist and the patient, and the key influences relating to this interaction are explored below.

Key Influences and Their Impact on Professional Judgement Formation
Professional, commercial and personal influences (PCPI) form part of the environment in which community pharmacists make decisions [6,39].Sensitivity to such influences, and to potential conflicts of interest, is an essential pre-requisite to professional judgement [2,17] as if one does not recognise a dilemma in the first instance there will be no perception of a need to reason through it.Likewise it is recognised that it is the actions (or failure to act) by the professional that will attract scrutiny [21], requiring the pharmacist to explain his/her actions and justifications for judgements formed.This increases the pressure on practitioners to themselves recognise and manage influences on the formation of professional judgement if they are to develop and maintain the competence to effectively impact on pharmacy practice.
Herein lies a professional challenge, particularly when provision of professional advice occurs in a retail setting [13,40], potentially creating tension between professional and commercial goals [7,16].The community pharmacist professional judgement debate is further complicated by the fact that from the pharmacist's perspective, personal values are a dimension that should be considered in context [9,17,38], particularly as the service provider is inseparable from the service.This highlights the conflict between the two roles of acting as a professional adviser and then providing the service or product the patient might need [16].Thus the objective of the community pharmacist's professional judgement formation is to minimise the risk of potential conflicts of interest (or self-interest) becoming actual conflicts of interest when providing advice (Table 2).

Professional
Risk of not acting in the patient's best interests due to: (a) an error of judgement, (b) inadequate control over the situation, (c) decreased formality levels in the CPB.
Desire to maintain "good standing": Influence of statutory/regulatory requirements and the risk of a charge of negligence.
(a) Inadequacies in professional communication skills leading to misunderstandings, which may be exacerbated by isolation [41]; (b) potential distractions in the pharmacy [42]; (c) Reduced formality can increase the risk of "layman" rather than "professional" judgement being applied to interactions with patients.
Protection of self-interest by restricting actions to the letter of the law rather than having the character to apply professional judgement is essential to meet the duty of care to a patient.

Commercial
Professional worth as assessed by commercial "success".
Time spent on patient counselling is unremunerated in the ROI (and is largely unremunerated in other jurisdictions).
Pharmacist responsibility, whether employee or owner, to all stakeholders.
Placing commercial objectives above duty of care.
Defensive formation of professional judgement where the pharmacist may act conservatively to avoid risk of "failure" [16].
Professional advice may not necessarily attract income [8], potentially influencing the pharmacist to supply product.
The reality of earning a living, pursuing profit, and pressure to repay debt influences decision making [17], particularly when in "survival" mode.
Where the pharmacist moves beyond commercial necessity in sole pursuit of commercial gain.

Personal
Self-protection: fear of increased public scrutiny and regulation.
Altruism: sensitivity to potential conflicts of interest; ethical reasoning.
Fear of having to explain his/her actions and provide justifications for judgements made may promote conservative judgement formation.
Subordination to patient or prescriber demands rather than acting according to "best interests" principles [41].
Motivated to accommodate the patient perspective to facilitate informed consent [17].
Table 2 summarises the professional, commercial and personal influences prevalent when forming professional judgements.These examples afford reader insight into the day-to-day tensions within and between each influence as evident in the range and scope of pharmacy services currently delivered by community pharmacists in the ROI.However, regardless of the scope of practice in a given jurisdiction, the commercial-professional dilemma is one which is amplified in modern economics, when national and international health policies and programmes are driving a cost agenda, potentially skewing the importance of this (commercial) influence in detriment of balanced professional judgement formation.The goal is to ensure the pharmacist has the appropriate competencies in order to offer the patient the "best" advice [25].The authors' propose that a framework of professional judgement formation, where the community pharmacist either expressly or inherently considers the influences pertaining to a competent judgement, offers professional value in this domain.

A Framework of Professional Judgement Formation
Figure 1 considers the professional, commercial and personal influences prevailing during the formation of the community pharmacist's professional judgement and how these influences interact with professional competencies pertinent to that judgement.By contemplating the interaction between the pharmacist's professional competencies (Table 1) and the individual influences on that pharmacist (Table 2), we can consider how these influences impact on the formation of the community pharmacist's professional judgement (Figure 1).
Professional influences: Community pharmacists' advise patients on how to deal with symptoms through the "safe, effective and rational use of medicines" [27] (p.391).They further advise the patient whether to have a prescription filled and they then supply the product the patient requires.Thus, the retail setting in which community pharmacists' practice can create uncertainty in patients' minds as to whether they ought to expect standards of retailing excellence or standards of healthcare excellence.In reality, both are required to fulfil the community pharmacist's "social contract" [24], a reality that can exacerbate the potential for commercial, professional and personal influences to conflict.
Personal influences: From a CPB perspective "it is not uncommon for professional pharmacists to experience conflict between their own … beliefs and duties and their obligations to the pharmaceutical organizations for which they work" [43] (p.296).Thus, there is a personal dimension in the decision process [38], wherein the community pharmacist's value system influences their judgement (Table 2), and ultimately the preferred option(s) offered to the patient [9].These personal influences may include (but are not limited to) personal and professional background, location and source of previous professional experience, moral reasoning competencies, personal lifestyle preference, personality traits, age, gender, religion and cultural background.The challenge from an ethical perspective is to ensure that the community pharmacist's personal preferences, value structures and self-protection mechanisms are reflected on when applying rational and ethical professional judgement.
Commercial influences: There is reason to believe that various forms of "service or success" challenges [8,16,40] exist for a community pharmacist, regardless of whether they are self-employed or not.In the ROI, the pharmacy's income is derived from sales evolving from advice that includes a recommendation to purchase a product or service from the pharmacy.The ROI pharmacy contract does not include payments for patient care services such as Medicines Usage Reviews (MURs) or Medicines Reviews as are provided in jurisdictions such as the UK and Canada.Thus, if the pharmacist does not recommend a purchase, he/she is not remunerated for that advice (Table 2).Indeed, if the community pharmacist refuses, ethically, to provide a patient with something for which they are prepared to pay, then not only does the community pharmacist get no remuneration, but they may also do potential damage to the business "goodwill".Further, a team-based approach raises specific professional challenges, where a patient may interact with non-professional members of staff over whose actions the responsible pharmacist may or may not have direct control [40,44].Finally, while the fact that, in the ROI, the initiation of prescription drug supply is not driven by the community pharmacist reduces the external appearance of a potential conflict, in reality pharmacists are regularly consulted by a patient who has been given a prescription for a medication he/she does not want to take (for example, in the case of prescribing for anti-depressant medication where the patient is not convinced that the chemical route is most appropriate) creating a need for professional judgement on the part of the pharmacist.

Conclusion and Recommendations
This paper explored the proposal that professional, commercial and personal criteria influence professional judgement formation and that these influences pressurise the competence requirements (knowledge, skills and attitude) under which the professional practices.In the case of the community pharmacist the potential for conflict is increased by:  The retail nature of the setting from which community pharmacy services are delivered. The risk that the increasing cost of meeting new regulatory demands will decrease the likelihood of commercial survival/success. The ROI professional remuneration system, the structure of which has created an incentive by rewarding high volumes of dispensing but, with the exception of a monthly service fees awarded for "High Tech" medicines regardless of whether the patient has that item dispensed in the given calendar month, rarely rewards patient care services.
The proposed framework emphasises the influences that exist as a result of the way in which community pharmacists', in the ROI at least, practice their profession, and reassures the professional that there can be no charge against a community pharmacist for their existence per se.In essence, the framework challenges a simplistic perspective when considering the "best" advice a pharmacist can give to a patient, and, by spotlighting existing professional, commercial and personal influences on decision-making, it highlights the complexity surrounding professional judgement formation in context.Lessons for practice include: (1) Contemplation of the interaction between PCP influences and specific competencies relating to competent professional practice offers a more comprehensive basis from which the pharmacist can consider the "best" advice to give a patient in a "bottom line" retail environment.(2) Confidence in one's system of forming professional judgement will reduce the likelihood that pharmacists will subordinate to patient, peer or prescriber influences.(3) Consideration of personal influences and reflection on inherent ethical dilemmas can assist with professional resilience, particularly when faced with increasingly complex commercial/professional environments.Whether or not complexity increases in which the community pharmacist's scope of practice has expanded further than in the ROI, to include pharmacist prescribing and various extended services, is unclear but certainly merits further consideration.(4) Facilitated deliberation as to the complexity of professional judgement formation and the elements of consideration therein enhance both knowledge and skill, key competencies which can help the pharmacist when forming professional judgements.
As discussed above, there is currently no evidence to confirm whether or not these professional judgement influences are resolved successfully.What is apparent is that, in every jurisdiction, a community pharmacist requires key professional, commercial and personal competencies applied in the identification and analysis of professional tensions and potential ethical dilemmas in order to appreciate the criteria which may affect both parties' (patient and pharmacist) decision making.Professional competence should create a dynamic where the patient's "best interests" are protected while tension resolution is reached by the pharmacist's professional decision process when considering both "best interest" and "bottom line".The authors recommend that professional development initiatives introduce participants to the proposed framework in order to explore the influences and competencies in a manner that increases reflective formation of professional judgement.

Figure 1 .
Figure 1.Community Pharmacist: influences on the formation of professional judgement.