The Pharmaceutical Journal Vol 267 No 7156 p55-56 July 14, 2001

Articles

Recruitment and retention initiatives and competence-based training for junior pharmacists

By Pippa Farrington, MRPharmS, Karen Buddell, MRPharmS, and Barry Jubraj, MRPharmS

Poor recruitment and retention levels within the hospital pharmacy sector have reduced the development of, and threatens, existing pharmacy services nationally. A variety of initiatives were developed to help resolve this issue at junior grade pharmacist level at the Chelsea and Westminster Hospital. This paper highlights some of these initiatives and in particular describes the competence-based training programme which has been established and developed during the past three years. This programme has resulted in reduced vacancy levels and increased periods of retention for pharmacists at the Chelsea and Westminster NHS Trust

The recruitment and retention of hospital pharmacists is a nationally recognised problem in the United Kingdom. Vacancy levels averaging 16 per cent have been reported across the London region with some central London teaching hospitals reporting vac-ancy levels of over 50 per cent. This problem is not new. A gradual increase in vacancies has been seen across the UK in recent years and this situation has been exacerbated by higher rates of pay in community, industrial and locum pharmacy, a desire to travel, and the development of primary care advisory roles. Recent work has indicated dissatisfaction with training opportunities among junior pharmacists. In addition, the degree course for pharmacists in England and Wales has changed from three to four years. In the summer of 2000, only students from Ireland and Scotland (three schools) graduated, resulting in a significant depletion of newly qualified pharmacists and further increasing vacancy levels in the year 2001–02, the so-called “fallow year”. Chelsea and Westminster Hospital The pharmacy department at the Chelsea and Westminster NHS Trust operates a 24-hour residency service outside the routine opening hours of 9am to 6pm Monday to Friday and 10am to noon on Saturday and Sunday. In September 1997 five resident pharmacists provided the on-call service on a rostered basis. Within three months only two of these residents remained in post. Exit interviews were held to determine the reason for resignation and any areas of dissatisfaction. The main reasons were too much time on call and unsociable hours, a 48-hour weekend, a lack of senior backup out of hours, inadequate training and attractive locum rates of pay elsewhere. It was clear that remedial action was needed, particularly if the residency service was to be maintained throughout the fallow year. There was also a desire to retain staff in whom much time and effort had been invested in terms of training. Recruitment and retention initiatives Between 1997 and now, the non-resident junior pharmacists employed at the Chelsea and Westminster hospital have been replaced with 13 resident pharmacists. The increased numbers of pharmacists providing this service has negated the need for a 48-hour weekend shift. The lack of senior back up was addressed by rostering senior staff to provide an advisory back up service 24 hours a day. Increased technical support is now also provided during weekend opening hours. A guarantee is made for support to study for a postgraduate diploma. A competence-based training programme has been developed and is now established in practice. As part of this scheme, funding was received in 1998 to link a grade/pay extension to the competence-based training programme. Competence-based training Junior pharmacist training at the Chelsea and Westminster Hospital had traditionally followed a rotational format, with three months spent in each section within the pharmacy department. The new rotational competence-based programme used the existing format as a base and extended rotation types to include more clinical areas of training and rotation length to four months. Each rotation is also linked with a specific ward commitment, for which a ward tutor (not necessarily the section head) is designated to provide training, support and assessment. The training role includes covering predetermined topics once weekly. The preregistration model of competence-based training is used as a template for our scheme. Each rotation is described in the programme as a “unit of competence”. Each unit has a number of elements which contain specific performance criteria against which evidence is collected (Table 1). Table 1: Performance criteria and competencies, and the evidence required to demonstrate them, for the inpatient dispensary unit Performance criterion/competency Evidence required Maintenance and upkeep of dispensary documentation Contribution to the “unusual doses” file Responsible for updating the “changes within the dispensary” file Demonstration of ability to write a procedure A clinical trial has been set up and a procedure written Participation in the training of a preregistration trainee Trained a preregistration trainee in Controlled Drug dispensing, and checked and signed off their CD accreditation Active participation in discussions on current practices in the dispensary and informing non-dispensary staff of any changes in practices Has chaired and minuted a dispensary/ward pharmacy meeting The performance criteria have been chosen to reflect the necessary skills expected of a junior pharmacist within each rotation. A manageable number of performance criteria are agreed between the section head and junior pharmacist at the start of each rotation, with consideration given to their previous experience. During the rotation, training is provided under the supervision of the section head. Evidence is collected, discussed and assessed throughout the rotation and at appraisal. It is the responsibility of the junior pharmacist to ensure that agreed performance criteria are covered and to highlight any problems encountered. The development of appropriate knowledge, skills and attitudes is achieved through the designated performance criteria. Some of these tend to be more prescriptive with the emphasis on expanding knowledge. Other performance criteria concentrate on the acquisition of skills and the development of professional attitudes. The ability to deputise for the section head, thereby facilitating independent practice within each section, is a key component of this aspect of training, which benefits the junior pharmacist in terms of professional development, and the department and trust in terms of the quality of service provided. Attainment of certain specified levels of competence in three rotations is linked to grade extension (B to B+ and B+ to C grade). The competence-based training manual and management of the scheme A manual has been written which describes the scheme and provides a comprehensive guide to all aspects of training and assessment. It includes a background description, guidelines, roles of stakeholders and all the performance criteria for each rotation. The appendices include the necessary paperwork for management of the scheme and crucially provides a checklist for how the paperwork should be managed at each stage. A copy is held by each section head and each junior pharmacist. Towards the end of each rotation, section heads meet for a handover meeting to discuss each junior pharmacist’s performance and training needs. Assessment The section head assesses evidence collected for performance criteria within each rotation. Assessment will usually be an ongoing process, with formal feedback at week eight and a final assessment during an appraisal at the end of the rotation. Junior pharmacists are responsible for collating all evidence in a ring-binder portfolio, with freedom to present their evidence as they wish. The section head works closely with the ward tutor, who is responsible for assessing junior pharmacists in their ward practice. This assessment involves the use of a ward pharmacy audit checklist which is administered twice during the rotation to provide an objective measurement of clinical performance and adherence to locally published ward pharmacy standards. Appraisals are integral to the assessment process and are conducted by section heads at the end of each rotation and by a mentor after every two rotations. All appraisal documentation has been adapted from the trust paperwork to adopt a user-friendly format for rotational staff. The portfolio of evidence forms the basis of the main appraisal. The main appraisal also incorporates feedback received from the residency manager with regard to on-call performance. An objective structured skills examination (OSSE) is a skills-based assessment tool which allows a student to demonstrate skill and competence in a particular area. It takes the form of a workstation where a scenario and associated task are set, and the student is required to attempt the task in the time allowed. An objective mark scheme (consisting of points that the candidate should cover) is used to assess performance. This is administered by a workstation assessor. Role players (in person or by telephone) are employed if an interpersonal interaction forms part of the workstation. Three OSSEs, which cover each rotation undertaken, are set for each pharmacist. Workstations are designed and assessed by the relevant section heads. An objective mark scheme set by the section head and approved by the principal pharmacist for the relevant section is written and stations are validated by piloting the workstation on a preregistration trainee and a senior pharmacist to assure the appropriate standard of the workstation. A short interview (viva voce) by the adjudication panel is conducted after three rotations to inform the final decision to award a grade extension from B to B+ or B+ to C grade. The interview may consist of any aspects of the grade extension candidate’s portfolios, appraisals, general performance, performance at examination and attitudes. Guidelines are set by which grade extensions may be granted. These guidelines include satisfactory completion of portfolios, on-call performance, ward assessment and OSSEs and relevant postgraduate study. Experience to date Our competence-based training manual was piloted in 1999 and implemented for the autumn 2000 intake of junior pharmacists. These pharmacists had either a hospital or community background. One cycle of the scheme has been completed and this has led to grade extensions for four pharmacists. The residency service has been maintained with 13 resident pharmacists in post last year. This year has seen some leavers, although exit interviews have revealed that all were for personal reasons rather than a lack of support or training. Some leavers have also been successful in moving to specialist posts within the department. Recruitment potential has increased with over 80 applicants for rotational junior pharmacist positions in spring 2000 compared with a previous inability to recruit on two occasions from advertisements in The Pharmaceutical Journal. In addition, retention periods have increased with three of our junior pharmacists still in post after 26 months compared with an average of six months in 1997–98. Handover meetings have worked well to enable appropriate support and encouragement to be provided. It has also become clear that continuing professional development (CPD) is encouraged by the scheme, for example, in developing these pharmacists into capable deputies for section heads. CPD is recorded in the portfolios, which contributes to the departmental clinical governance requirements. Future work The following planned initiatives are intended to build upon the success of the current scheme: A new rotation to include a placement in New Zealand, as part of an exchange scheme Project work to be included as part of revised performance criteria Modernisation of pharmacy services which will require new performance criteria as pharmacists are redeployed An equivalent scheme for pharmacy technicians An equivalent scheme for C to D grade pharmacists

Pippa Farrington is chief pharmacist, Karen Buddell is principal pharmacist (patient services) and Barry Jubraj is principal pharmacist (education and training) at the Chelsea and Westminster Healthcare NHS Trust. Correspondence to Mr Jubraj at Pharmacy Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9MH (e-mail barry.jubraj@chelwest.nhs.uk)

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