The Pharmaceutical Journal
Vol 269 No 7209 p171-173
3 August 2002

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Lifelong learning in pharmacy conference

Wake the sleeping beast — the challenge for continuing professional development

Participants from 16 nations attended the Lifelong Learning Conference. They were given a challenge by Nadine Butler, of the University of the Western Cape, South Africa, who said that within us all was a "sleeping beast" — ethics — which needed awakening. Ethics was a question of what "ought" to be done and, as part of that, pharmacists had a moral obligation to participate in continuing professional development. In South Africa, newly qualified pharmacists swore an oath which they said alongside qualified colleagues. The first pledge, which came before all the others to do with being custodians of medicines, said, "I solemnly pledge to continuously renew, augment and improve my knowledge and expertise." Energy being spent on the process, the "how to do", was deflecting us from the ethical focus, the "ought to do". She went on to say that mandatory CPD swamped the ethical dimension. We needed to market the ethical aspect to achieve a greater uptake of CPD.

Compromise

An alternative to mandatory CPD, "managed CPD", was suggested by Al Hanson, associate professor, University of Wisconsin-Madison. The term implied there was a difference between personal CPD and managed CPD. A survey of the status of continuing education (CE) and CPD in many countries had been conducted since the previous Lifelong Learning conference in 2000. Different countries and cultures use the different terms of CE, CPD and lifelong learning interchangeably. Mr Hanson came up with a definition of CPD as "postgraduate professional education involving a cycle by which individual practitioners assess their learning needs, create a personal learning plan, implement the plan, and evaluate the effectiveness of the education intervention as it applies to their pharmacy practice". In the United States, all states apart from Hawaii had introduced mandatory CE; Florida had a system in place in 1965. The average requirement was 30 hours over two years. CE in the US was partly funded by the individual and partly by grants from the pharmaceutical industry.

Standards

Mike Rouse, executive assistant director of the American Council on Pharmaceutical Education (ACPE), was keen to emphasise that undergraduate education and training prepared pharmacists to enter the profession; it did not provide them with everything they would need to know throughout their professional careers. He was concerned that, globally, quality assurance systems for CE and CPD were not as well developed (if existing at all) as they were for undergraduate degree programmes.

The ACPE had a CE accreditation programme with seven standards for CE providers. There was a danger, however, that too much emphasis was on process and not enough on outcome, which was difficult to define and measure.

Another concern was that, however high the quality programme, it does not guarantee learning. Mandatory CE in the US fulfilled a requirement for hours of attendance or credits but was no guarantee of the quality of learning. Mr Rouse described a gallery of CE participants: the back row newspaper reader, the snoozing participant, the totally confused, and those present in body but not in mind. CPD allowed the introduction of better systems for quality assurance, with the accreditor, the provider and the practitioner all having to undergo a continuous quality improvement cycle.

Mr Rouse had developed an international quality assurance network to address some of these issues (www.acpe-accredit.org). One of the areas for discussion were the essential elements of quality:

• Efficiency — how well it performs its limited functions
• Reliability — you can depend upon it
• Durability — how long it lasts
• Integrity — delivers what it promises
• Consistency — the same every time
• Purity — absence of unwanted elements
• Functionality — what it can do or achieve
• Authenticity — not false or an imitation
• Ease of use — good appearance or satisfying to use

CPD in Canada

Bernie des Roches, Ontario College of Pharmacists, described the situation in Canada where most provinces, apart from Ontario, had a mandatory requirement of around 15 hours of CE per year. There was a national agreement on the core competencies for all pharmacists.

In Ontario, standards of practice have been developed from these and it is mandatory to comply with them. A self-assessment survey is sent to all pharmacists in the province to allow them to reflect on their personal needs. Records of CE are not assessed but a sample of 20 per cent of practising pharmacists is called for a practice review every year. The review consists of assessment of the pharmacist's interaction with five scenarios and their clinical knowledge of 15 cases. The review is held four times a year at one location to achieve standardisation of conditions. Pharmacists are given three months notice of their practice review. The idea is not to be punitive but to identify areas that need development. Approximately 15 per cent of candidates require remediation. They meet with a peer support group of pharmacists and public members and prepare an action plan for remedial CE. In addition to being directed to remedial resources and mentoring, they receive coaching throughout the remediation process.

CPD in South Africa

João Carapinha, Pharmaceutical Society of South Africa (PSSA), said that the PSSA expected compulsory CPD to be a prerequisite for practice registration. The PSSA existed to mentor and facilitate CPD. It assisted in the generation of standards though a peer review system. In future, it will sample portfolios, with all being assessed over a three- to five-year period. He queried whether pharmacists were equipped to undertake voluntary CPD because of the past low uptake of CE. A user friendly self-assessment tool was need together with extension of the role of higher education institutes.

CPD in New Zealand

In New Zealand, a CPD programme called "Enhance" has been in development since 1997. Bronwyn Clark, of the Pharmaceutical Society of New Zealand, presented a poster and discussion on the programme, which was based on a set of practical standards that defined the skills, knowledge and attitudes required of a New Zealand pharmacist. The Enhance programme, which encompasses a practice review and learning plan, has been piloted by 350 pharmacists, and the next phase is due to start soon.

Mentoring

Parallel workshops and breakout discussions during the conference enabled participants to attend topics of their choice. Jennifer Archer, assistant director, Centre for Pharmacy Postgraduate Education, University of Manchester, led a workshop on mentoring, an essential interpersonal process for CPD. She said it is important to differentiate between coaching and mentoring. Coaching is a structured two-way process in which individuals develop skills and achieve defined competencies through assessment, guided practice experience and regular feedback. However, mentoring is a relationship rather than a process. A mentor is a friend and trusted counsellor without any management or performance improvement responsibility. In the role as personal facilitator a mentor listens, encourages, challenges and questions in such a way as to empower the other person to achieve certain goals. Participants at the workshop were given a range of techniques to support them as mentors, one being a guide to what might be included in a mentoring contract (see Panel).

Employers' support for CPD

The support for lifelong learning by employers was well demonstrated by various presentations from S Buys, a corporate pharmacy group based in South Africa. Ina Rothmann, director of human resources and research, said that the service economy was not about products any more. In fostering a competitive edge, it was more important to focus on the softer issues in the workplace, such as leadership skills, intra- and interpersonal skills, teamwork and sustained performance. Research carried out by the group had shown a homogenous tendency of both pharmacists and technicians. They tended to be people who:

• Have strong needs for group membership and responsibility
• Value stability, order and collaboration
• Depend on hierarchy and authority
• Champion previous experiences and tend to resist change
• Perform well in logistics and the maintenance of traditions

In order to bring about change it was necessary to use an "inside-out" model, starting from within the person rather than from the organisation. Ms Rothmann said that, to be successful, the planning, implementation and management of change needed to include self-development. Some of the questions that need to be asked where:

• Who am I?
• What are my strengths and weaknesses?
• What are my paradigms and perceptions? How do these influence my seeing and being?
• Why am I in this job? What are my career anchors?
• How do I cope with stressful situations?
• How do I influence situations and people around me?

A self-development programme, to form the basis for training and development programmes within the S Buys groups, was evaluated by a controlled trial among 35 pharmacists. Results indicated that participants undergoing the self-development programme gained more faith in their personal skills and abilities, a fundamental need in self-development. It was suggested that if participants gained faith in themselves it would affect the way they look at themselves, their work, their organisation and their contribution.

CPD forces in Europe

Barry Andrews, non-executive chairman of Moss Pharmacy, described some of the driving forces for CPD across the European countries in which Alliance UniChem had pharmacies. In Italy where the company had taken over local health authority pharmacies, it was the regional health body that was driving CPD. In the Netherlands and Switzerland the health insurers were the organisations demanding that community pharmacists showed evidence of a commitment to CPD before they could dispense their prescriptions. In Switzerland, however, the requirement for accreditation was unrealistic and impractical given the time required to meet the standards and the shortage of pharmacists.The Netherlands was taking a more pragmatic approach. In Norway, CPD was very much at the top of the agenda for recruitment purposes. A CPD portfolio was an important part of recruitment to new health centre Moss pharmacies. The company recognised the need to sustain pharmacists throughout their careers. There is a clear business benefit to ensure that pharmacists can adapt to change.

Problem-based learning approaches

Kick-starting life-long learning at undergraduate level can be achieved by problem-based learning (PBL). Professor Rob Summers, school of pharmacy, Medical University of South Africa, described the theoretical basis of PBL. It involved contextual learning, information processing and co-operative learning. The challenge of PBL for schools of pharmacy was that it required intensive faculty resources, time-intensive content delivery, new infrastructural support systems and new quality control mechanisms. The theory which supported PBL was a move away from controlled motivation or "you should" towards autonomous motivation " I should". The former generated pressure and anxiety whereas the latter provided personal satisfaction. PBL involved varied learning activities such as small group sessions, workshops, individual projects, site visits, information retrieval and sessions for reflection. For small group work, a seven-stage approach was used:

1. Understand the terms

2. Define the problem

3. Brainstorm to activate poor knowledge

4. Arrange ideas

5. Define learning objectives

6. Self-study

7. Report back

Professor Summers described PBL as the heart of the CPD cycle.

A PBL approach was described in one of the posters from the Finnish Centre for Continuing Pharmaceutical Education. Sinnika Kesseli-Pulkkinen described how 49 community pharmacists had signed up for the pilot project. Six groups had been formed after an initial two-day training on how to use the method. The groups met monthly and chose the topics to work on based on their importance in everyday work. Although most participants considered PBL as a good method to be used for CPD, the project highlighted difficulties in evaluating different sources of information and the need for more support for learners.

Alice Ward, School of Pharmacy, University of London, presented work on the use of PBL as part of a diploma course. She also identified the need for developing tutor training to support the role as PBL facilitators as distinct from the expert role in that specialist area.

Mystery shoppers

An approach to support the move from talking about change to implementing change was described by Dr Abilio de Neto, University of Sydney.

In Australia pseudo-customers or "mystery shoppers" have been used to complement the role-plays undertaken in a workshop situation. The approach is collaborative: pharmacists are made aware of impending visits and receive a copy of the feedback sheet, which highlights the essential features of the target behaviour. This approach has been important in imple-menting standards of practice for non-prescription medicines. The government had said that pharmacists had to fulfil a counselling role on non-prescription medicines or these would be deregulated. This had left the profession with the challenge of changing behaviour in a short period.

The advantage of the pseudo-customer approach is that assessment is by direct observation in the natural environment. It focuses on the key behaviours to be tested and minimises the risk of assessment being reactive. As a result of the feedback given to the pharmacists, the assessment was found to increase the participant's confidence and it could also be used as the basis for acquiring further skills. There were some additional benefits in that pharmacists practise their counselling skills with every person unfamiliar to them, whom they suspect could be the mystery shopper. Frequent practice of newly acquired skills is more likely to become routine and automatic behaviour.

The approach made use of the powerful psychological phenomenon of cognitive dissonance, that is a state of psychological discomfort created when an individual behaviour (eg, not providing information to customers) is discrepant with beliefs, attitudes, and feelings about oneself (eg, I am a good professional, I care about my patients). The resultant effect of this is a change to behaviour rather than a change of attitudes or beliefs.

Learning from within

Change was also the subject of the presentation by Zubin Austin, Faculty of Pharmacy, University of Toronto. He described the principles of memetics, the study of idea transmission and the concept that changes do not happen incrementally — they happen dramatically at the point of inflection, or tipping point.

Research conducted into the process of developing pharmaceutical care plans by a group of internal pharmacy graduates studying a web-based distance learning course made use of various theories and analytical tools to identify what was happening. Results had shown that the primary source of information was from within the peer groups. The implications are that learning happens from within peer groups and cannot be imposed from outside. Group socialisation theory may therefore be important to the development of pharmacists.

Participants' challenge

Participants' own continuing professional development was not forgotten while they attended the conference. Peter Wilson, of the Royal Pharmaceutical Society of Great Britain's CPD advisory group, who had opened the conference, challenged participants to evaluate their experience by applying the three "whats" to each session attended:

• What — what have I learned?

• So what — what is the relevance?

• Now what — how will I use it?

Participants left the conference ready to start the journey along "the road less travelled" with a commitment to meet again in two years time in Canada to report on progress.