- Email: [email protected]
Pharmacists' and pharmacy technicians' views on a process of revalidation of pharmacy professionals in Great Britain
Research in Social and Administrative Pharmacy 9 (2013) 142–154
Original Research
Pharmacists’ and pharmacy technicians’ views on a process of revalidation of pharmacy professionals in Great Britain Helen Potter, Ph.D., M.Pharm.S.a, Karen Hassell, Ph.D.b,*, Peter R. Noyce, C.B.E., Ph.D., F.R.Pharm.S.a a NHS Trafford, 3rd Floor, Oakland House, Talbot Road, Old Trafford, Manchester M16 0PQ, UK School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK
b
Abstract Background: Revalidation will be introduced for pharmacy professionals in Great Britain. However, what pharmacists and technicians understand about it as a process remains unexplored. Objectives: This study aimed to explore the views of pharmacists and technicians about the revalidation of fitness to practice. Views were gathered on the sources of evidence that could be used, assessment methods, who should undertake the assessment, and how often it should occur. Methods: A multiple methods study was conducted with community and hospital pharmacists and technicians. It included 6 focus groups, 14 one-to-one interviews, and a postal survey sent in March 2009 to a 10% randomly selected sample of 4640 practising pharmacists and 738 technicians working in England, Scotland, and Wales. Results: Twenty-nine pharmacists and 16 technicians participated in the focus groups and interviews; 1206 (26.4%) pharmacists and 240 (32.8%) technicians returned a completed questionnaire. A large majority of both pharmacists (86%) and technicians (81%) were in favor of continuing professional development (CPD) records being used as evidence to inform revalidation, but only a small proportion of both groups agreed that patient feedback should be used. Evidence from appraisals and peers/colleagues was also well supported. Technicians were significantly more likely than pharmacists to indicate that their assessment for revalidation should be undertaken by their main employer. Although most technicians (49%) believed that revalidation should take place every 2–3 years, most pharmacists (58%) believed that it should occur only every 5 years. Conclusions: Pharmacists and technicians do not share the same views on all aspects of revalidation, suggesting that 1 single model may not be desirable or practicable. Both groups identified CPD, appraisal, and feedback from peers as possible components of revalidation, but concerns about impartiality and independence of assessors were raised. Crown Copyright Ó 2013 Published by Elsevier Inc. All rights reserved. Keywords: Community pharmacy; Revalidation; Regulation; Pharmacists; Technician
* Corresponding author. Tel.: þ44 161 275 2422; fax: þ44 161 275 2416. E-mail address: [email protected] (K. Hassell). 1551-7411/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2012.07.008
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Introduction In the United Kingdom, 2 very high profile negligence cases identified failures of competence and performance in the medical profession (subsequently known as the Bristol1 and Shipman2 inquiries). They acted as a catalyst for action by government and professional regulatory bodies to review the fitness to practice procedures in an endeavor to ensure that health care practitioners do not pose a risk to patients and to maintain public confidence and trust.3 Government reviews and policy papers4-6 that followed the Bristol and Shipman inquiries called for the introduction of a system of revalidation for all health care professionals, defined as a periodic assessment of a health care professional’s fitness to practice. This study was undertaken to explore pharmacy professionals’ perspectives on the proposed implementation of revalidation.
Pharmacy professionals and revalidation internationally Within the Great Britain (GB)a context, there are 2 types of professionals, pharmacists and pharmacy technicians, both of whom have to be registered with the pharmacy regulator (the General Pharmaceutical Council [GPhC]). In GB, pharmacy technicians are a relatively new profession. At the time the study reported here was conducted, registration for pharmacy technicians was voluntary and only became mandatory in 2011, whereas the mandatory registration for pharmacists has been a long-established requirement to practice. Once registered, both pharmacists and technicians must undertake mandatory continuing professional development (CPD). They also have to meet a set of minimum standards of conduct, ethics, and performance. In common with other British health professional regulators, the GPhC will have to consult and implement a revalidation process for all its registrants. This will involve deciding on the frequency, challenges, and burden of revalidation; what sources of evidence should be used to support revalidation; who conducts assessments; whether different processes are required for different groups of registrants; and the time for remediation. a
143
Some consideration has been given to the types of evidence that could be used to inform pharmacy revalidation, particularly the use of CPD and appraisals.7 Pharmacists working in the managed care sectors, within England only, participate in appraisals operated under the Knowledge and Skills Framework (KSF, a generic appraisal system for all National Health Service [NHS]b staff regardless of the disciplinary background)8 so that they have an opportunity to gather evidence that could be used toward their revalidation. However, a comparable framework for community pharmacists, or pharmacists in non-patient-facing roles, is not in place. In any case, questions about the KSF not being specific enough to assess pharmacy professional’s fitness to practice and whether it would be sufficiently robust to either identify poor performance or act as a primary source of evidence for revalidation have been raised.9-12 Views on appraisals from practitioners themselves are unknown. Elsewhere within the pharmacy profession, pharmacists in Canada, New Zealand, and Singapore (countries where the number of pharmacists is much smaller than in GB) are required by their professional regulatory body to perform satisfactorily in a process of periodic revalidation to retain their right to practice. In the United States, periodic recertification is a requirement of the Board of Pharmacy Specialties for maintaining certification as a specialist pharmacist practitioner.13 In New Zealand, where the Pharmacy Council introduced annual recertification for its members in 2006, revalidation is based solely on CPD.14,15 Once every 5 years, 20% of pharmacists submit their CPD records for audit, and if the Pharmacy Council considers records to be unsatisfactory, a pharmacist can be suspended. The Singapore Pharmacy Council (formerly Board) issues practising certificates (PCs) to pharmacists, allowing them to practice for 2 years from the date of issue. Since January 2009, pharmacists have had to demonstrate that they have achieved a minimum number of continuing professional education (CPE) points from a range of approved activities, undertaken within the qualifying period of the previous
The United Kingdom comprises England, Scotland, Wales, and Northern Ireland (NI), whereas NI is not a part of
GB. b
The NHS is the comprehensive publicly funded health care system of the United Kingdom. It provides acute and long-term care at primary, secondary, and tertiary tiers, as well as emergency care. Secondary and tertiary care is provided by directly employed NHS staff, for example, hospital pharmacists. Primary care is provided by NHS contractors, for example, general medical practitioners and community pharmacists, on national terms and conditions.
144
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
2-year PC.16 The council issues 2 types of PC–normal and restricteddfor which the CPE requirements are quantitatively similar but qualitatively different. For pharmacists to practice in all areas of pharmacy including pharmaceutical care areas (ie, patient-facing practice), they must hold a normal PC. Despite their widespread use, concerns have been raised internationally about CPE/CPD assuring professional competence,17 and in GB, doubt has been expressed about relying on CPD records alone to confirm fitness to practice of GB pharmacy professionals.18 In Canada, 2 provincial regulators, the Ontario College of Pharmacists and the College of Pharmacists of British Columbia, have introduced systems for revalidating their members. Pharmacists in Ontario, where periodic competency assessment has been in place since 1997, are required annually to declare whether they are providing direct patient care, that is, providing pharmacy services directly to the public. Those that so declare are placed on part A of the register; they must practice a minimum of 600 hours over a 3-year period and, when selected, must undergo a practice review.19 A pharmacist’s patient care competencies are directly assessed through a process of CPD and peer review.20 Each year, 20% of the 9600 registered pharmacists are randomly selected to submit a selfassessment survey and CPD activity record, and a small proportion of these is selected annually for peer review. This consists of a written test of clinical knowledge and a practice-based assessment (an objective structured clinical examination [OSCE]) using standardized patient scenarios. Assessors (who are pharmacists) are trained to assess those undergoing review in a standardized fashion.19 The Professional Development and Assessment Program in British Columbia is similar to that in Ontario.19 So, in Canada, although the current revalidation methods determine a patient facing pharmacist’s fitness to practice, through the use of the OSCE in assessing a pharmacist’s patient care competencies,20 a pharmacist’s performance in their day-to-day practice is yet to be observed. A system of revalidation for pharmacy technicians does not exist in Canada or elsewhere. Revalidation in other health care professions Doctors in Australia, New Zealand, Canada, the United States, and some European countries undergo some form of periodic revalidation or
relicensure, either on a mandatory or on a voluntary basis.4,21 At its simplest, this involves medical practitioners undertaking continuing medical education CPD. Other methods used for doctors include peer review, external evaluation, practice inspection,21 and multisource feedback, sometimes known as 360-degree review.22 The latter involves assessment against specific performance criteria with feedback from patients, peers, and colleagues who know the work of the person being assessed. In the United Kingdom, revalidation developments and its implementation in the medical profession are at a more advanced stage than in pharmacy and are currently expected to begin in December 2012.23 The duties of a doctor registered with the General Medical Council are defined in “Good Medical Practice,” in which it is made explicit that “serious or persistent failure to follow this guidance will put your registration at risk.”24 Revalidation of doctors will almost certainly involve participation in 360-degree feedback and annual appraisal.25 In the nursing profession in the United Kingdom, the Nursing and Midwifery Council (NMC), the statutory body for all UK nurses, midwives, and specialist community public health nurses, places a requirement on all their members to reregister every 3 years.26 Reregistration is based again on CPD, with nurses and midwives encouraged to reflect on their practice using standards set by the NMC.26 To maintain registration, nurses and midwives are required to have worked a minimum of 450 hours in the previous 3 years. Although this work must be related to their nursing or midwifery qualification, nurses do not have to be in clinical practice, that is, a nurse may be a clinical nurse supervisor responsible for the education and training of nurses but not in a patientfacing role. Practising midwives, however, must be in clinical practice before renewal of registration, and nurses and midwives are required to submit a notification of practice form declaring that they have met the NMC standards, they have worked their practice requirements, and undertaken 35 hours of CPD relevant to their practice. The dentistry regulator in the United Kingdom is aiming to introduce revalidation for dentists in 2014. To date, proposals are that dentists will have to demonstrate and declare compliance with relevant standards, in a 5-year cycle, and the supporting CPD evidence will be checked at least once in every revalidation cycle by an approved external verifier. Dentists will be removed from
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
the register if they fail to make a declaration, and where standards are not met, dentists will be given 6 months to remedy any deficiencies.27 From this brief description of revalidation processes and assessment mechanisms for different health care professionals, actual or proposed, in English-speaking countries, it is evident that the processes and frequency of revalidation or relicensing and who is involved differs, and the assessment methods and sources of evidence used to demonstrate fitness to practice are numerous. Furthermore, little is known about what pharmacy professionals think about revalidation in general. As the first pharmacy study about revalidation in GB, the main aim of the research reported here was to gain insight into the views of pharmacists and technicians on requirements for revalidation. Building on what was known about pharmacy revalidation in Canada, New Zealand, and Singapore and about revalidation of medical practitioners, dentists, and nurses, the study explored areas of pharmacy practice that pharmacists and pharmacy technicians felt were important for a revalidation process and, integral to this, how these areas of practice could be assessed. Pharmacists and pharmacy technicians in both patient facing, that is, with patient care responsibilities, and non-patient-facing roles, were invited to participate in the study. This article reports findings on assessment methods, assessors, and expectations for a revalidation process. Areas of pharmacy practice, that is, competencies and skills, that will need to be assessed for revalidation are not considered.
Methods After ethical approval, a multiple methods approach was used. Qualitative work in the form of focus groups and interviews preceded a postal survey. The qualitative work was undertaken between October 2007 and April 2008. In the first instance, a convenience sample of pharmacists and technicians with whom the first author was acquainted was recruited. In addition, to recruit practitioners unknown to the researcher and to help ensure demographic diversity among respondents (eg, age and gender), a stratified random sample of pharmacists and technicians was identified from the register of the regulator (then the Royal Pharmaceutical Society of Great Britain). Stratification was based on sector of the profession, that is, working within community, hospital, or
145
primary care, and only practitioners based in the North West of England were sampled to keep interviewing costs to a minimum. In total, invitation letters were sent to 310 pharmacists and technicians. Focus groups and, when necessary, one-to-one interviews were conducted using a topic guide, and continued until theoretical saturation of data was achieved.28-30 The interviews were audiotaped and transcribed verbatim. A thematic framework approach was used to analyze the transcripts.31 As with any research involving qualitative methods, findings may have limited generalizability.31 However, the qualitative stage of this study focused on gaining insight into what was a new area of enquiry. It helped ground the topic in the reality of everyday practice for pharmacists and technicians and helped formulate ideas worth following up using a survey, so as such did not set out to generalize beyond the individuals who took part. To help ensure the integrity of the qualitative work, views were captured from a range of pharmacists and technicians from different sociodemographic and work-related backgrounds. Careful piloting of the topic guide ensured that questions were clear and relevant to the research participants and helped ensure the face and content validity of the data collection instruments. A second researcher checked transcripts against the coding schedule to help ensure that the analysis and interpretation of the interview data were credible, dependable, and transparent. In the main, the focus groups and interviews revealed the level of knowledge and attitudes toward revalidation of the practitioners and highlighted differences in opinions between those working in different sectors and in different roles within the sector. There was little to suggest that opinions differed according to age or gender of the practitioners. Along with information from relevant literature,32 the insights gained from this preliminary stage were then used to inform the design and content of a questionnaire. This was intended to ascertain the generalizability of the preliminary findings. The questionnaire contained 31 questions in total, divided into 5 sections, each covering a theme around revalidation: (1) competencies to be assessed, (2) assessment methods, (3) the assessment process, (4) the outcome, and (5) an open section in which respondents were invited to add other comments/views on revalidation. A mixture of question style and type was used, including attitudinal statements using a 5-point
146
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Likert scale, which allowed respondents to indicate levels of agreement. After piloting, the questionnaire was mailed to a 10% random sample of pharmacists and technicians in England, Scotland, and Wales who were identified as practising, that is, working in a patientor non-patient-facing role within the profession, through the register. Between April and July 2009, a total of 4640 questionnaires were sent to 3902 pharmacists and 738 technicians, with 1 reminder. This article primarily focuses on findings from the survey, reporting the similarities and differences between pharmacists’ and technicians’ views on the process for revalidation. The nonparametric c2 was used for testing significance, set at the 0.05 level. An indication is given at the start of each section about what emerged on the topic from the qualitative stage, with survey findings supplemented with narrative quotes from the interviews and focus groups to help illustrate the numerical data from the survey.
Results In total, 6 focus groups and 14 interviews involving 29 pharmacists and 16 pharmacy technicians were conducted. Groups consisted of pharmacists or technicians within their specific sector of practice. The survey response rate was 26.4% (n ¼ 1206) and 25.2% (n ¼ 966) for pharmacists and 32.8% (240) for technicians, respectively. Almost two-thirds (63.6%) of pharmacist respondents to the survey were women; this is slightly higher than the proportion of practising female pharmacists on the register (58%) at the time. The mean age of pharmacist respondents was 43 years compared with that of 40 years among practising pharmacists on the register. Almost, a quarter (24%) worked in the hospital sector, whereas 58% worked in community pharmacy, which compares with 21% and 66%, respectively, of the register.33 Thus, among pharmacist respondents, women, and older pharmacists, were slightly overrepresented in the sample, whereas community pharmacists were underrepresented slightly. Overall, 93.7% of pharmacy technician respondents were females. This figure compares very well with the proportion of females on the practicing register (93.3%) at the time.34 The mean age of pharmacy technician respondents was 43 years, which again compares favorably with the c
population as a whole. Like the pharmacists who replied to the survey, technicians from the community sector were also underrepresented compared with the register (64% and 73%, respectively). General attitudes toward revalidation The qualitative interviews and focus groups indicated that pharmacists and pharmacy technicians were mostly supportive of revalidation as a process to maintain professional standards and highlight poor practice, as the following quote illustrates: The thought of doing it is quite horrifying really but . and I think that’s partly because you don’t know what the process is likely to be and how difficult it will be . but I think it’s essential that we have something in place to guarantee safety of public isn’t it? I think there needs to be support in actually going through the process as well. Certainly in the initial stages, because it’ll be quite daunting for lots of pharmacists to have to go through and understand what they need to bring with them, and you’ll need a lot of guidance and support in carrying them through the whole process. But then I think we need to make sure there’s a support mechanism in place, and it has to be local as well, I think, for pharmacists who don’t meet the competencies. (Primary care pharmacist in focus group 3)
Although supportive, the aforementioned pharmacist nevertheless expressed some concerns. Interviewees from different sectors shared similar anxieties, for example, time and costs associated with any revalidation process, and hospital sector employees in particular had a lot to say about the appraisal process and its relevancy to pharmacyspecific revalidation: Who’s going to create time for us to do it? That is going to be the massive factor. As (name withheld) just said, the new contract has created us an infinite amount more paperwork etc to go with it. If we are going to do that, which is our livelihood, how would we then create time considering the situation of actually getting pharmacists in at the moment to do extra work to release us to do this type of thing? We are already doing seventy hour weeks. Where else do we find the time to do this? (Community pharmacist in focus group 1) Although I think it is a good idea, it’s good for us and things like that, but it does worry me about how much it is going to cost us and also the time involved when we are already doing KSFc and
KSF is a generic appraisal system for all NHS staff in England regardless of the disciplinary background.
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154 CPD. If it could be linked in with that rather than being in addition . (Hospital technician in focus group 6) I mean if you were doing a KSF and you were doing your appraisals then I don’t think you would need revalidation. If everyone followed the KSF the way it should be followed and carried it out that way then actually I would be confident that people probably wouldn’t need revalidation because you could bring some of those elements into it. But I mean, people don’t even have appraisals, they don’t even have one to one’s and things like that so I think there has to be something for, that’s fair, that’s supportive . but because KSF is NHS wide . it has to cover all the different types of professions, so its not specific to pharmacy so it wouldn’t kind of say that you’re, you can accuracy check very well or anything like. (Hospital pharmacist from focus group 5)
Potential sources of evidence for revalidation Although CPD and appraisals are the most common sources of evidence used where revalidation is in place, a number of other sources of evidence have potential to be of use, and these were explored in the qualitative stage of the study. Although not unanimous, findings indicated that many pharmacists and technicians supported the use of colleague and peer feedback in the revalidation process, especially those working in the hospital sector, as the following dialogue from 1 of the focus groups indicates: Pharm 3: I like the idea of 360-degree really; I think that is potentially a good way of determining how competent somebody is. But looking at it, it would have to be multidisciplinary 360-degree, I think. Pharm 5: If you did a 360 you’d get somebody else’s opinion as to your communication skills or clinical skills or whatever you’re asking for. Pharm 1: Yes, I think that’s really good actually because it gives you a really rounded view.
Concerns were raised, however, by those working within the community sector about the availability and suitability of personnel to provide feedback, particularly in relation to pharmacists working alone, locums, and other nonpermanent members of staff, and there was particular unease about the risks peer feedback posed to working relationships: Tech 2: That would be very encouraging (when discussing 360-degree feedback) and boost your confidence enormously, but if you had something
147
that was a bit derogatory you might be very upset, I think I’d be hurt. I would be devastated if somebody I worked with said she doesn’t know what she’s talking about. Tech 1: It wouldn’t do much for your working relationship. Tech 2: No, exactly. Tech 3: I think it would be useful but yes, it has to be dealt with in a diplomatic and professional manner sort of thing. Tech 1: You see I wouldn’t be able to give bad . Tech 2: Because if there’s personality clashes or something it would be really awkward. Tech 1: You see if I had to do that with somebody and I had to give them negative feedback, I would be absolutely dreadful. Tech 2: Yes, exactly, and the more I was thinking about it some people might hold back because they didn’t want to upset whereas some people might just not like you so slate you.
Using a series of statements that respondents could agree or disagree with the survey assessed how pharmacists and technicians felt about peer review and 8 other sources of evidence either commonly used in revalidation or relicensing or with potential (see Table 1). The overwhelming majority of pharmacists, and technicians, agreed that CPD should form part of the evidence for revalidation (86% and 81%, respectively). The necessity for revalidation to be linked to appraisal was also evident, in which 84.3% (n ¼ 194) of technicians and 73.2% (n ¼ 692) of pharmacists agreed that appraisal should form part of the revalidation process. Technicians were significantly more likely to agree with this compared with pharmacists, and they were also significantly more likely than pharmacists to agree that their counseling skills should be observed in practice. When survey respondents were asked to indicate their strength of agreement or disagreement to the statement “Evidence gathered towards revalidation should include feedback from work colleagues and peers,” that is, 360-degree feedback, 65.4% (n ¼ 151) of technicians and 58.4% (n ¼ 555) of pharmacists thought that it should. However, the evidence from patient feedback was viewed less favorably by both groups. Further analysis in relation to sector of practice did not reveal any statistically significant differences across the professions.
148
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Table 1 Views on assessment methods and forms of evidence for revalidation Assessment methods, forms of evidence, and the revalidation process
All respondents who agreed or strongly agreed, n (%)
Pharmacists who agreed or strongly agreed, n (%)
Technicians who agreed or strongly agreed, n (%)
Statistical significance
Revalidation should include providing evidence of CPD that is relevant to my practice Revalidation should include providing evidence of a fitness to practice appraisal (ie, not focused on financial or performance targets but on my ability to perform as a pharmacist/ technician) Revalidation should be ongoing, a continuous process as opposed to a comprehensive assessment event scheduled periodically Evidence gathered toward revalidation should include feedback from work colleagues and peers For revalidation, I should have a portfolio of written evidence of good practice For counseling skills, I should be observed in practice I should be able to selfcertify that I am fit to practice and not have to undergo any form of assessment Evidence gathered toward revalidation should include feedback from patients In the community setting, information from mystery shoppers should form part of the evidence gathered for revalidation
1033 (86.3)
843 (87.6)
190 (80.9)
c2 ¼ 7.341, df ¼ 2, P ¼ .025
886 (75.4)
692 (73.2)
194 (84.3)
c2 ¼ 12.495, df ¼ 2, P ¼ .002
824 (69.4)
665 (69.9)
159 (67.4)
NS
706 (59.7)
555 (58.4)
151 (65.4)
c2 ¼ 6.314, df ¼ 2, P ¼ .043
592 (50.0)
464 (48.9)
128 (54.5)
NS
518 (47.6)
387 (44.1)
131 (62.1)
c2 ¼ 23.554, df ¼ 2, P ¼ .000
485 (40.9)
401 (42.2)
84 (35.6)
NS
308 (27.8)
261 (29.3)
47 (21.8)
NS
238 (24.8)
193 (24.7)
45 (25.4)
c2 ¼ 23.234, df ¼ 1, P ¼ .000
NS, not significant.
Who should conduct a revalidation assessment? It was very clear-cut during the qualitative stage of the work that pharmacists and technicians held different opinions regarding who should conduct
their assessment. Technicians were at ease with being assessed by their main employer. Community pharmacists, however, expressed concerns about the potential for bias if assessments for revalidation
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
only involved internal management systems. They also questioned whether company managers, who may not be pharmacy professionals themselves, would be able to understand a pharmacist’s role and the professional ethics by which they have to abide sufficiently well to conduct a revalidation assessment. Although those employed within the NHS were familiar with their managers reviewing their performance, many hospital pharmacists in the focus groups echoed the concerns of community colleagues by emphasizing the need for there to be a quality assurance system that ensured the assessors were themselves, properly trained. As illustrated by the following dialogue taken from a focus group with hospital pharmacists, there was a view that input from an external organization would help ensure that the revalidation process was impartial and consistent: Pharm 4: I think it would be better externally (when discussing who would oversee the process) because then if you’re doing it internally then you’re relying on people’s sort of skills or education skills or sort of assessment skills, where as if it’s somebody external then hopefully they’ll have been trained and they’ve got all the case. Pharm 5: It could be more objective rather than subjective. Pharm 2: And also maintain some sort of standard across the whole profession rather than, you know, you may find that one institution’s standards maybe lower or higher than another’s and that would defeat the object of revalidation if it’s to sort of provide for equity and suggest that people have a suitable standard.
When pharmacists and technicians were asked in the survey to choose 1 assessor (from a number on offer; Table 2), who they thought should conduct their assessment for revalidation, both were more likely to select an assessor employed by their main employer, although technicians were significantly more likely than pharmacists to select this option (P % .05). Conversely, pharmacists were significantly more likely than technicians to indicate that their assessment should be conducted by somebody other than an assessor employed by their main employer. Not surprisingly then, when survey respondents were asked if they thought that an external organization should oversee the process, 50.7% (n ¼ 145/286) of pharmacists compared with 32.5% (n ¼ 41/126) of technicians, agreed that an external organization should be involved (P % 0.05).
149
Further exploration of survey respondents’ attitudes toward their assessor revealed that of paramount importance to pharmacists was the need for the person who conducts their assessment to be a peer (ie, another pharmacist), with an understanding of their role; 80.4% (n ¼ 741) of pharmacists thought it important compared with 35.5% (n ¼ 81) of technicians. Furthermore, pharmacists were more likely than technicians to indicate that it was very important to them that the person who conducts their assessment had been trained and accredited by the regulator; 58.3% (n ¼ 536) compared with 46.4% (n ¼ 104), respectively.
How often should revalidation occur? During the qualitative phase of the research, pharmacists and technicians expressed similar views about the scheduling of revalidation (ie, that it should be an ongoing process rather than a scheduled event); however, they expressed very different views when asked how often they felt that they would need to undergo revalidation, as the 2 quotes that follow illustrate: I suppose you could do revalidation on a timescale according to when they qualified, so every five years or so. Then you’d have cohorts wouldn’t you, everyone who qualified in that year being revalidated at that time and then it would be more staggered. I’ve got to five years now and I’m thinking do I still remember as much as I did when I qualified. It would be nice to know if I’m actually still up to date. (Pharmacist) It’s difficult isn’t it really because they’re going to have to keep track on it as well aren’t they? And if you say five (years) is too much and one’s . and five is too late, one’s not, you know, because you are doing your CPD cycles in between and then you’ve got revalidation. I would probably say two or three years maybe . (Technician)
The survey confirmed these qualitative findings. Thus, when asked to indicate their strength of agreement with the statement “Revalidation should be ongoing, a continuous process as opposed to a comprehensive assessment event scheduled periodically,” 69.9% (n ¼ 665) of pharmacists and 67.4% (n ¼ 159) of technicians either agreed or strongly agreed. However, as shown in Table 3, most pharmacists felt that revalidation should be conducted every 5 years when given a number of different options to choose from,
150
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Table 2 Respondents choice of who should be involved in conducting assessments for revalidation Assessor
Pharmacists choosing the option, n (%)
Pharmacy technicians choosing the option, n (%)
All respondents choosing the option, n (%)
My assessment should be conducted by an assessor employed by my main employer (ie, reviewed within the NHS, a company, or an organization) who forward a recommendation directly to the pharmacy regulator My assessment should be conducted independently by a senior pharmacy professional based at local level (ie, within the geographical area where you work) who forward a recommendation directly to the pharmacy regulator My assessment should be conducted independently by a senior pharmacy professional from outside the geographical area where I work. This person should forward a recommendation directly to the pharmacy regulator My assessment should be conducted directly by an assessor from the pharmacy regulator My assessment should be conducted by a variety of assessors from more than one source (ie, my employer, and/or an independent senior pharmacy professional, and/or the pharmacy regulator) I do not have a preference regarding who should undertake my assessment
288* (30.2)
136* (58.4)
424 (35.7)
129 (13.5)
20 (8.6)
149 (12.6)
63 (6.6)
2 (0.9)
65 (5.5)
138 (14.5)
17 (7.3)
155 (13.1)
119 (12.5)
18 (7.7)
137 (11.5)
217 (22.7)
40 (17.2)
257 (21.7)
954 (100)
233 (100)
Total
1187
c2 ¼ 70.280; df ¼ 5; P ¼ .000. * Some missing data.
whereas most technicians felt that revalidation should be conducted every 2 or 3 years (P % .05). Outcome of the revalidation assessment When pharmacists and technicians were asked to consider what should be involved for those who were not successful at meeting the revalidation standard, 68.7% (n ¼ 651) of pharmacists and 54.2% (n ¼ 128) of technicians thought that they should be allowed to continue to practice on condition that they were reassessed and then met the revalidation standard. Technicians were significantly more likely than pharmacists to indicate that individuals who fail to meet the revalidation standard should be allowed to continue to
practice under supervision, until they were reassessed and the standard was met: 42.8% (n ¼ 101) compared with 23.1% (n ¼ 219), respectively (c2 ¼ 40.433, df ¼ 4, P % .05). Pharmacy technicians were also significantly more likely than pharmacists to indicate that for reassessment, individuals should be assessed using the same revalidation tool that was used at their initial assessment but should also undergo further assessment in practice: 53% (n ¼ 122) compared with 43.3% (n ¼ 393), respectively (c2 ¼ 9.747, df ¼ 3, P % .021). Finally, survey respondents were asked how many attempts at meeting the revalidation standard a pharmacist or technician should be allowed (from 1, 2, or as many as necessary). Overall,
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154 Table 3 Respondents choice of the frequency of professional revalidation Revalidation Pharmacists Pharmacy technicians frequency choosing option, choosing option, n (%) n (%) Annually Every 2 y Every 3 y Every 4 y Every 5 y Other
27 80 191 27 556 75
(2.8) (8.4) (20) (2.8) (58.2) (7.8)
Total
956 (100)
13 55 60 8 95 5
(5.5) (23.3) (25.4) (3.4) (40.3) (2.1)
236 (100)
c ¼ 64.580; df ¼ 5; P ¼ .000. 2
43.1% (n ¼ 488) indicated a total of 3 attempts, that is, their initial assessment and 2 repeat assessments, should be permitted. Pharmacists were more likely than technicians to indicate that they felt 3 attempts would suffice: 44.1% (n ¼ 397) compared with 39.2% (n ¼ 91), respectively. Conversely, technicians (32.8%; n ¼ 76) were significantly more likely than pharmacists (19.6%; n ¼ 176) to indicate that they felt 2 attempts, that is, the initial assessment and 1 repeat assessment, were adequate (P % .05). Discussion This study, the first to explore GB pharmacist’s and technician’s views on revalidation, used multiple methods: qualitative work provided an in-depth insight into pharmacists’ and pharmacy technicians’ views on revalidation and helped to inform the design of a subsequent postal survey that set out to validate and quantify the qualitative findings over a wider sample and provide opportunity for triangulation of research findings. However, with an overall response rate of 26.4%, it is possible that nonresponse bias could affect the generalizability of the survey results and the conclusions drawn.35 Furthermore, as the technician sample used for the study was taken from the voluntary register of pharmacy technicians, it is difficult to say whether the technicians’ views captured were those from a more proactive group of individuals. The pharmacists and technicians who responded to the survey were broadly representative of the registers from which they were drawn, so the authors are confident about the overall generalizability of the findings.
151
Despite these limitations, this study reassuringly demonstrated that views on revalidation were mostly positive, and it has provided valuable insight on how members of the pharmacy profession in GB envisage a revalidation process. The study demonstrated that although pharmacists and technicians share the same views on some aspects of the revalidation process, there is some variation in how they want their assessment for revalidation to take place. Overall, revalidation was seen as a continuous process with CPD forming part of the evidence. Pharmacists were more likely than technicians to want CPD to be considered for revalidation; however, this may be a reflection of the fact that technicians had not been mandated to the register at the time of this study and had not been subjected to mandatory CPD for as long as pharmacists. The preference shown for CPD to be used as evidence in the revalidation process concurs with the Ontario model for revalidation19 and that being implemented by the medical profession in the United Kingdom.25 More recently, the GPhC has confirmed that revalidation will be aligned with the Non-Medical Revalidation Working Group’s principles for revalidation, which include CPD.7,32 Contrary to the Ontario model,19 however, pharmacists and technicians did not want revalidation to be a scheduled event, that is, individuals selected by the regulator for annual peer review. This finding is of particular importance in the United Kingdom, as the GPhC has announced that revalidation will be based on assurance of continuing fitness to practice and will not be a fixed point assessment.7 In general, appraisal was deemed to be a useful source of evidence for revalidation, provided appraisal focused on an individual’s ability to perform as a pharmacist or technician, and not on financial or performance targets. The drawbacks associated with using the preexisting appraisals system for pharmacists and technicians working in the managed care sector (the KSF)8 have been mentioned earlier. Because a national system of appraisal does not exist for those working outside the NHS, that is, in community pharmacy, academia, or industry, it seems likely that the GPhC, if it wants to incorporate appraisal into the revalidation process, should consider developing a standard appraisal tool that can be used across the profession, in a similar way to that developed for the medical profession.25 Feedback from colleagues and peers, that is, 360-degree feedback, was also viewed as a useful
152
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
source of evidence for revalidation, although concerns were raised by those within the community sector that it may be difficult to identify appropriate peers. Although one can envisage how feedback from colleagues and peers on a doctor’s performance could provide useful evidence for revalidation, it must be emphasized that the vast majority of the medical profession work in teams and, as such, have access to the appropriate personnel, that is, other doctors or nurses, who can provide them with feedback. Even within primary care, locum doctors work in surgeries where there are other GPs who can provide feedback on their performance. Although this working environment is very similar to those working in hospital pharmacy, it is very different to the one that a community pharmacist will normally encounter, in which they commonly find themselves working as a lone pharmacist. It is therefore of no surprise that those working within the community expressed concerns that they may not be able to find the appropriate personnel to provide them with feedback. If the GPhC, and other regulatory bodies from other countries, wishes to introduce a system of revalidation that is fair across the profession, findings from this study demonstrate that regulators will need to consider whether feedback from colleagues and peers could provide the profession with a consistent approach. Overall, views on a model for revalidation demonstrated that it may not be desirable within the pharmacy profession to have a single model of revalidation. Pharmacy technicians appear to be more comfortable with being revalidated by someone within their work environment. Pharmacists, however, were concerned about how impartiality within the revalidation process could be assured; they appeared more attracted to the idea that an assessor who was either an independent senior pharmacy professional or an assessor from the pharmacy regulator should be involved. Although this finding may be explained by the fact that the vast majority of technicians are employees who work under supervised practice, it may also be a reflection that technicians are more familiar and therefore more comfortable with their work being observed in practice. The community pharmacists in the qualitative phase of the study believed that pharmacy companies should not be involved in revalidating their own managers, is perhaps a reflection of the professional isolation that exists within community pharmacy today, and reflects concerns expressed
elsewhere that assessments may be carried out by managers who are not pharmacists.36 Findings that pharmacists were more likely than technicians to indicate that it was very important to them for their assessor to be a peer, that is, a pharmacist with an understanding of their role, corroborates this view, and perhaps demonstrates further the concern that exists among community pharmacists on the use of business targets during performance reviews. The involvement of the GPhC would concur with the system of revalidation in Ontario, Canada, where the pharmacy regulator is directly involved in the assessment of a pharmacist’s fitness to practice via the appointment of pharmacists who the regulator trains and accredits as assessors on their behalf.19 Consistent with both the UK General Medical and Dental Councils23,27 models for revalidation, this research provides evidence to suggest that revalidation, if conducted every 5 years, would be an acceptable time frame to the pharmacy profession. Although some technicians indicated that revalidation every 2 or 3 years may be necessary, this is probably a reflection of the period over which they learn leading to their professional qualification, that is, 5 years of training for pharmacists and 2 years for technicians. With approximately 46,000 practising pharmacists and around 20,500 technicians on the register in GB, and with the GPhC already reviewing pharmacists’ and technicians’ CPD every 5 years, the question remains as to whether it would be practical for the GPhC to expect a pharmacist or technician to have to undergo revalidation more often than every 5 years. However, it could be considered for particular groups, those posing a greater risk to patient safety for example, or for those in which performance concerns have been raised and remediation actions identified. In GB, the National Clinical Assessment Service,37 an organization that offers practical support to health care professionals whose performance has been identified as falling short of professional norms, could work closely with the regulator to ensure this happens.
Conclusion CPD, appraisal, and multisource (360-degree) feedback from colleagues and peers were identified as possible components of revalidation, although questions remain on the use of feedback from patients. Within the profession, revalidation every 5 years was acceptable, but there appears to
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
be some variation in how pharmacists and technicians envisage a revalidation process. Findings suggest that a single model of revalidation would not be desirable or practicable. Technicians were more open to their assessment being conducted by someone within their work environment, whereas pharmacists were concerned about impartiality and preferred that an independent senior pharmacy professional or an assessor from the GPhC be involved. Further research is necessary to explore the role of employers and the GPhC in the revalidation process and establish how assessors involved in revalidation assessments could be accredited and quality assured. References 1. Department of Health. Learning from Bristol: The Report of the Public Inquiry Into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995. Command Paper: CM 5207. London, UK: The Stationary Office; 2001. Available at: http://www.bristolinquiry.org.uk/finalreport. Accessed 25.07.12. 2. Department of Health. The Shipman Inquiry. Fifth Report. Safeguarding Patients: Lessons From the PastdProposals for the Future. Command Paper : CM 6394. London, UK: The Stationary Office; 2004. Available at: http://www.shipman-inquiry. org.uk/fifthreport.asp. Accessed 25.07.12. 3. Noyce P. Governance and the pharmaceutical workforce in England. Res Social Adm Pharm 2006;2: 408–419. 4. Department of Health. Good Doctors, Safer Patients. Proposals to Strengthen the System to Assure and Improve the Performance of Doctors and to Protect the Safety of Patients. A Report by the Chief Medical Officer, Sir Liam Donaldson. London, UK: Department of Health; 2006. 5. Department of Health. The Regulation of NonMedical Healthcare Professionals. A Review by the Department of Health, Chaired by Andrew Foster. London, UK: Department of Health; 2006. 6. Her Majesty’s Stationary Office. Trust, Assurance and SafetydThe Regulation of Health Professionals in the 21st Century. London, UK: The Stationary Office; 2007. 7. Royal Pharmaceutical Society of Great Britain. A Draft Model for Revalidation in Pharmacy. Report to the Department of Health. London, UK: RPSGB; 2009. 8. Department of Health. The NHS Knowledge and Skills Framework and Development Review Process. London, UK: Department of Health; 2004. 9. NHS Knowledge and Skills Framework. Revalidation Project. A Report Commissioned for the Department of Health Working Group for Non-Medical Revalidation. London, UK: Prime Research and Development Ltd; 2009.
153
10. Finlay K, McLauren S. Does appraisal enhance learning, improve practice and encourage continuing professional development? A survey of general practitioners’ experiences of appraisal. Qual Prim Care 2009;17(6):387–395. 11. Middlemass J, Siriwardena AN. General practitioners, revalidation and appraisal: a cross sectional survey of attitudes, beliefs and concerns in Lincolnshire. Med Educ 2003;37:778–785. 12. Boylan O, Bradley T, McKnight A. GP perceptions of appraisal: professional development, performance management, or both? Br J Gen Pract 2005;55: 544–545. 13. Board of Pharmacy Specialties. Certification, maintenance and recertification. Available at: http://www. bpsweb.org/recertification/general.cfm. Accessed 26. 07.12. 14. Bellingham C. Split success: New Zealand’s story. Pharm J 2006;277:509. 15. Pharmacy Council of New Zealand. Available at: http://www.pharmacycouncil.org.nz/cms_show_down load.php?id¼164. Accessed 19.03.12. 16. Singapore Pharmacy Board. A guide to compulsory CPE for pharmacists. Version 1, July 2006. Available at: http://www.healthprofessionals.gov.sg. Accessed 25.07.12. 17. Winslade N, Tamblyn R, Taylor L, Schuwirth L, Van der Vleuten C. Integrating performance assessment, maintenance of competence and continuing professional development of community pharmacists. Am J Pharm Educ 2007;71(1):1–9. 18. Hasman A. Get ready for revalidation in pharmacy. Pharm J 2009;283:485–487. 19. The Royal Pharmaceutical Society of Great Britain. Pharmacy Regulation and Education in Ontario and British Columbia CanadadRPSGB Study Tour Report. London, UK: The Royal Pharmaceutical Society of Great Britain; 2005. 20. Austin Z, Marini A, Croteau D, Violato C. Assessment of pharmacists’ patient care competencies: validity evidence from Ontario (Canada)’s quality assurance and peer review process. Pharm Educ 2004;4(1):23–32. 21. Merkur S, Mossialos E, Long M, McKee M. Physician revalidation in Europe. Clin Med 2008;8(4): 371–376. 22. Violato C, Lockyer J, Fidler H. Multisource feedback: a method of assessing surgical practice. BMJ 2003;326:546–548. 23. General Medical Council. Revalidation. GMC, 2012. Available at: http://www.gmc-uk.org/doctors/revali dation.asp. Accessed 26.07.12. 24. General Medical Council. Good Medical Practice. London, UK: General Medical Council; 2009. 25. General Medical Council. The good medical practice framework for appraisal and revalidation. Available at: http://www.gmc-uk.org/GMP_frame work_for_appraisal_and_revalidation.pdf_41326960. pdf. Accessed 26.07.12.
154
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
26. Nursing and Midwifery Council. The Prep Handbook. London, UK: Nursing and Midwifery Council; 2008. 27. General Dental Council. Revalidation for dentists: our proposals. 2012. Available at: http://www.gdc. uk.org/Dentalprofessionals/Revalidation/Documents/ revalidationconsultationpaper. Accessed 26.07.12. 28. Strauss A, Corbin J. Basics of Qualitative Research. London, UK: Sage Publications, Inc; 1990. 29. Krueger R. Focus Groups: A Practical Guide for Applied Research. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc; 1994. 30. Morgan D. Focus Groups as Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc; 1997. 31. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess R, eds. Analyzing Qualitative Data. London, UK: Routledge; 1994. 32. Department of Health. Principles for Revalidation. Report of the Working Group for Non-Medical
33.
34.
35.
36.
37.
RevalidationdProfessional Regulation and Patient Safety Programme. London, UK: Department of Health; 2008. Seston E, Hassell K. An overview of the main findings from the 2008 pharmacy workforce census. Pharm J 2009;283:419–420. Seston E, Hassell K. First census of pharmacy technicians: 1. Demographics and working patterns. Pharm J 2012;288:140–141. Bowling C. Research Methods in Health. Investigating Health and Health Services. 2nd ed. Maidenhead, UK: Open University Press; 2002. Jee SD, Jacobs S, Schafheutle EI, et al. An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain. Res Social Admin Pharm 2013;9: 155–165. National Clinical Assessment Service. Helping Ensure Safe Pharmacy Practice. London, UK: National Clinical Assessment Service; 2009.
Original Research
Pharmacists’ and pharmacy technicians’ views on a process of revalidation of pharmacy professionals in Great Britain Helen Potter, Ph.D., M.Pharm.S.a, Karen Hassell, Ph.D.b,*, Peter R. Noyce, C.B.E., Ph.D., F.R.Pharm.S.a a NHS Trafford, 3rd Floor, Oakland House, Talbot Road, Old Trafford, Manchester M16 0PQ, UK School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK
b
Abstract Background: Revalidation will be introduced for pharmacy professionals in Great Britain. However, what pharmacists and technicians understand about it as a process remains unexplored. Objectives: This study aimed to explore the views of pharmacists and technicians about the revalidation of fitness to practice. Views were gathered on the sources of evidence that could be used, assessment methods, who should undertake the assessment, and how often it should occur. Methods: A multiple methods study was conducted with community and hospital pharmacists and technicians. It included 6 focus groups, 14 one-to-one interviews, and a postal survey sent in March 2009 to a 10% randomly selected sample of 4640 practising pharmacists and 738 technicians working in England, Scotland, and Wales. Results: Twenty-nine pharmacists and 16 technicians participated in the focus groups and interviews; 1206 (26.4%) pharmacists and 240 (32.8%) technicians returned a completed questionnaire. A large majority of both pharmacists (86%) and technicians (81%) were in favor of continuing professional development (CPD) records being used as evidence to inform revalidation, but only a small proportion of both groups agreed that patient feedback should be used. Evidence from appraisals and peers/colleagues was also well supported. Technicians were significantly more likely than pharmacists to indicate that their assessment for revalidation should be undertaken by their main employer. Although most technicians (49%) believed that revalidation should take place every 2–3 years, most pharmacists (58%) believed that it should occur only every 5 years. Conclusions: Pharmacists and technicians do not share the same views on all aspects of revalidation, suggesting that 1 single model may not be desirable or practicable. Both groups identified CPD, appraisal, and feedback from peers as possible components of revalidation, but concerns about impartiality and independence of assessors were raised. Crown Copyright Ó 2013 Published by Elsevier Inc. All rights reserved. Keywords: Community pharmacy; Revalidation; Regulation; Pharmacists; Technician
* Corresponding author. Tel.: þ44 161 275 2422; fax: þ44 161 275 2416. E-mail address: [email protected] (K. Hassell). 1551-7411/$ - see front matter Crown Copyright Ó 2013 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2012.07.008
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Introduction In the United Kingdom, 2 very high profile negligence cases identified failures of competence and performance in the medical profession (subsequently known as the Bristol1 and Shipman2 inquiries). They acted as a catalyst for action by government and professional regulatory bodies to review the fitness to practice procedures in an endeavor to ensure that health care practitioners do not pose a risk to patients and to maintain public confidence and trust.3 Government reviews and policy papers4-6 that followed the Bristol and Shipman inquiries called for the introduction of a system of revalidation for all health care professionals, defined as a periodic assessment of a health care professional’s fitness to practice. This study was undertaken to explore pharmacy professionals’ perspectives on the proposed implementation of revalidation.
Pharmacy professionals and revalidation internationally Within the Great Britain (GB)a context, there are 2 types of professionals, pharmacists and pharmacy technicians, both of whom have to be registered with the pharmacy regulator (the General Pharmaceutical Council [GPhC]). In GB, pharmacy technicians are a relatively new profession. At the time the study reported here was conducted, registration for pharmacy technicians was voluntary and only became mandatory in 2011, whereas the mandatory registration for pharmacists has been a long-established requirement to practice. Once registered, both pharmacists and technicians must undertake mandatory continuing professional development (CPD). They also have to meet a set of minimum standards of conduct, ethics, and performance. In common with other British health professional regulators, the GPhC will have to consult and implement a revalidation process for all its registrants. This will involve deciding on the frequency, challenges, and burden of revalidation; what sources of evidence should be used to support revalidation; who conducts assessments; whether different processes are required for different groups of registrants; and the time for remediation. a
143
Some consideration has been given to the types of evidence that could be used to inform pharmacy revalidation, particularly the use of CPD and appraisals.7 Pharmacists working in the managed care sectors, within England only, participate in appraisals operated under the Knowledge and Skills Framework (KSF, a generic appraisal system for all National Health Service [NHS]b staff regardless of the disciplinary background)8 so that they have an opportunity to gather evidence that could be used toward their revalidation. However, a comparable framework for community pharmacists, or pharmacists in non-patient-facing roles, is not in place. In any case, questions about the KSF not being specific enough to assess pharmacy professional’s fitness to practice and whether it would be sufficiently robust to either identify poor performance or act as a primary source of evidence for revalidation have been raised.9-12 Views on appraisals from practitioners themselves are unknown. Elsewhere within the pharmacy profession, pharmacists in Canada, New Zealand, and Singapore (countries where the number of pharmacists is much smaller than in GB) are required by their professional regulatory body to perform satisfactorily in a process of periodic revalidation to retain their right to practice. In the United States, periodic recertification is a requirement of the Board of Pharmacy Specialties for maintaining certification as a specialist pharmacist practitioner.13 In New Zealand, where the Pharmacy Council introduced annual recertification for its members in 2006, revalidation is based solely on CPD.14,15 Once every 5 years, 20% of pharmacists submit their CPD records for audit, and if the Pharmacy Council considers records to be unsatisfactory, a pharmacist can be suspended. The Singapore Pharmacy Council (formerly Board) issues practising certificates (PCs) to pharmacists, allowing them to practice for 2 years from the date of issue. Since January 2009, pharmacists have had to demonstrate that they have achieved a minimum number of continuing professional education (CPE) points from a range of approved activities, undertaken within the qualifying period of the previous
The United Kingdom comprises England, Scotland, Wales, and Northern Ireland (NI), whereas NI is not a part of
GB. b
The NHS is the comprehensive publicly funded health care system of the United Kingdom. It provides acute and long-term care at primary, secondary, and tertiary tiers, as well as emergency care. Secondary and tertiary care is provided by directly employed NHS staff, for example, hospital pharmacists. Primary care is provided by NHS contractors, for example, general medical practitioners and community pharmacists, on national terms and conditions.
144
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
2-year PC.16 The council issues 2 types of PC–normal and restricteddfor which the CPE requirements are quantitatively similar but qualitatively different. For pharmacists to practice in all areas of pharmacy including pharmaceutical care areas (ie, patient-facing practice), they must hold a normal PC. Despite their widespread use, concerns have been raised internationally about CPE/CPD assuring professional competence,17 and in GB, doubt has been expressed about relying on CPD records alone to confirm fitness to practice of GB pharmacy professionals.18 In Canada, 2 provincial regulators, the Ontario College of Pharmacists and the College of Pharmacists of British Columbia, have introduced systems for revalidating their members. Pharmacists in Ontario, where periodic competency assessment has been in place since 1997, are required annually to declare whether they are providing direct patient care, that is, providing pharmacy services directly to the public. Those that so declare are placed on part A of the register; they must practice a minimum of 600 hours over a 3-year period and, when selected, must undergo a practice review.19 A pharmacist’s patient care competencies are directly assessed through a process of CPD and peer review.20 Each year, 20% of the 9600 registered pharmacists are randomly selected to submit a selfassessment survey and CPD activity record, and a small proportion of these is selected annually for peer review. This consists of a written test of clinical knowledge and a practice-based assessment (an objective structured clinical examination [OSCE]) using standardized patient scenarios. Assessors (who are pharmacists) are trained to assess those undergoing review in a standardized fashion.19 The Professional Development and Assessment Program in British Columbia is similar to that in Ontario.19 So, in Canada, although the current revalidation methods determine a patient facing pharmacist’s fitness to practice, through the use of the OSCE in assessing a pharmacist’s patient care competencies,20 a pharmacist’s performance in their day-to-day practice is yet to be observed. A system of revalidation for pharmacy technicians does not exist in Canada or elsewhere. Revalidation in other health care professions Doctors in Australia, New Zealand, Canada, the United States, and some European countries undergo some form of periodic revalidation or
relicensure, either on a mandatory or on a voluntary basis.4,21 At its simplest, this involves medical practitioners undertaking continuing medical education CPD. Other methods used for doctors include peer review, external evaluation, practice inspection,21 and multisource feedback, sometimes known as 360-degree review.22 The latter involves assessment against specific performance criteria with feedback from patients, peers, and colleagues who know the work of the person being assessed. In the United Kingdom, revalidation developments and its implementation in the medical profession are at a more advanced stage than in pharmacy and are currently expected to begin in December 2012.23 The duties of a doctor registered with the General Medical Council are defined in “Good Medical Practice,” in which it is made explicit that “serious or persistent failure to follow this guidance will put your registration at risk.”24 Revalidation of doctors will almost certainly involve participation in 360-degree feedback and annual appraisal.25 In the nursing profession in the United Kingdom, the Nursing and Midwifery Council (NMC), the statutory body for all UK nurses, midwives, and specialist community public health nurses, places a requirement on all their members to reregister every 3 years.26 Reregistration is based again on CPD, with nurses and midwives encouraged to reflect on their practice using standards set by the NMC.26 To maintain registration, nurses and midwives are required to have worked a minimum of 450 hours in the previous 3 years. Although this work must be related to their nursing or midwifery qualification, nurses do not have to be in clinical practice, that is, a nurse may be a clinical nurse supervisor responsible for the education and training of nurses but not in a patientfacing role. Practising midwives, however, must be in clinical practice before renewal of registration, and nurses and midwives are required to submit a notification of practice form declaring that they have met the NMC standards, they have worked their practice requirements, and undertaken 35 hours of CPD relevant to their practice. The dentistry regulator in the United Kingdom is aiming to introduce revalidation for dentists in 2014. To date, proposals are that dentists will have to demonstrate and declare compliance with relevant standards, in a 5-year cycle, and the supporting CPD evidence will be checked at least once in every revalidation cycle by an approved external verifier. Dentists will be removed from
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
the register if they fail to make a declaration, and where standards are not met, dentists will be given 6 months to remedy any deficiencies.27 From this brief description of revalidation processes and assessment mechanisms for different health care professionals, actual or proposed, in English-speaking countries, it is evident that the processes and frequency of revalidation or relicensing and who is involved differs, and the assessment methods and sources of evidence used to demonstrate fitness to practice are numerous. Furthermore, little is known about what pharmacy professionals think about revalidation in general. As the first pharmacy study about revalidation in GB, the main aim of the research reported here was to gain insight into the views of pharmacists and technicians on requirements for revalidation. Building on what was known about pharmacy revalidation in Canada, New Zealand, and Singapore and about revalidation of medical practitioners, dentists, and nurses, the study explored areas of pharmacy practice that pharmacists and pharmacy technicians felt were important for a revalidation process and, integral to this, how these areas of practice could be assessed. Pharmacists and pharmacy technicians in both patient facing, that is, with patient care responsibilities, and non-patient-facing roles, were invited to participate in the study. This article reports findings on assessment methods, assessors, and expectations for a revalidation process. Areas of pharmacy practice, that is, competencies and skills, that will need to be assessed for revalidation are not considered.
Methods After ethical approval, a multiple methods approach was used. Qualitative work in the form of focus groups and interviews preceded a postal survey. The qualitative work was undertaken between October 2007 and April 2008. In the first instance, a convenience sample of pharmacists and technicians with whom the first author was acquainted was recruited. In addition, to recruit practitioners unknown to the researcher and to help ensure demographic diversity among respondents (eg, age and gender), a stratified random sample of pharmacists and technicians was identified from the register of the regulator (then the Royal Pharmaceutical Society of Great Britain). Stratification was based on sector of the profession, that is, working within community, hospital, or
145
primary care, and only practitioners based in the North West of England were sampled to keep interviewing costs to a minimum. In total, invitation letters were sent to 310 pharmacists and technicians. Focus groups and, when necessary, one-to-one interviews were conducted using a topic guide, and continued until theoretical saturation of data was achieved.28-30 The interviews were audiotaped and transcribed verbatim. A thematic framework approach was used to analyze the transcripts.31 As with any research involving qualitative methods, findings may have limited generalizability.31 However, the qualitative stage of this study focused on gaining insight into what was a new area of enquiry. It helped ground the topic in the reality of everyday practice for pharmacists and technicians and helped formulate ideas worth following up using a survey, so as such did not set out to generalize beyond the individuals who took part. To help ensure the integrity of the qualitative work, views were captured from a range of pharmacists and technicians from different sociodemographic and work-related backgrounds. Careful piloting of the topic guide ensured that questions were clear and relevant to the research participants and helped ensure the face and content validity of the data collection instruments. A second researcher checked transcripts against the coding schedule to help ensure that the analysis and interpretation of the interview data were credible, dependable, and transparent. In the main, the focus groups and interviews revealed the level of knowledge and attitudes toward revalidation of the practitioners and highlighted differences in opinions between those working in different sectors and in different roles within the sector. There was little to suggest that opinions differed according to age or gender of the practitioners. Along with information from relevant literature,32 the insights gained from this preliminary stage were then used to inform the design and content of a questionnaire. This was intended to ascertain the generalizability of the preliminary findings. The questionnaire contained 31 questions in total, divided into 5 sections, each covering a theme around revalidation: (1) competencies to be assessed, (2) assessment methods, (3) the assessment process, (4) the outcome, and (5) an open section in which respondents were invited to add other comments/views on revalidation. A mixture of question style and type was used, including attitudinal statements using a 5-point
146
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Likert scale, which allowed respondents to indicate levels of agreement. After piloting, the questionnaire was mailed to a 10% random sample of pharmacists and technicians in England, Scotland, and Wales who were identified as practising, that is, working in a patientor non-patient-facing role within the profession, through the register. Between April and July 2009, a total of 4640 questionnaires were sent to 3902 pharmacists and 738 technicians, with 1 reminder. This article primarily focuses on findings from the survey, reporting the similarities and differences between pharmacists’ and technicians’ views on the process for revalidation. The nonparametric c2 was used for testing significance, set at the 0.05 level. An indication is given at the start of each section about what emerged on the topic from the qualitative stage, with survey findings supplemented with narrative quotes from the interviews and focus groups to help illustrate the numerical data from the survey.
Results In total, 6 focus groups and 14 interviews involving 29 pharmacists and 16 pharmacy technicians were conducted. Groups consisted of pharmacists or technicians within their specific sector of practice. The survey response rate was 26.4% (n ¼ 1206) and 25.2% (n ¼ 966) for pharmacists and 32.8% (240) for technicians, respectively. Almost two-thirds (63.6%) of pharmacist respondents to the survey were women; this is slightly higher than the proportion of practising female pharmacists on the register (58%) at the time. The mean age of pharmacist respondents was 43 years compared with that of 40 years among practising pharmacists on the register. Almost, a quarter (24%) worked in the hospital sector, whereas 58% worked in community pharmacy, which compares with 21% and 66%, respectively, of the register.33 Thus, among pharmacist respondents, women, and older pharmacists, were slightly overrepresented in the sample, whereas community pharmacists were underrepresented slightly. Overall, 93.7% of pharmacy technician respondents were females. This figure compares very well with the proportion of females on the practicing register (93.3%) at the time.34 The mean age of pharmacy technician respondents was 43 years, which again compares favorably with the c
population as a whole. Like the pharmacists who replied to the survey, technicians from the community sector were also underrepresented compared with the register (64% and 73%, respectively). General attitudes toward revalidation The qualitative interviews and focus groups indicated that pharmacists and pharmacy technicians were mostly supportive of revalidation as a process to maintain professional standards and highlight poor practice, as the following quote illustrates: The thought of doing it is quite horrifying really but . and I think that’s partly because you don’t know what the process is likely to be and how difficult it will be . but I think it’s essential that we have something in place to guarantee safety of public isn’t it? I think there needs to be support in actually going through the process as well. Certainly in the initial stages, because it’ll be quite daunting for lots of pharmacists to have to go through and understand what they need to bring with them, and you’ll need a lot of guidance and support in carrying them through the whole process. But then I think we need to make sure there’s a support mechanism in place, and it has to be local as well, I think, for pharmacists who don’t meet the competencies. (Primary care pharmacist in focus group 3)
Although supportive, the aforementioned pharmacist nevertheless expressed some concerns. Interviewees from different sectors shared similar anxieties, for example, time and costs associated with any revalidation process, and hospital sector employees in particular had a lot to say about the appraisal process and its relevancy to pharmacyspecific revalidation: Who’s going to create time for us to do it? That is going to be the massive factor. As (name withheld) just said, the new contract has created us an infinite amount more paperwork etc to go with it. If we are going to do that, which is our livelihood, how would we then create time considering the situation of actually getting pharmacists in at the moment to do extra work to release us to do this type of thing? We are already doing seventy hour weeks. Where else do we find the time to do this? (Community pharmacist in focus group 1) Although I think it is a good idea, it’s good for us and things like that, but it does worry me about how much it is going to cost us and also the time involved when we are already doing KSFc and
KSF is a generic appraisal system for all NHS staff in England regardless of the disciplinary background.
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154 CPD. If it could be linked in with that rather than being in addition . (Hospital technician in focus group 6) I mean if you were doing a KSF and you were doing your appraisals then I don’t think you would need revalidation. If everyone followed the KSF the way it should be followed and carried it out that way then actually I would be confident that people probably wouldn’t need revalidation because you could bring some of those elements into it. But I mean, people don’t even have appraisals, they don’t even have one to one’s and things like that so I think there has to be something for, that’s fair, that’s supportive . but because KSF is NHS wide . it has to cover all the different types of professions, so its not specific to pharmacy so it wouldn’t kind of say that you’re, you can accuracy check very well or anything like. (Hospital pharmacist from focus group 5)
Potential sources of evidence for revalidation Although CPD and appraisals are the most common sources of evidence used where revalidation is in place, a number of other sources of evidence have potential to be of use, and these were explored in the qualitative stage of the study. Although not unanimous, findings indicated that many pharmacists and technicians supported the use of colleague and peer feedback in the revalidation process, especially those working in the hospital sector, as the following dialogue from 1 of the focus groups indicates: Pharm 3: I like the idea of 360-degree really; I think that is potentially a good way of determining how competent somebody is. But looking at it, it would have to be multidisciplinary 360-degree, I think. Pharm 5: If you did a 360 you’d get somebody else’s opinion as to your communication skills or clinical skills or whatever you’re asking for. Pharm 1: Yes, I think that’s really good actually because it gives you a really rounded view.
Concerns were raised, however, by those working within the community sector about the availability and suitability of personnel to provide feedback, particularly in relation to pharmacists working alone, locums, and other nonpermanent members of staff, and there was particular unease about the risks peer feedback posed to working relationships: Tech 2: That would be very encouraging (when discussing 360-degree feedback) and boost your confidence enormously, but if you had something
147
that was a bit derogatory you might be very upset, I think I’d be hurt. I would be devastated if somebody I worked with said she doesn’t know what she’s talking about. Tech 1: It wouldn’t do much for your working relationship. Tech 2: No, exactly. Tech 3: I think it would be useful but yes, it has to be dealt with in a diplomatic and professional manner sort of thing. Tech 1: You see I wouldn’t be able to give bad . Tech 2: Because if there’s personality clashes or something it would be really awkward. Tech 1: You see if I had to do that with somebody and I had to give them negative feedback, I would be absolutely dreadful. Tech 2: Yes, exactly, and the more I was thinking about it some people might hold back because they didn’t want to upset whereas some people might just not like you so slate you.
Using a series of statements that respondents could agree or disagree with the survey assessed how pharmacists and technicians felt about peer review and 8 other sources of evidence either commonly used in revalidation or relicensing or with potential (see Table 1). The overwhelming majority of pharmacists, and technicians, agreed that CPD should form part of the evidence for revalidation (86% and 81%, respectively). The necessity for revalidation to be linked to appraisal was also evident, in which 84.3% (n ¼ 194) of technicians and 73.2% (n ¼ 692) of pharmacists agreed that appraisal should form part of the revalidation process. Technicians were significantly more likely to agree with this compared with pharmacists, and they were also significantly more likely than pharmacists to agree that their counseling skills should be observed in practice. When survey respondents were asked to indicate their strength of agreement or disagreement to the statement “Evidence gathered towards revalidation should include feedback from work colleagues and peers,” that is, 360-degree feedback, 65.4% (n ¼ 151) of technicians and 58.4% (n ¼ 555) of pharmacists thought that it should. However, the evidence from patient feedback was viewed less favorably by both groups. Further analysis in relation to sector of practice did not reveal any statistically significant differences across the professions.
148
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Table 1 Views on assessment methods and forms of evidence for revalidation Assessment methods, forms of evidence, and the revalidation process
All respondents who agreed or strongly agreed, n (%)
Pharmacists who agreed or strongly agreed, n (%)
Technicians who agreed or strongly agreed, n (%)
Statistical significance
Revalidation should include providing evidence of CPD that is relevant to my practice Revalidation should include providing evidence of a fitness to practice appraisal (ie, not focused on financial or performance targets but on my ability to perform as a pharmacist/ technician) Revalidation should be ongoing, a continuous process as opposed to a comprehensive assessment event scheduled periodically Evidence gathered toward revalidation should include feedback from work colleagues and peers For revalidation, I should have a portfolio of written evidence of good practice For counseling skills, I should be observed in practice I should be able to selfcertify that I am fit to practice and not have to undergo any form of assessment Evidence gathered toward revalidation should include feedback from patients In the community setting, information from mystery shoppers should form part of the evidence gathered for revalidation
1033 (86.3)
843 (87.6)
190 (80.9)
c2 ¼ 7.341, df ¼ 2, P ¼ .025
886 (75.4)
692 (73.2)
194 (84.3)
c2 ¼ 12.495, df ¼ 2, P ¼ .002
824 (69.4)
665 (69.9)
159 (67.4)
NS
706 (59.7)
555 (58.4)
151 (65.4)
c2 ¼ 6.314, df ¼ 2, P ¼ .043
592 (50.0)
464 (48.9)
128 (54.5)
NS
518 (47.6)
387 (44.1)
131 (62.1)
c2 ¼ 23.554, df ¼ 2, P ¼ .000
485 (40.9)
401 (42.2)
84 (35.6)
NS
308 (27.8)
261 (29.3)
47 (21.8)
NS
238 (24.8)
193 (24.7)
45 (25.4)
c2 ¼ 23.234, df ¼ 1, P ¼ .000
NS, not significant.
Who should conduct a revalidation assessment? It was very clear-cut during the qualitative stage of the work that pharmacists and technicians held different opinions regarding who should conduct
their assessment. Technicians were at ease with being assessed by their main employer. Community pharmacists, however, expressed concerns about the potential for bias if assessments for revalidation
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
only involved internal management systems. They also questioned whether company managers, who may not be pharmacy professionals themselves, would be able to understand a pharmacist’s role and the professional ethics by which they have to abide sufficiently well to conduct a revalidation assessment. Although those employed within the NHS were familiar with their managers reviewing their performance, many hospital pharmacists in the focus groups echoed the concerns of community colleagues by emphasizing the need for there to be a quality assurance system that ensured the assessors were themselves, properly trained. As illustrated by the following dialogue taken from a focus group with hospital pharmacists, there was a view that input from an external organization would help ensure that the revalidation process was impartial and consistent: Pharm 4: I think it would be better externally (when discussing who would oversee the process) because then if you’re doing it internally then you’re relying on people’s sort of skills or education skills or sort of assessment skills, where as if it’s somebody external then hopefully they’ll have been trained and they’ve got all the case. Pharm 5: It could be more objective rather than subjective. Pharm 2: And also maintain some sort of standard across the whole profession rather than, you know, you may find that one institution’s standards maybe lower or higher than another’s and that would defeat the object of revalidation if it’s to sort of provide for equity and suggest that people have a suitable standard.
When pharmacists and technicians were asked in the survey to choose 1 assessor (from a number on offer; Table 2), who they thought should conduct their assessment for revalidation, both were more likely to select an assessor employed by their main employer, although technicians were significantly more likely than pharmacists to select this option (P % .05). Conversely, pharmacists were significantly more likely than technicians to indicate that their assessment should be conducted by somebody other than an assessor employed by their main employer. Not surprisingly then, when survey respondents were asked if they thought that an external organization should oversee the process, 50.7% (n ¼ 145/286) of pharmacists compared with 32.5% (n ¼ 41/126) of technicians, agreed that an external organization should be involved (P % 0.05).
149
Further exploration of survey respondents’ attitudes toward their assessor revealed that of paramount importance to pharmacists was the need for the person who conducts their assessment to be a peer (ie, another pharmacist), with an understanding of their role; 80.4% (n ¼ 741) of pharmacists thought it important compared with 35.5% (n ¼ 81) of technicians. Furthermore, pharmacists were more likely than technicians to indicate that it was very important to them that the person who conducts their assessment had been trained and accredited by the regulator; 58.3% (n ¼ 536) compared with 46.4% (n ¼ 104), respectively.
How often should revalidation occur? During the qualitative phase of the research, pharmacists and technicians expressed similar views about the scheduling of revalidation (ie, that it should be an ongoing process rather than a scheduled event); however, they expressed very different views when asked how often they felt that they would need to undergo revalidation, as the 2 quotes that follow illustrate: I suppose you could do revalidation on a timescale according to when they qualified, so every five years or so. Then you’d have cohorts wouldn’t you, everyone who qualified in that year being revalidated at that time and then it would be more staggered. I’ve got to five years now and I’m thinking do I still remember as much as I did when I qualified. It would be nice to know if I’m actually still up to date. (Pharmacist) It’s difficult isn’t it really because they’re going to have to keep track on it as well aren’t they? And if you say five (years) is too much and one’s . and five is too late, one’s not, you know, because you are doing your CPD cycles in between and then you’ve got revalidation. I would probably say two or three years maybe . (Technician)
The survey confirmed these qualitative findings. Thus, when asked to indicate their strength of agreement with the statement “Revalidation should be ongoing, a continuous process as opposed to a comprehensive assessment event scheduled periodically,” 69.9% (n ¼ 665) of pharmacists and 67.4% (n ¼ 159) of technicians either agreed or strongly agreed. However, as shown in Table 3, most pharmacists felt that revalidation should be conducted every 5 years when given a number of different options to choose from,
150
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
Table 2 Respondents choice of who should be involved in conducting assessments for revalidation Assessor
Pharmacists choosing the option, n (%)
Pharmacy technicians choosing the option, n (%)
All respondents choosing the option, n (%)
My assessment should be conducted by an assessor employed by my main employer (ie, reviewed within the NHS, a company, or an organization) who forward a recommendation directly to the pharmacy regulator My assessment should be conducted independently by a senior pharmacy professional based at local level (ie, within the geographical area where you work) who forward a recommendation directly to the pharmacy regulator My assessment should be conducted independently by a senior pharmacy professional from outside the geographical area where I work. This person should forward a recommendation directly to the pharmacy regulator My assessment should be conducted directly by an assessor from the pharmacy regulator My assessment should be conducted by a variety of assessors from more than one source (ie, my employer, and/or an independent senior pharmacy professional, and/or the pharmacy regulator) I do not have a preference regarding who should undertake my assessment
288* (30.2)
136* (58.4)
424 (35.7)
129 (13.5)
20 (8.6)
149 (12.6)
63 (6.6)
2 (0.9)
65 (5.5)
138 (14.5)
17 (7.3)
155 (13.1)
119 (12.5)
18 (7.7)
137 (11.5)
217 (22.7)
40 (17.2)
257 (21.7)
954 (100)
233 (100)
Total
1187
c2 ¼ 70.280; df ¼ 5; P ¼ .000. * Some missing data.
whereas most technicians felt that revalidation should be conducted every 2 or 3 years (P % .05). Outcome of the revalidation assessment When pharmacists and technicians were asked to consider what should be involved for those who were not successful at meeting the revalidation standard, 68.7% (n ¼ 651) of pharmacists and 54.2% (n ¼ 128) of technicians thought that they should be allowed to continue to practice on condition that they were reassessed and then met the revalidation standard. Technicians were significantly more likely than pharmacists to indicate that individuals who fail to meet the revalidation standard should be allowed to continue to
practice under supervision, until they were reassessed and the standard was met: 42.8% (n ¼ 101) compared with 23.1% (n ¼ 219), respectively (c2 ¼ 40.433, df ¼ 4, P % .05). Pharmacy technicians were also significantly more likely than pharmacists to indicate that for reassessment, individuals should be assessed using the same revalidation tool that was used at their initial assessment but should also undergo further assessment in practice: 53% (n ¼ 122) compared with 43.3% (n ¼ 393), respectively (c2 ¼ 9.747, df ¼ 3, P % .021). Finally, survey respondents were asked how many attempts at meeting the revalidation standard a pharmacist or technician should be allowed (from 1, 2, or as many as necessary). Overall,
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154 Table 3 Respondents choice of the frequency of professional revalidation Revalidation Pharmacists Pharmacy technicians frequency choosing option, choosing option, n (%) n (%) Annually Every 2 y Every 3 y Every 4 y Every 5 y Other
27 80 191 27 556 75
(2.8) (8.4) (20) (2.8) (58.2) (7.8)
Total
956 (100)
13 55 60 8 95 5
(5.5) (23.3) (25.4) (3.4) (40.3) (2.1)
236 (100)
c ¼ 64.580; df ¼ 5; P ¼ .000. 2
43.1% (n ¼ 488) indicated a total of 3 attempts, that is, their initial assessment and 2 repeat assessments, should be permitted. Pharmacists were more likely than technicians to indicate that they felt 3 attempts would suffice: 44.1% (n ¼ 397) compared with 39.2% (n ¼ 91), respectively. Conversely, technicians (32.8%; n ¼ 76) were significantly more likely than pharmacists (19.6%; n ¼ 176) to indicate that they felt 2 attempts, that is, the initial assessment and 1 repeat assessment, were adequate (P % .05). Discussion This study, the first to explore GB pharmacist’s and technician’s views on revalidation, used multiple methods: qualitative work provided an in-depth insight into pharmacists’ and pharmacy technicians’ views on revalidation and helped to inform the design of a subsequent postal survey that set out to validate and quantify the qualitative findings over a wider sample and provide opportunity for triangulation of research findings. However, with an overall response rate of 26.4%, it is possible that nonresponse bias could affect the generalizability of the survey results and the conclusions drawn.35 Furthermore, as the technician sample used for the study was taken from the voluntary register of pharmacy technicians, it is difficult to say whether the technicians’ views captured were those from a more proactive group of individuals. The pharmacists and technicians who responded to the survey were broadly representative of the registers from which they were drawn, so the authors are confident about the overall generalizability of the findings.
151
Despite these limitations, this study reassuringly demonstrated that views on revalidation were mostly positive, and it has provided valuable insight on how members of the pharmacy profession in GB envisage a revalidation process. The study demonstrated that although pharmacists and technicians share the same views on some aspects of the revalidation process, there is some variation in how they want their assessment for revalidation to take place. Overall, revalidation was seen as a continuous process with CPD forming part of the evidence. Pharmacists were more likely than technicians to want CPD to be considered for revalidation; however, this may be a reflection of the fact that technicians had not been mandated to the register at the time of this study and had not been subjected to mandatory CPD for as long as pharmacists. The preference shown for CPD to be used as evidence in the revalidation process concurs with the Ontario model for revalidation19 and that being implemented by the medical profession in the United Kingdom.25 More recently, the GPhC has confirmed that revalidation will be aligned with the Non-Medical Revalidation Working Group’s principles for revalidation, which include CPD.7,32 Contrary to the Ontario model,19 however, pharmacists and technicians did not want revalidation to be a scheduled event, that is, individuals selected by the regulator for annual peer review. This finding is of particular importance in the United Kingdom, as the GPhC has announced that revalidation will be based on assurance of continuing fitness to practice and will not be a fixed point assessment.7 In general, appraisal was deemed to be a useful source of evidence for revalidation, provided appraisal focused on an individual’s ability to perform as a pharmacist or technician, and not on financial or performance targets. The drawbacks associated with using the preexisting appraisals system for pharmacists and technicians working in the managed care sector (the KSF)8 have been mentioned earlier. Because a national system of appraisal does not exist for those working outside the NHS, that is, in community pharmacy, academia, or industry, it seems likely that the GPhC, if it wants to incorporate appraisal into the revalidation process, should consider developing a standard appraisal tool that can be used across the profession, in a similar way to that developed for the medical profession.25 Feedback from colleagues and peers, that is, 360-degree feedback, was also viewed as a useful
152
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
source of evidence for revalidation, although concerns were raised by those within the community sector that it may be difficult to identify appropriate peers. Although one can envisage how feedback from colleagues and peers on a doctor’s performance could provide useful evidence for revalidation, it must be emphasized that the vast majority of the medical profession work in teams and, as such, have access to the appropriate personnel, that is, other doctors or nurses, who can provide them with feedback. Even within primary care, locum doctors work in surgeries where there are other GPs who can provide feedback on their performance. Although this working environment is very similar to those working in hospital pharmacy, it is very different to the one that a community pharmacist will normally encounter, in which they commonly find themselves working as a lone pharmacist. It is therefore of no surprise that those working within the community expressed concerns that they may not be able to find the appropriate personnel to provide them with feedback. If the GPhC, and other regulatory bodies from other countries, wishes to introduce a system of revalidation that is fair across the profession, findings from this study demonstrate that regulators will need to consider whether feedback from colleagues and peers could provide the profession with a consistent approach. Overall, views on a model for revalidation demonstrated that it may not be desirable within the pharmacy profession to have a single model of revalidation. Pharmacy technicians appear to be more comfortable with being revalidated by someone within their work environment. Pharmacists, however, were concerned about how impartiality within the revalidation process could be assured; they appeared more attracted to the idea that an assessor who was either an independent senior pharmacy professional or an assessor from the pharmacy regulator should be involved. Although this finding may be explained by the fact that the vast majority of technicians are employees who work under supervised practice, it may also be a reflection that technicians are more familiar and therefore more comfortable with their work being observed in practice. The community pharmacists in the qualitative phase of the study believed that pharmacy companies should not be involved in revalidating their own managers, is perhaps a reflection of the professional isolation that exists within community pharmacy today, and reflects concerns expressed
elsewhere that assessments may be carried out by managers who are not pharmacists.36 Findings that pharmacists were more likely than technicians to indicate that it was very important to them for their assessor to be a peer, that is, a pharmacist with an understanding of their role, corroborates this view, and perhaps demonstrates further the concern that exists among community pharmacists on the use of business targets during performance reviews. The involvement of the GPhC would concur with the system of revalidation in Ontario, Canada, where the pharmacy regulator is directly involved in the assessment of a pharmacist’s fitness to practice via the appointment of pharmacists who the regulator trains and accredits as assessors on their behalf.19 Consistent with both the UK General Medical and Dental Councils23,27 models for revalidation, this research provides evidence to suggest that revalidation, if conducted every 5 years, would be an acceptable time frame to the pharmacy profession. Although some technicians indicated that revalidation every 2 or 3 years may be necessary, this is probably a reflection of the period over which they learn leading to their professional qualification, that is, 5 years of training for pharmacists and 2 years for technicians. With approximately 46,000 practising pharmacists and around 20,500 technicians on the register in GB, and with the GPhC already reviewing pharmacists’ and technicians’ CPD every 5 years, the question remains as to whether it would be practical for the GPhC to expect a pharmacist or technician to have to undergo revalidation more often than every 5 years. However, it could be considered for particular groups, those posing a greater risk to patient safety for example, or for those in which performance concerns have been raised and remediation actions identified. In GB, the National Clinical Assessment Service,37 an organization that offers practical support to health care professionals whose performance has been identified as falling short of professional norms, could work closely with the regulator to ensure this happens.
Conclusion CPD, appraisal, and multisource (360-degree) feedback from colleagues and peers were identified as possible components of revalidation, although questions remain on the use of feedback from patients. Within the profession, revalidation every 5 years was acceptable, but there appears to
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
be some variation in how pharmacists and technicians envisage a revalidation process. Findings suggest that a single model of revalidation would not be desirable or practicable. Technicians were more open to their assessment being conducted by someone within their work environment, whereas pharmacists were concerned about impartiality and preferred that an independent senior pharmacy professional or an assessor from the GPhC be involved. Further research is necessary to explore the role of employers and the GPhC in the revalidation process and establish how assessors involved in revalidation assessments could be accredited and quality assured. References 1. Department of Health. Learning from Bristol: The Report of the Public Inquiry Into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995. Command Paper: CM 5207. London, UK: The Stationary Office; 2001. Available at: http://www.bristolinquiry.org.uk/finalreport. Accessed 25.07.12. 2. Department of Health. The Shipman Inquiry. Fifth Report. Safeguarding Patients: Lessons From the PastdProposals for the Future. Command Paper : CM 6394. London, UK: The Stationary Office; 2004. Available at: http://www.shipman-inquiry. org.uk/fifthreport.asp. Accessed 25.07.12. 3. Noyce P. Governance and the pharmaceutical workforce in England. Res Social Adm Pharm 2006;2: 408–419. 4. Department of Health. Good Doctors, Safer Patients. Proposals to Strengthen the System to Assure and Improve the Performance of Doctors and to Protect the Safety of Patients. A Report by the Chief Medical Officer, Sir Liam Donaldson. London, UK: Department of Health; 2006. 5. Department of Health. The Regulation of NonMedical Healthcare Professionals. A Review by the Department of Health, Chaired by Andrew Foster. London, UK: Department of Health; 2006. 6. Her Majesty’s Stationary Office. Trust, Assurance and SafetydThe Regulation of Health Professionals in the 21st Century. London, UK: The Stationary Office; 2007. 7. Royal Pharmaceutical Society of Great Britain. A Draft Model for Revalidation in Pharmacy. Report to the Department of Health. London, UK: RPSGB; 2009. 8. Department of Health. The NHS Knowledge and Skills Framework and Development Review Process. London, UK: Department of Health; 2004. 9. NHS Knowledge and Skills Framework. Revalidation Project. A Report Commissioned for the Department of Health Working Group for Non-Medical Revalidation. London, UK: Prime Research and Development Ltd; 2009.
153
10. Finlay K, McLauren S. Does appraisal enhance learning, improve practice and encourage continuing professional development? A survey of general practitioners’ experiences of appraisal. Qual Prim Care 2009;17(6):387–395. 11. Middlemass J, Siriwardena AN. General practitioners, revalidation and appraisal: a cross sectional survey of attitudes, beliefs and concerns in Lincolnshire. Med Educ 2003;37:778–785. 12. Boylan O, Bradley T, McKnight A. GP perceptions of appraisal: professional development, performance management, or both? Br J Gen Pract 2005;55: 544–545. 13. Board of Pharmacy Specialties. Certification, maintenance and recertification. Available at: http://www. bpsweb.org/recertification/general.cfm. Accessed 26. 07.12. 14. Bellingham C. Split success: New Zealand’s story. Pharm J 2006;277:509. 15. Pharmacy Council of New Zealand. Available at: http://www.pharmacycouncil.org.nz/cms_show_down load.php?id¼164. Accessed 19.03.12. 16. Singapore Pharmacy Board. A guide to compulsory CPE for pharmacists. Version 1, July 2006. Available at: http://www.healthprofessionals.gov.sg. Accessed 25.07.12. 17. Winslade N, Tamblyn R, Taylor L, Schuwirth L, Van der Vleuten C. Integrating performance assessment, maintenance of competence and continuing professional development of community pharmacists. Am J Pharm Educ 2007;71(1):1–9. 18. Hasman A. Get ready for revalidation in pharmacy. Pharm J 2009;283:485–487. 19. The Royal Pharmaceutical Society of Great Britain. Pharmacy Regulation and Education in Ontario and British Columbia CanadadRPSGB Study Tour Report. London, UK: The Royal Pharmaceutical Society of Great Britain; 2005. 20. Austin Z, Marini A, Croteau D, Violato C. Assessment of pharmacists’ patient care competencies: validity evidence from Ontario (Canada)’s quality assurance and peer review process. Pharm Educ 2004;4(1):23–32. 21. Merkur S, Mossialos E, Long M, McKee M. Physician revalidation in Europe. Clin Med 2008;8(4): 371–376. 22. Violato C, Lockyer J, Fidler H. Multisource feedback: a method of assessing surgical practice. BMJ 2003;326:546–548. 23. General Medical Council. Revalidation. GMC, 2012. Available at: http://www.gmc-uk.org/doctors/revali dation.asp. Accessed 26.07.12. 24. General Medical Council. Good Medical Practice. London, UK: General Medical Council; 2009. 25. General Medical Council. The good medical practice framework for appraisal and revalidation. Available at: http://www.gmc-uk.org/GMP_frame work_for_appraisal_and_revalidation.pdf_41326960. pdf. Accessed 26.07.12.
154
Potter et al. / Research in Social and Administrative Pharmacy 9 (2013) 142–154
26. Nursing and Midwifery Council. The Prep Handbook. London, UK: Nursing and Midwifery Council; 2008. 27. General Dental Council. Revalidation for dentists: our proposals. 2012. Available at: http://www.gdc. uk.org/Dentalprofessionals/Revalidation/Documents/ revalidationconsultationpaper. Accessed 26.07.12. 28. Strauss A, Corbin J. Basics of Qualitative Research. London, UK: Sage Publications, Inc; 1990. 29. Krueger R. Focus Groups: A Practical Guide for Applied Research. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc; 1994. 30. Morgan D. Focus Groups as Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc; 1997. 31. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess R, eds. Analyzing Qualitative Data. London, UK: Routledge; 1994. 32. Department of Health. Principles for Revalidation. Report of the Working Group for Non-Medical
33.
34.
35.
36.
37.
RevalidationdProfessional Regulation and Patient Safety Programme. London, UK: Department of Health; 2008. Seston E, Hassell K. An overview of the main findings from the 2008 pharmacy workforce census. Pharm J 2009;283:419–420. Seston E, Hassell K. First census of pharmacy technicians: 1. Demographics and working patterns. Pharm J 2012;288:140–141. Bowling C. Research Methods in Health. Investigating Health and Health Services. 2nd ed. Maidenhead, UK: Open University Press; 2002. Jee SD, Jacobs S, Schafheutle EI, et al. An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain. Res Social Admin Pharm 2013;9: 155–165. National Clinical Assessment Service. Helping Ensure Safe Pharmacy Practice. London, UK: National Clinical Assessment Service; 2009.