FIP 2008: Workforce, competence and education — what might the future hold?
Catherine Duggan reports from a session run by the board ofpharmaceutical practice, at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences
Catherine Duggan reports from a session run by the board of pharmaceutical practice, at the 2008 World Congress of Pharmacy and Pharmaceutical Sciences
A pharmaceutical practice session sought to describe current issues related to the pharmacy workforce (including issues such as migration and how that impacts on planning to deliver healthcare) fitness for purpose, regulation, reforms taking place in pharmacy education to ensure the workforce is competent to deliver current and future pharmacy services, and the role of technology in supporting the safe use of medicines.
Migration: symptom rather than cause
The first presentation, by Tana Wuliji, a project lead for FIP in the Netherlands, was entitled “Global pharmacy workforce and migration — an FIP perspective”. Ms Wuliji put forward several strands to her argument.
The first was the increased expectation we have for the profession of pharmacy around the safe, appropriate and effective use of medicines, as well as the prevention of disease, through self-care programmes.
She outlined the many collaborations FIP has established with other global agencies (eg, the World Health Organization, the Global Health Workforce Alliances, United Nations agencies, the World Medical Association, the World Dental Federation and the International Council of Nurses), pharmacy itself, students and publications.
One such collaboration is the Pharmacy Education Taskforce (see Panel below).
Taskforce to develop pharmacy education to meet future demands
Claire Anderson, from the University of Nottingham, UK, spoke of the formation of the Pharmacy Education Taskforce, which is a tripartite partnership between the World Health Organization, United Nations Educational, Scientific and Cultural Organization and FIP in November 2007.
This is a co-ordinating body of organisations, agencies, institutions, and individuals with the shared goal of catalysing actions to develop pharmacy education and working to improve pharmacy education at local, regional and national levels.
Professor Anderson described the purpose of the taskforce as overseeing the implementation of an action plan for 2008–10. The plan aims to enable the sustainability of a pharmacy workforce that is relevant to local needs. It is dedicated to three domains of action: quality assurance, academic and institutional capacity, and competency and vision for pharmacy education.
She went on to outline the complexity behind the definition of competence and how, with appropriate acquisition of knowledge, skills, values and behaviours, a pharmacist is able to demonstrate competence over time to be able to perform in practice.
Fundamental to ensuring performance, is applying the appropriate knowledge in the appropriate way, Professor Anderson said. Academic institutions and staff are, by definition, the basis of pharmacy education.
However, many institutions lack the resources and capacity to train sufficient numbers of pharmacists and other pharmacy support staff. Others face poor physical institutional infrastructure where basic facilities may be insufficient or are non-existent.
In recent years, the demand for an academic faculty and facilities that can meet the needs of a growing student intake has stretched limited resources even further.
The aims of the taskforce Academic and Institutional Capacity project team are to better understand these challenges and develop tools, which can be used by institutions to overcome them. The team objectives are to:
A second strand to Ms Wuliji’s presentation was to highlight the lack of evidence or profile for the effectiveness of pharmacy interventions, especially when contrasted with our medical colleagues. Ms Wuliji reported the WHO measures of health need, where less than 2.5 health workers per 1,000 head of population would be regarded as a crisis in terms of health delivery.
However, this is an everyday occurrence for many countries and in others, the number is even lower. All of this raises the question of where pharmacies are situated, which is of particular importance when considering the associations between child mortality rates and poor access to medicines.
Her conclusion was that the pharmacy workforce is not always sited where it is needed — in some countries there is less than one pharmacist per 100,000 population.
Alongside the pharmacy workforce inequity between countries, the distribution is also unequal within countries where pharmacists seem more plentiful in cities and often negligible in rural areas. Ms Wuliji went on to explore the rationale for some of these inequities, linking them to workforce issues.
There is little strategy worldwide for the numbers of pharmacists we need — from how many to recruit into the education system, to the numbers we need to train to meet the local needs of patients. We have, therefore, little real idea of the number of pharmacists we need at each level of practice and for each career level.
In addition, there are workforce issues to contend with, related to performance, deployment, systems of working, recruitment and retention, and lifelong learning and development. Then we should consider factors that may influence whether pharmacists leave employment, which include:
- health (or ill health)
- family commitments
- career change
With an ageing population (as in many developed countries) the numbers of retirees exceeds the numbers of juniors, meaning there will be fewer mentors, trainers and roles models to support their development in the longer term.
Ms Wuliji further emphasised the absolute link between workforce and access to medicines and spoke about the need to empower the entire workforce to deliver the new, ambitious roles for pharmacy. She proposed that migration is not the cause of workforce shortages, indeed it is a symptom — a form of attrition in the profession, which is due to many other issues.
There is also a suggestion in the literature that low numbers of staff are not related to migration but that people leave the profession because there are too few staff (ie, a vicious circle).
The problem of migration (poor retention) is multifactorial. It is not just about money, but it is also about education, work environment and quality of life.
Ms Wuliji ended her presentation with findings from a survey of 800 respondents. This showed that migration was clearly associated with perceptions of problems in their own countries together with perceptions that there were no such problems in the migrant country.
Revalidation: a way to build trust
Professor Hassell began with the issue of trust and how, in the UK, some high profile cases of criminal behaviour in healthcare professionals that had, in recent years, led to a breakdown of trust between health professionals and the public.
There followed the publication of a Government White Paper, Trust, Safety, Assurance in 2007, which sought to outline the principles of regulation in all health professions. These were:
- To protect patients and raise standards
- To ensure regulators are independent and proportionate
- To ensure minimum risk to patients
- To improve standards and identify poor performance
One issue that arises is that of revalidation — a mechanism that allows health professionals to demonstrate fitness to practise. This is made up of competence and performance and should be robust enough to identify poor performance.
At present, there are two tiers being considered: revalidation of core practice, which will be regulated against contemporary standards, and of advanced practice, the standards for which will be set by the professional body and which may be later regulated.
Professor Hassell considered the factors contributing to poor performance. These include human failures, which are related to factors such as illness, drugs and alcohol problems, and system failures, which are related to errors in the workplace and workload.
She then considered poor performance in terms of making an error time and again, maybe due to not keeping up to date; giving wrong advice and doing things outside ones capability. The regulator would see the risk to patients of poor performance as well as deviation from standards and performance norms (which needs robust definition).
Professor Hassell went on to give current examples of performance management that could be related to the community pharmacy contract and prescribing norms. These would include not keeping up to date and complaints from patients and peers. They would give the regulator cause for concern and require remedies of one sort or another.
Examples of remedies include striking off after a set number of warnings (the “two strikes and you’re out rule”), peer support, involvement and appraisal and continuing professional development — the mainstay of revalidation.
When considering the extended roles of revalidation for the GPhC in 2010, we have to think about who should be targeted, Professor Hassell said. There are varied views on this, from revalidation for everyone (similar to our medical colleagues in the UK), to only for people returning from career breaks or poor performers.
Although the ideal may well be for everyone to be revalidated, Professor Hassell said this would be unlikely due to the vast numbers of pharmacists on the register.
Pharmacy technicians revalidation is also under consideration, as is the regulation of all those who come into contact with patients and the public as a matter of course.
How often we would be regulated is also being considered. In Canada, for example, 20 per cent of the profession is revalidated every year. There is much to consider and much to get right, she said. The UK perspective is a useful focus for others to learn from.
Adoption of technologies to enhance pharmacists’ effectiveness and patient safety
William Churchill, from Brigham and Woman’s Hospital in the US, related experiences of developing and using automation to enhance patient safety and reduce errors.
In Professor Churchill’s hospital, a medicine is administered every five seconds, involving hardware, software and “people-ware” to ensure safe and appropriate administration. They have worked hard to develop team-based training and a culture of learning to work with each other and the technology — something that has not always been easy, he said.
The best systems work when you connect all the various elements of managing the various components of medicines administration, he said. Research by Bates and Leape found that computerised ordered entry (COE) prevents more than 55 per cent of medicine errors, improves readability and improves efficiency of ordering.
However, for all these strengths, there are some weaknesses, including the need to plan for the technology to be central to ensuring patient safety. How well staff deal with the system is key — too few alerts and they become unconscious of problems, too many and they become over sensitised to them, he explained.
The system is still evolving. The number of medicines can vary widely, from 19 to 44 per patient dependent on diagnosis and the COE does not have the capacity to prioritise so, perhaps not surprisingly, there needs to be some professional input, he said.
When COE was implemented, a needs assessment (looking at the needs of nurses, doctors and pharmacists) was conducted. It found a system with too little flexibility, that did not link all the systems together and that did not address fully the need to link clinical decision-making support and the interaction between the professionals. They had to “re-infrastructure”, which included installing wireless information and using barcodes to identify patients.
Some of the technology, taken from Fed Ex, allows a smaller barcode that can contain three times the information. This means more information about each drug can be included and the degree of accuracy is increased. Decisions were also made regarding hardware to invalidate some systems for nurses and to enhance safety, including daily logins (with punitive measures if staff forget their identity cards). Many stages and blocks were also installed in the system to prevent error.
Professor Churchill outlined how they were able to design bi-directional software to ensure immediate discussions around choices of drug for an individual patient. This also enables links via e-mails for wider discussions around interventions and has enabled inter professional working to move to another level. For example, when a nurse has a question, he or she can link to information sources and other professionals.
Warnings also appear, for example, for overdue medicines or medicines that are currently due. In addition, warnings are displayed for wrong patients or wrong drugs. The alerts do not allow the system to proceed.
However, Professor Churchill admitted that the system can be abused (ie, overridden at stages) so there is a constant business of monitoring. They have found nurses who squirrel away supplies, but have modified the system so that it captures each time this is done. Subverting the technology is a violation and is appropriately managed, he said.
Another example of how technology needs to be central to the design of safe medicines management is the use of smart pumps. The system now sends the data about patients (eg, time, dose, flow rate, etc), linking the patient and the pump via a barcode. The nurse scans both and then the patient receives the drug. This is a fairly simple idea, but essential, Professor Churchill said.
He detailed how smart pumps cannot be used alone to drive errors out of the system. Similarly, automated dispensing cabinets are not designed for safety but, can be used to enhance safety as part of a holistic approach. One needs the interfaces to be there, he explained.
Professor Churchill concluded his presentation with a set of summary points:
Reports from the 68th World Congress of Pharmacy and Pharmaceutical Sciences
Citation: The Pharmaceutical Journal URI: 10038128
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