Texas student pharmacists' approaches to community pharmacy drug diversion: A mixed-methods study using criminal justice models

Drug diversion in community pharmacy is a persistent patient safety, ethical, and regulatory challenge. Despite its prevalence, pharmacy curricula may inadequately prepare student pharmacists to identify and respond to diversion incidents. Prior qualitative work suggests student approaches can be categorized using King's models of criminal justice; however, no validated instrument exists to quantitatively evaluate these approaches or to explore the motivations underlying students' decision-making. This study aimed to (1) identify the predominant criminal justice models endorsed by student pharmacists when resolving community pharmacy drug diversion incidents using a validated survey instrument and (2) explore the motivations informing their preferred approaches. Phase 2 of an exploratory mixed-methods study was conducted among student pharmacists recruited from multiple Texas colleges of pharmacy. A 22-item, theory-informed survey grounded in King's six criminal justice models was distributed using convenience sampling. Quantitative data were analyzed using repeated-measures ANOVA with Greenhouse–Geisser correction, while open-ended responses were analyzed using inductive thematic analysis. A total of 199 student pharmacists participated. The most endorsed approaches were the Due Process and Medical models, followed closely by the Status Passage model, while the Bureaucratic model was the least endorsed. Four dominant motivational themes emerged: Conditioning, Retribution versus Rightfulness, Holistic Approach, and Professional Expectations. Motivations commonly reflected ethical reasoning, perceived professional duties, concern for patient safety, and contextual factors surrounding diversion incidents. Student pharmacists most frequently favor justice-oriented and rehabilitative approaches to community pharmacy drug diversion. The identified motivations reveal procedural, punitive, and patient-centered perspectives. These findings provide evidence supporting targeted, theory-informed curricular interventions to better align students' decision-making with ethical, professional, and public health expectations. • Student pharmacists most strongly endorsed justice-oriented and rehabilitative approaches. • Students deprioritize procedural efficiency in favor of approaches seen as more ethical, patient-centered, or fair. • Four major motivational themes shaped students' decision-making. • Results highlight inconsistent or insufficient training on drug diversion response in PharmD curricula.