Predictors of Ethical Dilemmas Among Undergraduate Pharmacy Students in Saudi Arabia: A Multicenter Cross-Sectional Study

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Orayj, Saad Alobid, Azfar Athar Ishaqui This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6671824/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract This multicenter cross-sectional study aimed to explore the factors influencing ethical dilemmas among undergraduate pharmacy students in Saudi Arabia, focusing on training duration, educational level, and type of training experiences. Participants included 259 students from eight universities, selected through stratified convenience sampling. Data were collected via questionnaires covering demographics, educational background, and ethical dilemmas encountered during training. The findings of the study revealed that students with more than six months of training were significantly more likely to report ethical dilemmas (53.09%) compared to those with shorter training periods (29.78%). Internship students reported more ethical issues (82.7%) than pre-internship students (17.3%), and students involved in clinical rounds with medical teams reported more dilemmas (41.98%) than those primarily engaged in dispensing (40.74%). Notably, no significant gender differences were found in reporting ethical dilemmas. The most common ethical dilemmas included treatment decisions (16.05%), obeying doctors' orders against their judgment (14.81%), and disclosing confidential patient data without consent (14.81%). Logistic regression analysis identified training duration and type as significant predictors of ethical dilemma reporting, with students in clinical rounds more likely to encounter dilemmas (OR = 0.56, p = 0.038). The findings emphasize on the importance of integrating practical, experiential learning and ethical training into pharmacy curricula to better prepare students for the ethical challenges they will face in professional practice. Ethics Pharmacy students Saudi Arabia Training and Dilemma Figures Figure 1 1. INTRODUCTION Ethical issues are a major challenge to the medical staff and doctors in the healthcare system, especially to the trainers (Loewy and Loewy 2004 ). Training pharmacy students involves various challenging different situations that test their ethical judgment. Therefore, it is crucial to integrate ethics into the curricula of pharmacy programs so that students are prepared to deal with several challenges they are likely to face in practice, as well as to contribute to the advancement of the pharmacy profession. Previous studies have shown that ethics is a vital component in teaching and learning in health facilities and significantly impacts students’ ethical thinking and behavior (Sturman and Saiepour 2014 , Hlaing et al., 2023 ). Ethics are very crucial in the conduct of pharmacy work, particularly in Saudi Arabia, where the health sector has experienced significant growth in the recent years. Therefore, there is a need for ethical standards to be followed by practitioners (Orayj et al., 2022 ). Since more pharmacists have become involved in patient care in recent years, the number of ethical dilemmas in the healthcare system will also increase. Many works focus on ethical principles in medical practice, and some of them are as old as ancient civilizations, such as the Hippocratic Oath, which can still be employed in the present day (Scheinman et al., 2018 ). Due to rising prices and ongoing improvements in pharmacy practice over the past few years, ethical issues in healthcare have become more complex (Chaar 2016 ). These moral problems have worsened over time due to the fact that pharmacies operate as businesses, commercial health insurance is becoming more critical, and the responsibilities of clinical pharmacists' are expanding (Salman Popattia et al., 2018 ). The bioethical principles spelled out in the Declaration of Geneva 1948, particularly after World War II, have significantly impacted modern healthcare ethics. These principles—beneficence, non-maleficence, justice, and autonomy—are at the heart of modern healthcare ethics and can be found worldwide in pharmacy codes of ethics (Parsa-Parsi 2017 ). Despite the presence of these standards, there is still a lack of ethics guidance specifically made for pharmacists in Saudi Arabia. The Saudi Commission for Health Specialties has established general ethical guidelines for healthcare professionals. However, these guidelines do not address how pharmacists should handle their unique ethical problems (Orayj et al., 2022 ). Ethical problems in healthcare often arise because individuals have different roles within the system. While healthcare professionals are expected to follow ethical standards, several challenges and pressures from patients, healthcare teams, and government rules make it complicated and limit their adherence to these standards (Ilori et al., 2024 ). Saudi Arabia's healthcare education system comprises many different public and private organizations, each with its own ethical guidelines and regulations. This diversity makes it an attractive case to study the ethical challenges faced by pharmacy students. By identifying these issues early, teachers and lawmakers can enhance ethics education and better prepare students to address and navigate these challenges and deal with them effectively (Richards and Dignum 2019 ). Al-Arifi ( 2014 ) has identified that community pharmacists in Saudi Arabia are exposed to ethical issues, highlighting the need for effective ethics education in pharmacy schools (Al-Arifi 2014 ). A comprehensive research conducted in the Asir region of Saudi Arabia has also supported this need by demonstrating the necessity for practice-specific ethical standards that enable pharmacists to address the issues they encounter. The study has also revealed that the principles of non-maleficence and beneficence were violated due to system-related factors, including the fact that community pharmacies had to achieve sales targets within a short period, thus engaging in cross-selling and upselling in order to generate profits for the business at the expense of the patient care (Orayj et al., 2022 ). Several variables that influence ethical decision-making in healthcare scenarios have been identified, including demographic factors like gender, age, educational background, academic success, and training experience (Latif 2004 , Hlaing et al., 2023 ). For instance, ethical sensitivity varies between men and women, with female students usually being more sensitive than their male counterparts (Sr and Costa 1994 ). Level of education and academic performance are also fundamental, where students with higher levels of education or better academic performance are more likely to learn about, discuss, and critically analyze ethical issues and cases (ULUTAŞ DENİZ and Eren 2023 ). Religion also plays a crucial role in making ethical choices, especially in conservative countries like Saudi Arabia, where many ethical choices are based on religious beliefs. As an example of how strongly Islamic teachings deeply influence professional behavior in Saudi Arabia, pharmacists were reluctant to dispense medications that contained alcohol, or that could be used for reasons other than medical ones, reflecting how religious values are deeply ingrained and significantly affect the professional behavior (Orayj et al., 2022 ). The training environment significantly affects how students are exposed to and deal with ethical issues. Clinical rounds, which involve direct patient care under the supervision of a physician or nurse, are the best way to experience practical ethical issues (Ismail et al., ). However, students who are mostly involved in dispensing drugs experience ethical issues, and at the same time, they fail to make important ethical decisions (Myers et al., 2017 ). This multiple-center cross-sectional study will seek to establish what leads to ethical issues among training students in Saudi Arabia. Hence, this study aims to establish the correlation between demographic factors, educational background, training experiences, and the occurrence of ethical issues in pharmacy education. The findings of the present study will be useful in designing targeted ethics education initiatives and improving the ethical standards of practice in pharmacy. 2. MATERIAL AND METHODS 2.1 Study Design This study employed a multicenter cross-sectional survey to identify the factors that training pharmacy students from eight different universities in Saudi Arabia believed would cause ethical dilemmas. 2.2 Study Population The study involved pharmacy students from eight universities in Saudi Arabia: These are Jazan University, King Saud bin Abdulaziz University for Health Sciences- Alahsa, Qassim University, King Khalid University, Taibah University, Umm Al-Qura University, King Saud University, and King Abdulaziz University. This made it possible for the study to capture various situations, experiences, and perceptions that pharmacy students have on the ethical issues they come across. 2.3 Sampling Method Stratified convenience sampling was employed in this study. 2.4 Data Collection The data were collected through a questionnaire, which was given to the students in the Pharmacy school academic year 2023–2024. The ethical dilemmas questionnaire was originally developed in Arabic. The English translation is provided in Supplementary File S1. The questionnaire was designed to obtain specific information on the student’s age, sex, education, training, and work experience, and the specific ethical issues they encounter. 2.5 Questionnaire Components The questionnaire included several sections to gather comprehensive data from the participants. The demographic section collected data on age and gender. The educational background section inquired about the students' education level, categorizing them as internship students (who had completed their five-year academic program and were undergoing a mandatory one-year training program) and pre-internship students (currently in Level 9 and 10, i.e., the last two semesters of their professional education). The section also included question related to participants academic performance measured by CGPA ( 3.0). The training experience section gathered information on the training locations, such as military hospitals, community pharmacies, health centers, Ministry of Health (MOH) hospitals, and private hospitals. It also inquired about information about the current university, the total training period (more than six months or one to six months), and the nature of the training (e.g., clinical rounds with the medical team, dispensing medications inside the pharmacy, research, and other activities). Additionally, the questionnaire included a section on whether the students had received educational material related to pharmacy ethics. The section on ethical dilemmas focused on whether the students had encountered ethical dilemmas and detailed the specific dilemmas they faced, such as obeying doctor's orders, lying to patients, or disclosing confidential information. 2.6 Data Analysis The collected data was analyzed using Statistical Package for the Social Sciences version 26. Descriptive statistics, including frequencies, percentages, means, and standard deviation was calculated to summarize the participants' demographic characteristics and training experiences. The chi-square test was applied to assess the associations between categorical variables and ethical dilemma reporting. Logistic regression analysis was conducted to identify significant predictors of ethical dilemmas. The results were reported as coefficients, standard errors, z-values, p-values, and 95% confidence intervals for each independent variable. A p-value of less than 0.05 was considered statistically significant. 3. RESULTS 3.1 Demographic Characteristics of Study Participants The demographic details of the 259 undergraduate pharmacy students who participated in this study are outlined in Table 1 . The mean age of the participants was 23.8 years, with a standard deviation of 1.74 years, and the age range was between 20 and 27 years. The majority of participants were female (57.1%), while males constituted 42.9% of the sample. Most of the participants were internship students (184, 71%) whereas 75 participants (29%) were pre-internship students. Regarding academic performance, (12.4% )of the students had a CGPA of less than 2.0, (16.9%) had a CGPA between 2.0 and 3.0, and the majority (70.6%) had a CGPA greater than 3.0. A substantial number of the participants (87.6%) reported that they had been given training materials about pharmacy ethics at their college, while (12.4%) had not. Table 1 Summarized demographic characteristics of study participants (n = 259) Variable Statistics Age Mean ± SD 23.8 ± 1.74 Median 23.7 Range 20–27 Gender Male 111 (42.9%) Female 148 (57.1%) Education Level Pre-internship students (Level 9 & 10) 75 (29%) Internship students (Level 11 & 12) 184 (71%) Academic Performance (out of 4 .0 CGPA) CGPA ( 3.0) 183 (70.6%) Academic Program Pharm-D 195 (75.3%) B-Pharm 64 (24.7%) Did you receive any educational material related to pharmacy ethics at your college? Yes 227 (87.6%) No 32 (12.4%) 3.2 Comparative Analysis of Participant Characteristics Based on Ethical Dilemma Reporting Table 2 shows a comparison of the traits of the participants based on whether they had encountered an ethical situation. Of the Eighty-one participants who reported ethical problems, (59.26%) had their training at MOH hospitals, (17.28%) at military hospitals, (12.35%) at other places, (7.41%) at community pharmacists, (2.47%) at health centers, and (1.23%) at private hospitals. In contrast, among the 178 participants who did not report ethical dilemmas, (60.11%) trained at MOH hospitals, (13.48%) at military hospitals, (8.99%) at private hospitals, (7.87%) at other locations, (7.30%) at community pharmacies, and (2.25%) at health centers. Table 2 Comparative Analysis of Participant Characteristics Based on Ethical Dilemma Reporting CHARACTERISTICS OVERALL (N = 259) YES ETHICAL DILEMMA (N = 81) NO ETHICAL DILEMMA (N = 178) TRAINING LOCATION Military Hospital 38 (14.7%) 14 (17.28%) 24 (13.48%) Community Pharmacy 19 (7.3%) 6 (7.41%) 13 (7.30%) Health Center 6 (2.3%) 2 (2.47%) 4 (2.25%) MOH Hospital 155 (59.8%) 48 (59.26%) 107 (60.11%) Others 24 (9.3%) 10 (12.35%) 14 (7.87%) Private Hospital 17 (6.5%) 1 (1.23%) 16 (8.99%) CURRENT UNIVERSITY Jazan University 26 (10.1%) 4 (4.94%) 22 (12.36%) King Saud University for Health Sciences 17 (6.6%) 9 (11.11%) 8 (4.49%) Qassim University 20 (7.7%) 9 (11.11%) 11 (6.18%) King Khalid University 59 (2.3%) 19 (23.46%) 42 (23.6%) Taibah University 5 (1.9%) 0 (0.00%) 5 (2.81%) Umm Al-Qura University 5 (1.9%) 1 (1.23%) 4 (2.25%) King Saud University 90 (3.5%) 32 (39.51%) 58 (32.58%) King Abdulaziz University 15 (5.8%) 3 (3.7%) 12 (6.74%) Others 22 (8.5%) 4 16 TOTAL TRAINING PERIOD More than 6 months 96 (37%) 43 (53.09%) 53 (29.78%) 1 to 6 months 163 (63%) 38 (46.91%) 125 (70.22%) NATURE OF TRAINING Clinical rounds with members of the medical team 73 (2.8%) 34 (41.98%) 39 (21.91%) Dispensing medications inside the pharmacy 142 (5.5%) 33 (40.74%) 109 (61.24%) Research 8 (3.1%) 1 (1.23%) 7 (3.93%) Others 36 (13.9%) 13 (16.05%) 23 (12.92%) Figure 1 presents a comparative analysis of ethical dilemma reporting among pharmacy students, with the chi-square test revealing significant differences based on training duration, educational level, academic performance, and nature of training, but not gender. Internship students (34.6%) and those with a CGPA above 3.0 (71.1%) reported significantly more ethical dilemmas than pre-internship students (19.1%) and those with lower GPAs (13.7%) (p < 0.05). Students with over six months of training (53.09%) and those involved in clinical rounds (41.98%) also reported more ethical issues compared to those with shorter training (29.78%) or dispensing-focused roles (p < 0.05). Regarding the influence of the university on the percentage of ethical dilemmas reported, (39.51%) of those who reported ethical dilemmas were from King Saud University, followed by (23.46%) from King Khalid University, (11.11%) each from King Saud bin Abdulaziz University for Health Sciences and Qassim University, (4.94%) from Jazan University, (3.70%) from King Abdulaziz University, (1.23%) from Umm Al-Qura University, and none from Taibah University. Conversely, among those who did not report ethical dilemmas, (32.58%) were from King Saud University, (23.60%) from King Khalid University, (12.36%) from Jazan University, (6.74%) from King Abdulaziz University, (6.18%) from Qassim University, (4.49%) from King Saud bin Abdulaziz University for Health Sciences, (2.81%) from Taibah University, and (2.25%) from Umm Al-Qura University. In terms of the training duration, (53.09%) of participants who reported ethical dilemmas had more than six months of training, compared to (29.78%) of those who did not report ethical dilemmas. Additionally, (46.91%) of those who reported ethical dilemmas had training periods of 1 to 6 months, compared to (70.22%) of those who did not report ethical dilemmas. The nature of training also varied between the two groups. Among participants who reported ethical dilemmas, (41.98%) were involved in clinical rounds with medical team members, (40.74%) in dispensing medications inside the pharmacy, (16.05%) in other training activities, and (1.23%) in research. Among those who did not report ethical dilemmas, (61.24%) were involved in dispensing medications inside the pharmacy, (21.91%) in clinical rounds with medical team members, (12.92%) in other training activities, and (3.93%) in research. 3.3 Distribution of Reported Ethical Dilemma Categories and Their Frequencies Table 3 shows the distribution of reported ethical dilemma categories and their frequencies among the study participants. The most commonly reported ethical dilemma was "facing ethical dilemmas in treatment decisions,” reported by 13 (16.05%) participants. This was followed by a dilemma related to "obeying your doctor's orders even if you think these orders are not in the patient's best interest" and "disclosing confidential patient data to the team without patient consent,” both reported by 12 (14.81%) of participants. Other common ethical dilemmas included "medicine was dispensed to an elderly patient, and he had side effects,” reported by 10 (12.35%) participants, and "failure to dispense a restricted prescription medicine to a known patient,” reported by 9 (11.11%) participants. Furthermore, eight (9.88%) participants have reported dilemmas related to "Lying to the patient for his benefit" and "unprofessional behavior towards colleagues.” Table 3 Distribution of Reported Ethical Dilemma Categories and Their Frequencies by Study Participants Ethical Dilemma Category N (%) Obey your doctor's orders even if you think these orders are not in the patient's best interest. 12 14.81 Lying to the patient for his benefit. 8 9.88 Failure to dispense a restricted prescription medicine to a known patient. 9 11.11 Disclosing confidential patient data to the team without patient consent. 12 14.81 Providing treatment without the patient’s full consent. 1 1.23 Medicine was dispensed to an elderly patient, and he had side effects. 10 12.35 Ignoring patient’s preferences during treatment. 2 2.47 Unprofessional behavior towards colleagues. 8 9.88 Conducting procedures without the patient’s informed consent. 0 0 Challenges in resource allocation during treatment. 0 0 Ignoring patient’s autonomy in decision-making. 0 0 Facing ethical dilemmas in treatment decisions. 13 16.05 Making treatment decisions without complete information. 0 0 Breaching patient confidentiality. 0 0 General ethical issues faced during training. 1 1.23 Miscellaneous 3 3.7 Less frequently reported dilemmas included 'ignoring patient’s preferences during treatment' (2.47%, 2), 'providing treatment without patient’s full consent' (1.23%, 1), and 'general ethical issues faced during training' (1.23%, 1). A few participants (3.7%, 3) reported miscellaneous ethical issues, which included situations such as conflicts of interest, professional misconduct, and issues related to patient safety. Notably, some ethical dilemmas were not reported by any participants including 'conducting procedures without patient’s informed consent’, ‘challenges in resource allocation during treatment,' 'ignoring patient’s autonomy in decision-making,' 'making treatment decisions without full information,' and 'breaching patient confidentiality.' This distribution highlights the variety of ethical challenges encountered by pharmacy students during their training, with many participants facing dilemmas related to treatment decisions, patient confidentiality, and adherence to doctors' orders that conflict with their professional judgment. 3.4 Logistic Regression Analysis Predicting Ethical Dilemma Responses Table 4 demonstrates the logistic regression analysis results. Two predictors emerged as statistically significant in relation to experiencing an ethical dilemma: a training period longer than six months and the type of training undertaken. Specifically, students with more than 6 months of training exhibit approximately twice the odds of encountering an ethical dilemma compared to those with only 1–6 months of training (OR = 2.06, 95% CI: 1.14–3.72, p = 0.017), suggesting that longer exposure to the training environment may increase awareness or occurrence of ethical challenges. Furthermore, the type of training is influential, with participants engaged in "other" types of training experiencing 44% lower odds of facing ethical dilemmas relative to those involved in clinical rounds (OR = 0.56, 95% CI: 0.30–1.05, p = 0.038), which implies that the structured nature or specific scenarios encountered during clinical rounds may present more ethical challenges. In contrast, other factors—including gender (males having 21% higher odds), educational level (pre-internship students having 40% lower odds), college GPA (a slight 6% increase), degree type (Pharm-D students having 19% lower odds), training location (non-MOH hospital training associated with double the odds), and receipt of prior ethics education (32% higher odds)—do not demonstrate statistically significant associations with the occurrence of ethical dilemmas, as their p-values exceed the conventional threshold of 0.05. Table 4 Logistic Regression Analysis Predicting Ethical Dilemma Responses Variable Category OR (95% CI) p-value Gender Female (Ref) – – Male 1.21 (0.68–2.16) 0.508 Educational Level Internship Students (Ref) – – Pre-Internship 0.60 (0.29–1.22) 0.157 College GPA CGPA 3 1.06 (0.57–1.97) 0.857 Degree Bachelor’s (Ref) – – Pharm-D 0.81 (0.42–1.60) 0.550 Training Location MOH Hospital (Ref) – – Non-MOH Hospital 2.06 (0.58–1.82) 0.911 Training Period 1–6 Months (Ref) – – > 6 Months 2.06 (1.14–3.72) 0.017 Training Type Clinical Rounds (Ref) – – Other 0.56 (0.30–1.05) 0.038 Received Prior Education No Prior Education (Ref) – – Yes 1.32 (0.52–3.33) 0.506 4. DISCUSSION This study examined various educational and social factors to identify the ethical challenges that pharmacy students in Saudi Arabia are likely to encounter during their training. Our results reveal that certain characteristics and events significantly influence the likelihood of facing ethical problems during their Pharmacy education. Internship students reported significantly more ethical dilemmas (67 out of 81, 82.7%) compared to pre-internship students, who reported only 14 out of 81 (17.3%). This finding aligns with the expectation that internship students, who have greater exposure to complex clinical and professional environments, are more likely to encounter ethical challenges. As students’ progress through their training and gain more practical experience, they become more aware of ethical issues and are better equipped to identify and report them (Scharr et al., 2011 , Almetwazi et al., 2020 ). However, this finding contrasts with some previous studies, such as Latif ( 2004 ), which found that junior students were more likely to report ethical dilemmas due to their lack of confidence and preparedness in handling complex situations (Latif 2004 ). This discrepancy may be attributed to differences in training environments, cultural contexts, or the specific ethical challenges faced by students in different regions. Regardless, the findings highlight the importance of experiential learning in shaping students' ethical awareness and decision-making skills. Thus, the analysis of the results of the study allows concluding that the majority of students (87. 6%) received training materials related to pharmacy ethics, which proves the existence of the proper educational framework. Nevertheless, the effectiveness of this kind of training in the enhancement of students’ ethical decision-making has not been properly evaluated in terms of its practical relevance. Past research has shown that while students must acquire theoretical knowledge in ethical matters, what improves the ethical reasoning of students is the capacity to apply such knowledge (Okoye et al., 2017 ). Thus, the use of practical activities such as case analyses and experiments in the pharmacy curriculum might enhance the students’ ethical reasoning in practice (Donaldson et al., 2010 ), (Okoro 2020 ). In our study, students with a CGPA above 3.0 reported significantly more ethical dilemmas (56 out of 81; 69.1%) compared to those with a lower CGPA. This finding suggests that high academic achievers may be more ethically sensitive or reflective in their practice, enabling them to identify and report ethical issues more frequently (Scharr et al., 2011 ). High-performing students often possess stronger critical thinking and problem-solving skills, which may make them more attuned to ethical complexities in clinical and professional settings. Furthermore, students with higher academic performance are more likely to engage in self-reflection and critical analysis of ethical scenarios, which may explain why they are more likely to report ethical dilemmas (Latif 2004 ). The reporting of ethical issues by pharmacy students was significantly influenced also by type of training experience. However, internship students who often participate in advanced training techniques such as clinical rounds or research reported more ethical dilemmas, which might be attributed to their more frequent exposure to ethically challenging situations. In the current study, students reported significantly more ethical dilemmas during clinical rounds (46.6% vs. 25.3%, p < 0.05) than in other training settings. The encounter and discussion of ethical issues in real-world settings occur during clinical rounds, which are structured sessions involving direct patient care and interprofessional collaboration 4 . This exposure is likely to increase their ethical sensitivity and decision-making skills, enabling them to detect and report ethical dilemmas more frequently 2 . However, students primarily engaged in dispensing medications encountered fewer ethical problems, perhaps because their tasks were more routine and they did not encounter many complex ethical scenarios. Nevertheless, it is important to note that clinical rounds also enable students to acquire better coping mechanisms for ethical challenges, thereby reducing the probability of ethical incidents in the future 5 . In this study, logistic regression analysis revealed that the duration and type of training had a significant impact on the reporting of ethical dilemmas by pharmacy students. Those who had received more than six months of training were about twice as likely as those with less than six months of training to encounter ethical dilemmas (OR = 2.06, 95% CI: 1.14–3.72, p = 0.017). This finding aligns with the research by Baykara et al. (2014), who found that exposure to complex scenarios in a clinical environment enhances ethical sensitivity due to prolonged exposure 5 . The more time students spend in training, the more likely they are to encounter situations that test their ethical judgment. Okoro and Jamiu (2021) also reported similar findings, emphasizing that inadequate exposure to ethical challenges during training leaves trainees unprepared to deal with ethical dilemmas in professional practice 6 . Rajiah and Venaktaraman (2020) found that age and work experience were reliable predictors of ethical decision-making, as more experienced pharmacists tend to feel more comfortable resolving ethical dilemmas 7 . Similarly, Allinson, Black, and White ( 2022 ) highlighted the importance of continual learning in practice, moral courage, and role modeling in ethical decision-making, further reinforcing the significance of structured experiential learning in ethical preparedness.(Allinson et al., 2022 ) The type of training also played a significant role. Students involved in clinical rounds reported more ethical dilemmas compared to those in other training settings (OR = 0.56, p = 0.038). Clinical rounds, which involve direct patient care and interprofessional collaboration, often present students with real-world ethical challenges, such as conflicts between patient autonomy and medical recommendations or issues related to confidentiality (Hlaing et al., 2023 ). Husted and Husted ( 2008 ) emphasized that clinical training environments provide structured opportunities for students to engage in ethical discussions, further developing their ability to navigate dilemmas (Husted and Husted 2008 ). Ibrahim and Sharif (2018) also highlighted that students with greater exposure to ethical dilemmas during clinical rotations develop stronger ethical reasoning and decision-making skills, preparing them for future challenges (Ibrahim and Sharif). While our study found no significant association between gender, CGPA, or prior ethics education and ethical dilemma reporting, several studies in the literature report contrasting findings. Latif (2011) conducted a national study assessing ethical reasoning among U.S. pharmacy students and found that female students scored significantly higher than males on ethical reasoning tests, suggesting that gender may influence ethical sensitivity (Latif 2004 ). Similarly, Monrouxe et al. ( 2015 ) reported that female medical and pharmacy students experienced greater moral distress when encountering ethical dilemmas compared to their male counterparts, which may indicate that gender plays a role in the emotional impact of ethical decision-making (Monrouxe et al., 2015 ). Regarding GPA as a predictor of ethical reasoning, Deniz and Eren (2023) found that pharmacy students with higher academic performance demonstrated greater ethical sensitivity and awareness, suggesting that students with stronger academic backgrounds may engage more critically with ethical dilemmas (ULUTAŞ DENİZ and Eren 2023 ). Similarly, a study by Altmyer et al. ( 2014 ) in business ethics education found that higher GPA students exhibited stronger ethical awareness than lower GPA students, indicating that academic performance may correlate with ethical reasoning (Altmyer et al., 2014 ). In contrast, our findings did not show a significant relationship between GPA and ethical dilemma reporting, which may suggest that practical exposure to ethical challenges plays a more influential role in ethical decision-making than academic performance. With respect to prior ethics education, our study did not find a significant impact on ethical dilemma reporting. However, DeMella et al. ( 2017 ) examined the effects of implementing an online ethics course in a pharmacy curriculum and found that while students perceived an improvement in their ethical reasoning skills, there was no statistically significant increase in their ethical decision-making ability (DeMella et al., 2017 ). This aligns with our findings, suggesting that passive exposure to ethics education without practical reinforcement may not be sufficient to enhance ethical decision-making. However, Ulutas Deniz and Eren (2023) reported that students who completed an ethics course had higher ethical sensitivity scores than those who had not, indicating that the content and structure of ethics education may determine its effectiveness (ULUTAŞ DENİZ and Eren 2023 ). The ethical dilemmas reported most often were about treatment and patient confidentiality, which are in line with the ethical concerns experienced in practice (Rajiah and Venkataraman 2018 ). Due to the nature of the cases described it is important that the curricula of pharmacy should encompass not only the knowledge of such matters but also the ways of handling them. Some teaching methods, such as debates and case approaches, may assist in the development of students’ critical thinking and ethical reasoning (Johnston et al., 2019 , Fino et al., 2021 ). The findings of the present study contribute to the knowledge about the factors that influence ethical dilemma reporting, where the length of the training and the type of training experiences are found to be the two most significant predictors of ethical dilemma reporting. This research also highlights the need for the enhancement of the amount of practical experience and interprofessional practice simulation in the education of pharmacy students, which prepares them for the ethical issues that they are going to encounter in practice (Baral et al., 2019 , ULUTAŞ DENİZ and Eren 2023 ). 5. CONCLUSION This study underscores the importance of integrating ethics education into pharmacy curricula, focusing on both theoretical knowledge and practical application. The findings suggest that enhancing experiential learning opportunities, particularly in clinical settings, can significantly improve students' ethical reasoning and decision-making skills. As pharmacy education continues to evolve, it is imperative to develop targeted ethics programs that address the unique challenges faced by pharmacy students, ultimately contributing to the cultivation of ethically competent practitioners in the healthcare field. Declarations Author Contributions KMO and SA contributed to designing the study and collecting data. KMO and AAI analyzed the results and drafted the manuscript. SA and AAI contributed to writing and revising the manuscript. All authors read and approved the final manuscript. Funding The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through small group research under grant number RGP1/11/46. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics Approval and Consent to Participate Ethical approval was granted by the Medical Research Ethics Committee of King Khalid University (Approval No.: ECM#2021-5715). The study adhered to the ethical principles outlined in the Declaration of Helsinki, ensuring respect for participants’ rights and dignity. Informed written consent was obtained from all participants, ensuring that participation was voluntary and that they had the option to withdraw at any time. Consent for Publication Not applicable. Competing Interests The authors declare no competing interests. References Al-Arifi, M. N., 2014. Community pharmacist perception and attitude toward ethical issues at community pharmacy setting in central Saudi Arabia. Saudi Pharmaceutical Journal. 22, 315-325. Allinson, M. D., P. E. Black and S. J. White, 2022. Professional dilemmas experienced by pharmacy graduates in the United Kingdom when transitioning to practice. American Journal of Pharmaceutical Education. 86, 8643. Almetwazi, M., A. Alhammad, A. Alhossan, et al., 2020. Pharmacy students’ satisfaction with Introductory Pharmacy Practice Experiences (IPPE) at community pharmacy: The case of Saudi Arabia. Saudi Pharmaceutical Journal. 28, 68-73. Altmyer, D., S.-P. Yang, K. Schallenkamp, et al., 2014. Student ethical awareness as affected by gender and grade point average. Business Education & Accreditation. 6, 11-22. Baral, S. R., D. R. Parajuli, S. Shrestha, et al., 2019. Undergraduate pharmacy students’ attitudes and perceived barriers toward provision of pharmaceutical care: a multi-institutional study in Nepal. Integrated Pharmacy Research and Practice. 47-59. Chaar, B., 2016. Ethical dilemmas: Are you across the EHC guidelines? Australian Pharmacist. 35, 72. DeMella, C., K. Donohoe, L. Morgan, et al., 2017. Implementation of an online ethics course into a pharmacy curriculum. Currents in Pharmacy Teaching and Learning. 9, 835-840. Donaldson, T. M., E. Fistein and M. Dunn, 2010. Case-based seminars in medical ethics education: how medical students define and discuss moral problems. Journal of medical ethics. 36, 816-820. Fino, L., I. A. Basheti, B. Saini, et al., 2021. Exploring and evaluating Vertically Integrated Teaching in Ethical Decision-Making (VIT-EDM) in pharmacy. Pharmacy Education. 21, 457-465. Hlaing, P. H., A. Hasswan, V. Salmanpour, et al., 2023. Health professions students’ approaches towards practice-driven ethical dilemmas; a case-based qualitative study. BMC medical education. 23, 307. Husted, J. H. and G. L. Husted, 2008. Ethical decision making in nursing and health care: The symphonological approach, Springer Publishing Company. Ibrahim, R. M. and S. I. Sharif, Teaching professionalism and ethical reasoning to pharmacy students: How important it is? Ilori, O., T. Kolawole and J. Olaboye, 2024. Ethical dilemmas in healthcare management: A comprehensive review. International Medical Science Research Journal. 4, 703-725. Ismail, T. S., S. Assyifa and R. Rusnaidi, Learning Clinical Ethics for Medical Students in Clinical Phase. Jurnal Pendidikan Kedokteran Indonesia: The Indonesian Journal of Medical Education. 13, 123-134. Johnston, D. M., I. Truter, Y. L. Irwin, et al., 2019. Pharmacy students’ opinions and experiences working on board the Transnet-Phelophepa Health Care Trains. International Journal of Pharmacy Practice. 27, 311-317. Latif, D. A., 2004. An Assessment of the Ethical Reasoning of United States Pharmacy Students: A National Study. American Journal of Pharmaceutical Education. 68, Loewy, E. E. and R. S. Loewy, 2004. Textbook of healthcare ethics, Springer Science & Business Media. Monrouxe, L. V., C. E. Rees, I. Dennis, et al., 2015. Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies. BMJ open. 5, e007518. Myers, J. R., M. E. Kiersma and K. S. Plake, 2017. Assessment of student pharmacists’ ethical decision-making. Currents in Pharmacy Teaching and Learning. 9, 996-1002. Okoro, R. N., 2020. Investigation of final-year pharmacy students' views on professionalism and ethics in pharmacy practice: an interventional study. International journal of pharmacy practice. 28, 130-133. Okoye, O., D. Nwachukwu and F. C. Maduka-Okafor, 2017. Must we remain blind to undergraduate medical ethics education in Africa? A cross-sectional study of Nigerian medical students. BMC Medical Ethics. 18, 1-8. Orayj, K., K. Alahmari and M. Alasiri, 2022. The Concept of Pharmacy Ethics and the Examples of Ethical Dilemmas Encountered by Pharmacists in the Asir Region, Saudi Arabia: A Qualitative Study. International Journal of General Medicine. 4985-4996. Parsa-Parsi, R. W., 2017. The revised declaration of Geneva: a modern-day physician’s pledge. Jama. 318, 1971-1972. Rajiah, K. and R. Venkataraman, 2018. Community pharmacists’ perceptions on ethical dilemmas, pharmacy values and decision-making. Indian Journal of Pharmacy Practice. 11, Richards, D. and V. Dignum, 2019. Supporting and challenging learners through pedagogical agents: Addressing ethical issues through designing for values. British Journal of Educational Technology. 50, 2885-2901. Salman Popattia, A., S. Winch and A. La Caze, 2018. Ethical responsibilities of pharmacists when selling complementary medicines: a systematic review. International Journal of Pharmacy Practice. 26, 93-103. Scharr, K., J.-F. Bussières, S. Prot-Labarthe, et al., 2011. A comparative pilot study of the professional ethical thinking of Quebec pharmacy residents and French pharmacy interns. International Journal of Clinical Pharmacy. 33, 974-984. Scheinman, S. J., P. Fleming and K. Niotis, 2018. Oath taking at US and Canadian medical school ceremonies: historical perspectives, current practices, and future considerations. Academic medicine. 93, 1301-1306. Sr, A. S. and A. D. Costa, 1994. Are women more ethical than men? Journal of Business Ethics. 859-871. Sturman, N. and N. Saiepour, 2014. How confident are general practitioners in teaching medical students about ethical issues on general practice placements? Australian Family Physician. 43, 880-885. ULUTAŞ DENİZ, E. and R. Eren, 2023. ETHICAL SENSITIVITY: A COMPARATIVE ANALYSIS OF PHARMACY STUDENTS TAKING AND NOT TAKING AN ETHICS COURSE IN TERMS OF VARIOUS VARIABLES. Ankara Üniversitesi Eczacılık Fakültesi Dergisi. 47, Additional Declarations No competing interests reported. Supplementary Files SupplementaryfileS1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 02 Aug, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 12 Jul, 2025 Reviewers agreed at journal 07 Jul, 2025 Reviewers invited by journal 04 Jul, 2025 Editor assigned by journal 02 Jul, 2025 Editor invited by journal 13 Jun, 2025 Submission checks completed at journal 11 Jun, 2025 First submitted to journal 11 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Orayj","email":"","orcid":"","institution":"King Khalid University","correspondingAuthor":false,"prefix":"","firstName":"Khalid","middleName":"M.","lastName":"Orayj","suffix":""},{"id":482241842,"identity":"6b4abcbb-20d2-42e8-b307-92bda9c2008b","order_by":1,"name":"Saad Alobid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBAC+QYg8YDhAAMbQ/JhiNABAloMQAoSwFrSkonUwgDVwsCQY0ykFvbDDz8kVNyR52PP+Wz4s41Bju9GAvOHH3i0yPekGUsknHlm2MbzdnMybxuDseSNBDbJHnzWHEgwkEhsO8zYJpG7GUgyJG4AamHgwafl/PPPP4Ba7Nskch4fBDqsHqiF+eMffFpu5JiBbEkEamFOADosweBGAoM0PlsMbrwpswD6JbmN55mxMc85CcOZZx62Scvg835/+uYbHyru2M5vT34s+aPMRp7vePLhj2/wOQwNSAAxYwMJGkbBKBgFo2AUYAMAWv9VjCOIYxcAAAAASUVORK5CYII=","orcid":"","institution":"King Saud University","correspondingAuthor":true,"prefix":"","firstName":"Saad","middleName":"","lastName":"Alobid","suffix":""},{"id":482241843,"identity":"0c556ba7-02a3-4a3d-940f-50574daf6f20","order_by":2,"name":"Azfar Athar Ishaqui","email":"","orcid":"","institution":"King Khalid University","correspondingAuthor":false,"prefix":"","firstName":"Azfar","middleName":"Athar","lastName":"Ishaqui","suffix":""}],"badges":[],"createdAt":"2025-05-15 10:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6671824/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6671824/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86319370,"identity":"06b8a539-6a8d-40d3-aa14-8891afaa1acb","added_by":"auto","created_at":"2025-07-09 09:25:10","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":187713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparative analysis of ethical dilemma reporting\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6671824/v1/b707934bb727a15e73f7059c.jpeg"},{"id":86319391,"identity":"4eb49fa1-82b9-4604-abe6-42c0d290cc0a","added_by":"auto","created_at":"2025-07-09 09:25:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1156930,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6671824/v1/c6cbacec-f5d1-40ec-868e-af9bb437e81a.pdf"},{"id":86319361,"identity":"0ecb2e22-fb39-4e08-97cf-b8f74c85a2fb","added_by":"auto","created_at":"2025-07-09 09:25:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17393,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6671824/v1/b0e35bcec175e9003a105888.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of Ethical Dilemmas Among Undergraduate Pharmacy Students in Saudi Arabia: A Multicenter Cross-Sectional Study","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eEthical issues are a major challenge to the medical staff and doctors in the healthcare system, especially to the trainers (Loewy and Loewy \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Training pharmacy students involves various challenging different situations that test their ethical judgment. Therefore, it is crucial to integrate ethics into the curricula of pharmacy programs so that students are prepared to deal with several challenges they are likely to face in practice, as well as to contribute to the advancement of the pharmacy profession. Previous studies have shown that ethics is a vital component in teaching and learning in health facilities and significantly impacts students\u0026rsquo; ethical thinking and behavior (Sturman and Saiepour \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, Hlaing et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Ethics are very crucial in the conduct of pharmacy work, particularly in Saudi Arabia, where the health sector has experienced significant growth in the recent years. Therefore, there is a need for ethical standards to be followed by practitioners (Orayj et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSince more pharmacists have become involved in patient care in recent years, the number of ethical dilemmas in the healthcare system will also increase. Many works focus on ethical principles in medical practice, and some of them are as old as ancient civilizations, such as the Hippocratic Oath, which can still be employed in the present day (Scheinman et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Due to rising prices and ongoing improvements in pharmacy practice over the past few years, ethical issues in healthcare have become more complex (Chaar \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). These moral problems have worsened over time due to the fact that pharmacies operate as businesses, commercial health insurance is becoming more critical, and the responsibilities of clinical pharmacists' are expanding (Salman Popattia et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e The bioethical principles spelled out in the Declaration of Geneva 1948, particularly after World War II, have significantly impacted modern healthcare ethics. These principles\u0026mdash;beneficence, non-maleficence, justice, and autonomy\u0026mdash;are at the heart of modern healthcare ethics and can be found worldwide in pharmacy codes of ethics (Parsa-Parsi \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Despite the presence of these standards, there is still a lack of ethics guidance specifically made for pharmacists in Saudi Arabia. The Saudi Commission for Health Specialties has established general ethical guidelines for healthcare professionals. However, these guidelines do not address how pharmacists should handle their unique ethical problems (Orayj et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEthical problems in healthcare often arise because individuals have different roles within the system. While healthcare professionals are expected to follow ethical standards, several challenges and pressures from patients, healthcare teams, and government rules make it complicated and limit their adherence to these standards (Ilori et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Saudi Arabia's healthcare education system comprises many different public and private organizations, each with its own ethical guidelines and regulations. This diversity makes it an attractive case to study the ethical challenges faced by pharmacy students. By identifying these issues early, teachers and lawmakers can enhance ethics education and better prepare students to address and navigate these challenges and deal with them effectively (Richards and Dignum \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Al-Arifi (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) has identified that community pharmacists in Saudi Arabia are exposed to ethical issues, highlighting the need for effective ethics education in pharmacy schools (Al-Arifi \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). A comprehensive research conducted in the Asir region of Saudi Arabia has also supported this need by demonstrating the necessity for practice-specific ethical standards that enable pharmacists to address the issues they encounter. The study has also revealed that the principles of non-maleficence and beneficence were violated due to system-related factors, including the fact that community pharmacies had to achieve sales targets within a short period, thus engaging in cross-selling and upselling in order to generate profits for the business at the expense of the patient care (Orayj et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSeveral variables that influence ethical decision-making in healthcare scenarios have been identified, including demographic factors like gender, age, educational background, academic success, and training experience (Latif \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e, Hlaing et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). For instance, ethical sensitivity varies between men and women, with female students usually being more sensitive than their male counterparts (Sr and Costa \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). Level of education and academic performance are also fundamental, where students with higher levels of education or better academic performance are more likely to learn about, discuss, and critically analyze ethical issues and cases (ULUTAŞ DENİZ and Eren \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Religion also plays a crucial role in making ethical choices, especially in conservative countries like Saudi Arabia, where many ethical choices are based on religious beliefs. As an example of how strongly Islamic teachings deeply influence professional behavior in Saudi Arabia, pharmacists were reluctant to dispense medications that contained alcohol, or that could be used for reasons other than medical ones, reflecting how religious values are deeply ingrained and significantly affect the professional behavior (Orayj et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe training environment significantly affects how students are exposed to and deal with ethical issues. Clinical rounds, which involve direct patient care under the supervision of a physician or nurse, are the best way to experience practical ethical issues (Ismail et al., ). However, students who are mostly involved in dispensing drugs experience ethical issues, and at the same time, they fail to make important ethical decisions (Myers et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e This multiple-center cross-sectional study will seek to establish what leads to ethical issues among training students in Saudi Arabia. Hence, this study aims to establish the correlation between demographic factors, educational background, training experiences, and the occurrence of ethical issues in pharmacy education. The findings of the present study will be useful in designing targeted ethics education initiatives and improving the ethical standards of practice in pharmacy.\u003c/p\u003e"},{"header":"2. MATERIAL AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003eThis study employed a multicenter cross-sectional survey to identify the factors that training pharmacy students from eight different universities in Saudi Arabia believed would cause ethical dilemmas.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study Population\u003c/h2\u003e\u003cp\u003eThe study involved pharmacy students from eight universities in Saudi Arabia: These are Jazan University, King Saud bin Abdulaziz University for Health Sciences- Alahsa, Qassim University, King Khalid University, Taibah University, Umm Al-Qura University, King Saud University, and King Abdulaziz University. This made it possible for the study to capture various situations, experiences, and perceptions that pharmacy students have on the ethical issues they come across.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Sampling Method\u003c/h2\u003e\u003cp\u003eStratified convenience sampling was employed in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data Collection\u003c/h2\u003e\u003cp\u003eThe data were collected through a questionnaire, which was given to the students in the Pharmacy school academic year 2023\u0026ndash;2024. The ethical dilemmas questionnaire was originally developed in Arabic. The English translation is provided in Supplementary File S1. The questionnaire was designed to obtain specific information on the student\u0026rsquo;s age, sex, education, training, and work experience, and the specific ethical issues they encounter.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Questionnaire Components\u003c/h2\u003e\u003cp\u003eThe questionnaire included several sections to gather comprehensive data from the participants. The demographic section collected data on age and gender. The educational background section inquired about the students' education level, categorizing them as internship students (who had completed their five-year academic program and were undergoing a mandatory one-year training program) and pre-internship students (currently in Level 9 and 10, i.e., the last two semesters of their professional education). The section also included question related to participants academic performance measured by CGPA (\u0026lt;\u0026thinsp;2.0, 2.0\u0026ndash;3.0, \u0026gt;\u0026thinsp;3.0). The training experience section gathered information on the training locations, such as military hospitals, community pharmacies, health centers, Ministry of Health (MOH) hospitals, and private hospitals. It also inquired about information about the current university, the total training period (more than six months or one to six months), and the nature of the training (e.g., clinical rounds with the medical team, dispensing medications inside the pharmacy, research, and other activities). Additionally, the questionnaire included a section on whether the students had received educational material related to pharmacy ethics. The section on ethical dilemmas focused on whether the students had encountered ethical dilemmas and detailed the specific dilemmas they faced, such as obeying doctor's orders, lying to patients, or disclosing confidential information.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Data Analysis\u003c/h2\u003e\u003cp\u003eThe collected data was analyzed using Statistical Package for the Social Sciences version 26. Descriptive statistics, including frequencies, percentages, means, and standard deviation was calculated to summarize the participants' demographic characteristics and training experiences. The chi-square test was applied to assess the associations between categorical variables and ethical dilemma reporting. Logistic regression analysis was conducted to identify significant predictors of ethical dilemmas. The results were reported as coefficients, standard errors, z-values, p-values, and 95% confidence intervals for each independent variable. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Demographic Characteristics of Study Participants\u003c/h2\u003e\u003cp\u003eThe demographic details of the 259 undergraduate pharmacy students who participated in this study are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the participants was 23.8 years, with a standard deviation of 1.74 years, and the age range was between 20 and 27 years. The majority of participants were female (57.1%), while males constituted 42.9% of the sample. Most of the participants were internship students (184, 71%) whereas 75 participants (29%) were pre-internship students. Regarding academic performance, (12.4% )of the students had a CGPA of less than 2.0, (16.9%) had a CGPA between 2.0 and 3.0, and the majority (70.6%) had a CGPA greater than 3.0. A substantial number of the participants (87.6%) reported that they had been given training materials about pharmacy ethics at their college, while (12.4%) had not.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummarized demographic characteristics of study participants (n\u0026thinsp;=\u0026thinsp;259)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStatistics\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111 (42.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148 (57.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-internship students (Level 9 \u0026amp; 10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (29%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternship students (Level 11 \u0026amp; 12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e184 (71%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcademic Performance (out of 4 .0 CGPA)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCGPA (\u0026lt;\u0026thinsp;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (12.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCGPA (2.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (16.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCGPA (\u0026gt;\u0026thinsp;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e183 (70.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcademic Program\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharm-D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e195 (75.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB-Pharm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64 (24.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDid you receive any educational material related to pharmacy ethics at your college?\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e227 (87.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (12.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Comparative Analysis of Participant Characteristics Based on Ethical Dilemma Reporting\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows a comparison of the traits of the participants based on whether they had encountered an ethical situation. Of the Eighty-one participants who reported ethical problems, (59.26%) had their training at MOH hospitals, (17.28%) at military hospitals, (12.35%) at other places, (7.41%) at community pharmacists, (2.47%) at health centers, and (1.23%) at private hospitals. In contrast, among the 178 participants who did not report ethical dilemmas, (60.11%) trained at MOH hospitals, (13.48%) at military hospitals, (8.99%) at private hospitals, (7.87%) at other locations, (7.30%) at community pharmacies, and (2.25%) at health centers.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparative Analysis of Participant Characteristics Based on Ethical Dilemma Reporting\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCHARACTERISTICS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOVERALL\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;259)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYES ETHICAL DILEMMA\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNO ETHICAL DILEMMA\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;178)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eTRAINING LOCATION\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMilitary Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (14.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (17.28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (13.48%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity Pharmacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (7.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (7.41%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (7.30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (2.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (2.25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMOH Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155 (59.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (59.26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e107 (60.11%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (9.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (12.35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (7.87%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (6.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (8.99%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCURRENT UNIVERSITY\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJazan University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (10.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4.94%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (12.36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKing Saud University for Health Sciences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (6.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (11.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (4.49%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQassim University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (7.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (11.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (6.18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKing Khalid University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (2.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (23.46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42 (23.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaibah University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (1.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (2.81%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUmm Al-Qura University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (1.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (2.25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKing Saud University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (3.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (39.51%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58 (32.58%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKing Abdulaziz University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (5.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (6.74%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTOTAL TRAINING PERIOD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96 (37%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (53.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53 (29.78%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1 to 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e163 (63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (46.91%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e125 (70.22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNATURE OF TRAINING\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical rounds with members of the medical team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (41.98%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39 (21.91%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDispensing medications inside the pharmacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e142 (5.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (40.74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109 (61.24%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResearch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (3.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (3.93%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (13.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (16.05%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (12.92%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a comparative analysis of ethical dilemma reporting among pharmacy students, with the chi-square test revealing significant differences based on training duration, educational level, academic performance, and nature of training, but not gender. Internship students (34.6%) and those with a CGPA above 3.0 (71.1%) reported significantly more ethical dilemmas than pre-internship students (19.1%) and those with lower GPAs (13.7%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Students with over six months of training (53.09%) and those involved in clinical rounds (41.98%) also reported more ethical issues compared to those with shorter training (29.78%) or dispensing-focused roles (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e Regarding the influence of the university on the percentage of ethical dilemmas reported, (39.51%) of those who reported ethical dilemmas were from King Saud University, followed by (23.46%) from King Khalid University, (11.11%) each from King Saud bin Abdulaziz University for Health Sciences and Qassim University, (4.94%) from Jazan University, (3.70%) from King Abdulaziz University, (1.23%) from Umm Al-Qura University, and none from Taibah University. Conversely, among those who did not report ethical dilemmas, (32.58%) were from King Saud University, (23.60%) from King Khalid University, (12.36%) from Jazan University, (6.74%) from King Abdulaziz University, (6.18%) from Qassim University, (4.49%) from King Saud bin Abdulaziz University for Health Sciences, (2.81%) from Taibah University, and (2.25%) from Umm Al-Qura University.\u003c/p\u003e\u003cp\u003eIn terms of the training duration, (53.09%) of participants who reported ethical dilemmas had more than six months of training, compared to (29.78%) of those who did not report ethical dilemmas. Additionally, (46.91%) of those who reported ethical dilemmas had training periods of 1 to 6 months, compared to (70.22%) of those who did not report ethical dilemmas.\u003c/p\u003e\u003cp\u003eThe nature of training also varied between the two groups. Among participants who reported ethical dilemmas, (41.98%) were involved in clinical rounds with medical team members, (40.74%) in dispensing medications inside the pharmacy, (16.05%) in other training activities, and (1.23%) in research. Among those who did not report ethical dilemmas, (61.24%) were involved in dispensing medications inside the pharmacy, (21.91%) in clinical rounds with medical team members, (12.92%) in other training activities, and (3.93%) in research.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Distribution of Reported Ethical Dilemma Categories and Their Frequencies\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the distribution of reported ethical dilemma categories and their frequencies among the study participants. The most commonly reported ethical dilemma was \"facing ethical dilemmas in treatment decisions,\u0026rdquo; reported by 13 (16.05%) participants. This was followed by a dilemma related to \"obeying your doctor's orders even if you think these orders are not in the patient's best interest\" and \"disclosing confidential patient data to the team without patient consent,\u0026rdquo; both reported by 12 (14.81%) of participants. Other common ethical dilemmas included \"medicine was dispensed to an elderly patient, and he had side effects,\u0026rdquo; reported by 10 (12.35%) participants, and \"failure to dispense a restricted prescription medicine to a known patient,\u0026rdquo; reported by 9 (11.11%) participants. Furthermore, eight (9.88%) participants have reported dilemmas related to \"Lying to the patient for his benefit\" and \"unprofessional behavior towards colleagues.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of Reported Ethical Dilemma Categories and Their Frequencies by Study Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEthical Dilemma Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObey your doctor's orders even if you think these orders are not in the patient's best interest.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLying to the patient for his benefit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFailure to dispense a restricted prescription medicine to a known patient.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisclosing confidential patient data to the team without patient consent.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProviding treatment without the patient\u0026rsquo;s full consent.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedicine was dispensed to an elderly patient, and he had side effects.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIgnoring patient\u0026rsquo;s preferences during treatment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnprofessional behavior towards colleagues.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConducting procedures without the patient\u0026rsquo;s informed consent.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChallenges in resource allocation during treatment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIgnoring patient\u0026rsquo;s autonomy in decision-making.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacing ethical dilemmas in treatment decisions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaking treatment decisions without complete information.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreaching patient confidentiality.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral ethical issues faced during training.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiscellaneous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLess frequently reported dilemmas included 'ignoring patient\u0026rsquo;s preferences during treatment' (2.47%, 2), 'providing treatment without patient\u0026rsquo;s full consent' (1.23%, 1), and 'general ethical issues faced during training' (1.23%, 1). A few participants (3.7%, 3) reported miscellaneous ethical issues, which included situations such as conflicts of interest, professional misconduct, and issues related to patient safety. Notably, some ethical dilemmas were not reported by any participants including 'conducting procedures without patient\u0026rsquo;s informed consent\u0026rsquo;, \u0026lsquo;challenges in resource allocation during treatment,' 'ignoring patient\u0026rsquo;s autonomy in decision-making,' 'making treatment decisions without full information,' and 'breaching patient confidentiality.' This distribution highlights the variety of ethical challenges encountered by pharmacy students during their training, with many participants facing dilemmas related to treatment decisions, patient confidentiality, and adherence to doctors' orders that conflict with their professional judgment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Logistic Regression Analysis Predicting Ethical Dilemma Responses\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e demonstrates the logistic regression analysis results. Two predictors emerged as statistically significant in relation to experiencing an ethical dilemma: a training period longer than six months and the type of training undertaken. Specifically, students with more than 6 months of training exhibit approximately twice the odds of encountering an ethical dilemma compared to those with only 1\u0026ndash;6 months of training (OR\u0026thinsp;=\u0026thinsp;2.06, 95% CI: 1.14\u0026ndash;3.72, p\u0026thinsp;=\u0026thinsp;0.017), suggesting that longer exposure to the training environment may increase awareness or occurrence of ethical challenges. Furthermore, the type of training is influential, with participants engaged in \"other\" types of training experiencing 44% lower odds of facing ethical dilemmas relative to those involved in clinical rounds (OR\u0026thinsp;=\u0026thinsp;0.56, 95% CI: 0.30\u0026ndash;1.05, p\u0026thinsp;=\u0026thinsp;0.038), which implies that the structured nature or specific scenarios encountered during clinical rounds may present more ethical challenges. In contrast, other factors\u0026mdash;including gender (males having 21% higher odds), educational level (pre-internship students having 40% lower odds), college GPA (a slight 6% increase), degree type (Pharm-D students having 19% lower odds), training location (non-MOH hospital training associated with double the odds), and receipt of prior ethics education (32% higher odds)\u0026mdash;do not demonstrate statistically significant associations with the occurrence of ethical dilemmas, as their p-values exceed the conventional threshold of 0.05.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLogistic Regression Analysis Predicting Ethical Dilemma Responses\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.21 (0.68\u0026ndash;2.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.508\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducational Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInternship Students (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Internship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.60 (0.29\u0026ndash;1.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCollege GPA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCGPA\u0026thinsp;\u0026lt;\u0026thinsp;3 (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCGPA\u0026thinsp;\u0026gt;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.06 (0.57\u0026ndash;1.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.857\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDegree\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor\u0026rsquo;s (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePharm-D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.81 (0.42\u0026ndash;1.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.550\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTraining Location\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMOH Hospital (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-MOH Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.06 (0.58\u0026ndash;1.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.911\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTraining Period\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;6 Months (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;6 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.06 (1.14\u0026ndash;3.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTraining Type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical Rounds (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.56 (0.30\u0026ndash;1.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived Prior Education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo Prior Education (Ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.32 (0.52\u0026ndash;3.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.506\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThis study examined various educational and social factors to identify the ethical challenges that pharmacy students in Saudi Arabia are likely to encounter during their training. Our results reveal that certain characteristics and events significantly influence the likelihood of facing ethical problems during their Pharmacy education.\u003c/p\u003e\u003cp\u003eInternship students reported significantly more ethical dilemmas (67 out of 81, 82.7%) compared to pre-internship students, who reported only 14 out of 81 (17.3%). This finding aligns with the expectation that internship students, who have greater exposure to complex clinical and professional environments, are more likely to encounter ethical challenges. As students\u0026rsquo; progress through their training and gain more practical experience, they become more aware of ethical issues and are better equipped to identify and report them (Scharr et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, Almetwazi et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, this finding contrasts with some previous studies, such as Latif (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), which found that junior students were more likely to report ethical dilemmas due to their lack of confidence and preparedness in handling complex situations (Latif \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). This discrepancy may be attributed to differences in training environments, cultural contexts, or the specific ethical challenges faced by students in different regions. Regardless, the findings highlight the importance of experiential learning in shaping students' ethical awareness and decision-making skills.\u003c/p\u003e\u003cp\u003eThus, the analysis of the results of the study allows concluding that the majority of students (87. 6%) received training materials related to pharmacy ethics, which proves the existence of the proper educational framework. Nevertheless, the effectiveness of this kind of training in the enhancement of students\u0026rsquo; ethical decision-making has not been properly evaluated in terms of its practical relevance. Past research has shown that while students must acquire theoretical knowledge in ethical matters, what improves the ethical reasoning of students is the capacity to apply such knowledge (Okoye et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Thus, the use of practical activities such as case analyses and experiments in the pharmacy curriculum might enhance the students\u0026rsquo; ethical reasoning in practice (Donaldson et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), (Okoro \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, students with a CGPA above 3.0 reported significantly more ethical dilemmas (56 out of 81; 69.1%) compared to those with a lower CGPA. This finding suggests that high academic achievers may be more ethically sensitive or reflective in their practice, enabling them to identify and report ethical issues more frequently (Scharr et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). High-performing students often possess stronger critical thinking and problem-solving skills, which may make them more attuned to ethical complexities in clinical and professional settings. Furthermore, students with higher academic performance are more likely to engage in self-reflection and critical analysis of ethical scenarios, which may explain why they are more likely to report ethical dilemmas (Latif \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe reporting of ethical issues by pharmacy students was significantly influenced also by type of training experience. However, internship students who often participate in advanced training techniques such as clinical rounds or research reported more ethical dilemmas, which might be attributed to their more frequent exposure to ethically challenging situations. In the current study, students reported significantly more ethical dilemmas during clinical rounds (46.6% vs. 25.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) than in other training settings. The encounter and discussion of ethical issues in real-world settings occur during clinical rounds, which are structured sessions involving direct patient care and interprofessional collaboration\u003csup\u003e4\u003c/sup\u003e. This exposure is likely to increase their ethical sensitivity and decision-making skills, enabling them to detect and report ethical dilemmas more frequently\u003csup\u003e2\u003c/sup\u003e. However, students primarily engaged in dispensing medications encountered fewer ethical problems, perhaps because their tasks were more routine and they did not encounter many complex ethical scenarios. Nevertheless, it is important to note that clinical rounds also enable students to acquire better coping mechanisms for ethical challenges, thereby reducing the probability of ethical incidents in the future\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this study, logistic regression analysis revealed that the duration and type of training had a significant impact on the reporting of ethical dilemmas by pharmacy students. Those who had received more than six months of training were about twice as likely as those with less than six months of training to encounter ethical dilemmas (OR\u0026thinsp;=\u0026thinsp;2.06, 95% CI: 1.14\u0026ndash;3.72, p\u0026thinsp;=\u0026thinsp;0.017). This finding aligns with the research by Baykara et al. (2014), who found that exposure to complex scenarios in a clinical environment enhances ethical sensitivity due to prolonged exposure\u003csup\u003e5\u003c/sup\u003e. The more time students spend in training, the more likely they are to encounter situations that test their ethical judgment. Okoro and Jamiu (2021) also reported similar findings, emphasizing that inadequate exposure to ethical challenges during training leaves trainees unprepared to deal with ethical dilemmas in professional practice\u003csup\u003e6\u003c/sup\u003e. Rajiah and Venaktaraman (2020) found that age and work experience were reliable predictors of ethical decision-making, as more experienced pharmacists tend to feel more comfortable resolving ethical dilemmas\u003csup\u003e7\u003c/sup\u003e. Similarly, Allinson, Black, and White (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) highlighted the importance of continual learning in practice, moral courage, and role modeling in ethical decision-making, further reinforcing the significance of structured experiential learning in ethical preparedness.(Allinson et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe type of training also played a significant role. Students involved in clinical rounds reported more ethical dilemmas compared to those in other training settings (OR\u0026thinsp;=\u0026thinsp;0.56, p\u0026thinsp;=\u0026thinsp;0.038). Clinical rounds, which involve direct patient care and interprofessional collaboration, often present students with real-world ethical challenges, such as conflicts between patient autonomy and medical recommendations or issues related to confidentiality (Hlaing et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Husted and Husted (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) emphasized that clinical training environments provide structured opportunities for students to engage in ethical discussions, further developing their ability to navigate dilemmas (Husted and Husted \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Ibrahim and Sharif (2018) also highlighted that students with greater exposure to ethical dilemmas during clinical rotations develop stronger ethical reasoning and decision-making skills, preparing them for future challenges (Ibrahim and Sharif).\u003c/p\u003e\u003cp\u003eWhile our study found no significant association between gender, CGPA, or prior ethics education and ethical dilemma reporting, several studies in the literature report contrasting findings. Latif (2011) conducted a national study assessing ethical reasoning among U.S. pharmacy students and found that female students scored significantly higher than males on ethical reasoning tests, suggesting that gender may influence ethical sensitivity (Latif \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Similarly, Monrouxe et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) reported that female medical and pharmacy students experienced greater moral distress when encountering ethical dilemmas compared to their male counterparts, which may indicate that gender plays a role in the emotional impact of ethical decision-making (Monrouxe et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRegarding GPA as a predictor of ethical reasoning, Deniz and Eren (2023) found that pharmacy students with higher academic performance demonstrated greater ethical sensitivity and awareness, suggesting that students with stronger academic backgrounds may engage more critically with ethical dilemmas (ULUTAŞ DENİZ and Eren \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Similarly, a study by Altmyer et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) in business ethics education found that higher GPA students exhibited stronger ethical awareness than lower GPA students, indicating that academic performance may correlate with ethical reasoning (Altmyer et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). In contrast, our findings did not show a significant relationship between GPA and ethical dilemma reporting, which may suggest that practical exposure to ethical challenges plays a more influential role in ethical decision-making than academic performance.\u003c/p\u003e\u003cp\u003eWith respect to prior ethics education, our study did not find a significant impact on ethical dilemma reporting. However, DeMella et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) examined the effects of implementing an online ethics course in a pharmacy curriculum and found that while students perceived an improvement in their ethical reasoning skills, there was no statistically significant increase in their ethical decision-making ability (DeMella et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This aligns with our findings, suggesting that passive exposure to ethics education without practical reinforcement may not be sufficient to enhance ethical decision-making. However, Ulutas Deniz and Eren (2023) reported that students who completed an ethics course had higher ethical sensitivity scores than those who had not, indicating that the content and structure of ethics education may determine its effectiveness (ULUTAŞ DENİZ and Eren \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe ethical dilemmas reported most often were about treatment and patient confidentiality, which are in line with the ethical concerns experienced in practice (Rajiah and Venkataraman \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Due to the nature of the cases described it is important that the curricula of pharmacy should encompass not only the knowledge of such matters but also the ways of handling them. Some teaching methods, such as debates and case approaches, may assist in the development of students\u0026rsquo; critical thinking and ethical reasoning (Johnston et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Fino et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The findings of the present study contribute to the knowledge about the factors that influence ethical dilemma reporting, where the length of the training and the type of training experiences are found to be the two most significant predictors of ethical dilemma reporting. This research also highlights the need for the enhancement of the amount of practical experience and interprofessional practice simulation in the education of pharmacy students, which prepares them for the ethical issues that they are going to encounter in practice (Baral et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, ULUTAŞ DENİZ and Eren \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eThis study underscores the importance of integrating ethics education into pharmacy curricula, focusing on both theoretical knowledge and practical application. The findings suggest that enhancing experiential learning opportunities, particularly in clinical settings, can significantly improve students' ethical reasoning and decision-making skills. As pharmacy education continues to evolve, it is imperative to develop targeted ethics programs that address the unique challenges faced by pharmacy students, ultimately contributing to the cultivation of ethically competent practitioners in the healthcare field.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKMO and SA contributed to designing the study and collecting data. KMO and AAI analyzed the results and drafted the manuscript. SA and AAI contributed to writing and revising the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their appreciation to the Deanship of Research and Graduate \u0026nbsp;Studies at King Khalid University for funding this work through small group research \u0026nbsp;under grant number RGP1/11/46.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Medical Research Ethics Committee of King Khalid University (Approval No.: ECM#2021-5715). The study adhered to the ethical principles outlined in the Declaration of Helsinki, ensuring respect for participants\u0026rsquo; rights and dignity. Informed written consent was obtained from all participants, ensuring that participation was voluntary and that they had the option to withdraw at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAl-Arifi, M. N., 2014. Community pharmacist perception and attitude toward ethical issues at community pharmacy setting in central Saudi Arabia. Saudi Pharmaceutical Journal. 22, 315-325.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAllinson, M. D., P. E. Black and S. J. White, 2022. Professional dilemmas experienced by pharmacy graduates in the United Kingdom when transitioning to practice. American Journal of Pharmaceutical Education. 86, 8643.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAlmetwazi, M., A. Alhammad, A. Alhossan, et al., 2020. Pharmacy students\u0026rsquo; satisfaction with Introductory Pharmacy Practice Experiences (IPPE) at community pharmacy: The case of Saudi Arabia. Saudi Pharmaceutical Journal. 28, 68-73.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAltmyer, D., S.-P. Yang, K. Schallenkamp, et al., 2014. Student ethical awareness as affected by gender and grade point average. Business Education \u0026amp; Accreditation. 6, 11-22.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBaral, S. R., D. R. Parajuli, S. Shrestha, et al., 2019. Undergraduate pharmacy students\u0026rsquo; attitudes and perceived barriers toward provision of pharmaceutical care: a multi-institutional study in Nepal. Integrated Pharmacy Research and Practice. 47-59.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eChaar, B., 2016. Ethical dilemmas: Are you across the EHC guidelines? Australian Pharmacist. 35, 72.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDeMella, C., K. Donohoe, L. Morgan, et al., 2017. Implementation of an online ethics course into a pharmacy curriculum. Currents in Pharmacy Teaching and Learning. 9, 835-840.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDonaldson, T. M., E. Fistein and M. Dunn, 2010. Case-based seminars in medical ethics education: how medical students define and discuss moral problems. Journal of medical ethics. 36, 816-820.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFino, L., I. A. Basheti, B. Saini, et al., 2021. Exploring and evaluating Vertically Integrated Teaching in Ethical Decision-Making (VIT-EDM) in pharmacy. Pharmacy Education. 21, 457-465.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHlaing, P. H., A. Hasswan, V. Salmanpour, et al., 2023. Health professions students\u0026rsquo; approaches towards practice-driven ethical dilemmas; a case-based qualitative study. BMC medical education. 23, 307.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHusted, J. H. and G. L. Husted, 2008. Ethical decision making in nursing and health care: The symphonological approach, Springer Publishing Company.\u003c/li\u003e\n \u003cli\u003eIbrahim, R. M. and S. I. Sharif, Teaching professionalism and ethical reasoning to pharmacy students: How important it is? \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIlori, O., T. Kolawole and J. Olaboye, 2024. Ethical dilemmas in healthcare management: A comprehensive review. International Medical Science Research Journal. 4, 703-725.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIsmail, T. S., S. Assyifa and R. Rusnaidi, Learning Clinical Ethics for Medical Students in Clinical Phase. Jurnal Pendidikan Kedokteran Indonesia: The Indonesian Journal of Medical Education. 13, 123-134.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJohnston, D. M., I. Truter, Y. L. Irwin, et al., 2019. Pharmacy students\u0026rsquo; opinions and experiences working on board the Transnet-Phelophepa Health Care Trains. International Journal of Pharmacy Practice. 27, 311-317.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLatif, D. A., 2004. An Assessment of the Ethical Reasoning of United States Pharmacy Students: A National Study. American Journal of Pharmaceutical Education. 68, \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLoewy, E. E. and R. S. Loewy, 2004. Textbook of healthcare ethics, Springer Science \u0026amp; Business Media.\u003c/li\u003e\n \u003cli\u003eMonrouxe, L. V., C. E. Rees, I. Dennis, et al., 2015. Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies. BMJ open. 5, e007518.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMyers, J. R., M. E. Kiersma and K. S. Plake, 2017. Assessment of student pharmacists\u0026rsquo; ethical decision-making. Currents in Pharmacy Teaching and Learning. 9, 996-1002.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOkoro, R. N., 2020. Investigation of final-year pharmacy students\u0026apos; views on professionalism and ethics in pharmacy practice: an interventional study. International journal of pharmacy practice. 28, 130-133.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOkoye, O., D. Nwachukwu and F. C. Maduka-Okafor, 2017. Must we remain blind to undergraduate medical ethics education in Africa? A cross-sectional study of Nigerian medical students. BMC Medical Ethics. 18, 1-8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOrayj, K., K. Alahmari and M. Alasiri, 2022. The Concept of Pharmacy Ethics and the Examples of Ethical Dilemmas Encountered by Pharmacists in the Asir Region, Saudi Arabia: A Qualitative Study. International Journal of General Medicine. 4985-4996.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eParsa-Parsi, R. W., 2017. The revised declaration of Geneva: a modern-day physician\u0026rsquo;s pledge. Jama. 318, 1971-1972.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRajiah, K. and R. Venkataraman, 2018. Community pharmacists\u0026rsquo; perceptions on ethical dilemmas, pharmacy values and decision-making. Indian Journal of Pharmacy Practice. 11, \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRichards, D. and V. Dignum, 2019. Supporting and challenging learners through pedagogical agents: Addressing ethical issues through designing for values. British Journal of Educational Technology. 50, 2885-2901.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSalman Popattia, A., S. Winch and A. La Caze, 2018. Ethical responsibilities of pharmacists when selling complementary medicines: a systematic review. International Journal of Pharmacy Practice. 26, 93-103.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eScharr, K., J.-F. Bussi\u0026egrave;res, S. Prot-Labarthe, et al., 2011. A comparative pilot study of the professional ethical thinking of Quebec pharmacy residents and French pharmacy interns. International Journal of Clinical Pharmacy. 33, 974-984.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eScheinman, S. J., P. Fleming and K. Niotis, 2018. Oath taking at US and Canadian medical school ceremonies: historical perspectives, current practices, and future considerations. Academic medicine. 93, 1301-1306. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSr, A. S. and A. D. Costa, 1994. Are women more ethical than men? Journal of Business Ethics. 859-871.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSturman, N. and N. Saiepour, 2014. How confident are general practitioners in teaching medical students about ethical issues on general practice placements? Australian Family Physician. 43, 880-885.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eULUTAŞ DENİZ, E. and R. Eren, 2023. ETHICAL SENSITIVITY: A COMPARATIVE ANALYSIS OF PHARMACY STUDENTS TAKING AND NOT TAKING AN ETHICS COURSE IN TERMS OF VARIOUS VARIABLES. Ankara \u0026Uuml;niversitesi Eczacılık Fak\u0026uuml;ltesi Dergisi. 47, \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ethics, Pharmacy students, Saudi Arabia, Training and Dilemma","lastPublishedDoi":"10.21203/rs.3.rs-6671824/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6671824/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e This multicenter cross-sectional study aimed to explore the factors influencing ethical dilemmas among undergraduate pharmacy students in Saudi Arabia, focusing on training duration, educational level, and type of training experiences. Participants included 259 students from eight universities, selected through stratified convenience sampling. Data were collected via questionnaires covering demographics, educational background, and ethical dilemmas encountered during training. The findings of the study revealed that students with more than six months of training were significantly more likely to report ethical dilemmas (53.09%) compared to those with shorter training periods (29.78%). Internship students reported more ethical issues (82.7%) than pre-internship students (17.3%), and students involved in clinical rounds with medical teams reported more dilemmas (41.98%) than those primarily engaged in dispensing (40.74%). Notably, no significant gender differences were found in reporting ethical dilemmas. The most common ethical dilemmas included treatment decisions (16.05%), obeying doctors' orders against their judgment (14.81%), and disclosing confidential patient data without consent (14.81%). Logistic regression analysis identified training duration and type as significant predictors of ethical dilemma reporting, with students in clinical rounds more likely to encounter dilemmas (OR\u0026thinsp;=\u0026thinsp;0.56, p\u0026thinsp;=\u0026thinsp;0.038). The findings emphasize on the importance of integrating practical, experiential learning and ethical training into pharmacy curricula to better prepare students for the ethical challenges they will face in professional practice.\u003c/p\u003e","manuscriptTitle":"Predictors of Ethical Dilemmas Among Undergraduate Pharmacy Students in Saudi Arabia: A Multicenter Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-09 09:24:01","doi":"10.21203/rs.3.rs-6671824/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-02T14:25:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89098052987159335433223253490164377360","date":"2025-07-13T09:29:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8520278041859394426606468539904904619","date":"2025-07-12T07:19:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121228405553042672410643215674803567884","date":"2025-07-07T15:24:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-04T11:22:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-02T14:01:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-13T12:19:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T15:13:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-06-11T15:10:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea24fca3-5798-469d-aba5-fa6e5730e940","owner":[],"postedDate":"July 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-09T09:24:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-09 09:24:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6671824","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6671824","identity":"rs-6671824","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}