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What makes continuing education effective: Perspectives of community

pharmacists

Article · February 2010

DOI: 10.1211/ijpp.15.4.0010

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IJPP.book Page 313 Thursday, November 1, 2007 6:55 PM
IJPP 2007, 15: 313–317
© 2007 The Authors
Received January 11, 2007
Accepted June 7, 2007
DOI 10.1211/ijpp.15.4.0010
ISSN 0961-7671
Victorian College of Pharmacy,
Monash University, Victoria,
Australia
Kevin Mc Namara, lecturer in
pharmacy practice
Jennifer L Marriott, senior lecturer
Gregory J Duncan, lecturer in
pharmacy practice
Greater Green Triangle
University Department of Rural
Health, Deakin and Flinders
Universities, Warrnambool,
Victoria, Australia
Kevin P Mc Namara, research
fellow
Correspondence: Mr Kevin P
McNamara, Lecturer in Pharmacy
Practice, Victorian College of
Pharmacy, Monash University,
381 Royal Parade, Parkville 3052,
Victoria, Australia. E-mail:
kevin.mcnamara@
vcp.monash.edu.au
Acknowledgements: The
authors would like to
acknowledge the substantial
contributions to this work from
Dr Phyllis Lau, Professor David
Prideaux, and Dr Ros Hurworth.
We would also like to
acknowledge the financial
support of the Community
Pharmacy Research Support
Centre in undertaking this
project.
What makes continuing education effective:
perspectives of community pharmacists
Kevin P Mc Namara, Jennifer L Marriott and Gregory J Duncan
Abstract
Objective To explore how different aspects of the professional environment for Australian com-
munity pharmacists are perceived to be influencing the effectiveness of continuing education mod-
els in improving practice.
Setting Australian community pharmacy.
Methods A convenience sample of practising community pharmacists (n = 15) was recruited using
the ‘snowballing’ technique to participate in one of four focus group teleconferences. Each focus
group examined continuing education experiences from different professional perspectives and
training needs (recent graduates, experienced practitioners, specialist practitioners and
rural/remote practitioners).
Key findings Facilitation of professional development by accreditation bodies, and new challenges
resulting from the introduction of cognitive services were seen to promote a favourable environ-
ment for continuing education engagement. Complex continuing education delivery models com-
bined with high costs and excessive workloads made it more difficult to engage with continuing
education systems or try to apply knowledge to the workplace.
Conclusion Results support findings from previous research that practice development requires a
multifaceted approach with continuing education as just one component. Affordable and inte-
grated models of continuing education are required in order to optimise efficacy for participants.
Introduction
Continuing education (CE) is acknowledged as an integral component of continuing profes-
sional development (CPD) and professional practice for pharmacists.1 In Australia this has
led to the development of a number of delivery organisations. The major organisations
involved in the delivery of pharmacist CE are the Society of Hospital Pharmacists of
Australia (SHPA, largely representing health system pharmacists), and the Pharmaceutical
Society of Australia (PSA, general pharmacist body). Fees for general membership with
these organisations were AU$341 and AU$575 respectively in 2007, which includes free
distance education to all members, and free regular contact education at major population
centres. Both organisations also offer conferences and intensive seminars of varying dura-
tion at an extra cost, typically about AU$400–600 per weekend course for members. Spe-
cialist training in medication management is available from the Australian Association of
Consultant Pharmacists (AACP), and pharmacists also widely avail themselves of govern-
ment-subsidised multidisciplinary education provided by the National Prescribing Service
(NPS) and the Rural Health Education Foundation (RHEF).
Pharmacist-accreditation organisations require practising pharmacists to undertake man-
datory CE on an annual basis. Despite this, anecdotal evidence suggests that participation in
formal CE activities by community pharmacists is far below what is desirable.
Research looking at other health professions has found that various enablers such as
reinforcement strategies and supportive management are required within the working envir-
onment to result in successful outcomes from CE in practice.2–4 This is supported by a
Cochrane review of the evidence for audit- and feedback-type educational interventions,
which found that a multifaceted approach to improving practice that reinforces important
messages is more successful than an educational intervention in isolation.5 Moreover, a US
study looking specifically at pharmacists failed to show an increased level of clinical
313
IJPP.book Page 314 Thursday, November 1, 2007 6:55 PM
314 The International Journal of Pharmacy Practice, December 2007
application despite increased knowledge and skills following
dyslipidaemia-related CE.6 Most research in this field relating
to pharmacy has largely focused on barriers to participation in
CE by pharmacists.7–10 Such research largely addresses fac-
tors at the individual practitioner level, including poor moti-
vation to attend, other demands on their time and a perceived
lack of clinical relevance and applicability.
There is an absence of literature examining whether the
wider professional context of community pharmacy practice
is contributing towards diminished relevance or applicability
of CE, although this has been strongly argued from a theoret-
ical viewpoint.11 If unfavourable conditions are perceived by
pharmacists to exist for uniting educational experiences with
practical outcomes, it would be expected to negatively impact
upon the value and priority given to CE, and would presuma-
bly contribute towards reluctance to undertake it. It is import-
ant to identify and address any such professional factors so
that potential impediments to the perceived value of CE
might be addressed.
Aim
The aim of this study was to explore how different aspects of
the professional environment for Australian community phar-
macists are perceived to be influencing the effectiveness of
CE models in improving practice.
Methods
This study was a qualitative analysis of the current state of
CE in Australia, which drew on the attitudes and experi-
ences of Australian community pharmacists who engaged in
CE. The study was approved by the Monash Standing Com-
mittee on Ethics in Research involving Humans, and the
Flinders University Social and Behavioural Research Ethics
Committee.
A convenience sample of Australian community pharma-
cists was invited to participate in a series of semi-structured
focus group teleconferences. The focus groups were
conducted by teleconference in order to ensure equal oppor-
tunity to participate regardless of geographical location.
Inclusion required that the participant was registered and
practising as a pharmacist in Australia, that they were not be
directly involved in the provision of education, and that they
belonged to at least one of the focus group categories
described below. Participants were identified through pub-
licly available sources and invited to contact the researchers
to indicate their willingness to participate. An announcement
was included on the internet discussion group for Australian
pharmacy, Auspharmlist (www.auspharmlist.net.au), inviting
volunteers from across Australia who met the inclusion
criteria. Participants were also recruited through academic
networks using the ‘snowball’ technique, requesting interes-
ted subjects to ask their colleagues to contact the researchers
if they were interested in participating. At the time of the
study the pharmacists were required to be registered,
practising in an Australian state or territory community
pharmacy, and have no direct involvement in CE delivery to
other pharmacists.
Four distinct focus groups of community pharmacists
allowed us to observe whether there were any differences
in opinion in different contexts. These groups were:
experienced pharmacists (more than five years qualified),
recently qualified pharmacists (less than five years quali-
fied), pharmacists practising in rural/remote areas, and
pharmacists with specialist training needs (e.g. home
medication reviews). An independent facilitator con-
ducted the focus groups, using an approved protocol that
included standardised questions to ensure each group
examined the same issues in the same order. The inter-
view questions were developed through a review of the
literature, and aimed to explore the issues that were
identified. Informed consent was given for discussions to
be recorded and then transcribed by the facilitator in prep-
aration for analysis.
A content analysis of the transcripts was undertaken using
inductive category development. The information obtained
from participants was also considered in terms of the theoret-
ical principles identified from the literature as being desirable
for effective CE delivery, and inferences made about the cur-
rent organisation of CE delivery for community pharmacy in
Australia.
For the purposes of analysis, CE models were defined as
those structures and systems in place designed to influence
educational practices and outcomes; perceived effectiveness
of CE was assessed based on participants’ reported ability to
translate their educational outcomes from CE into pharmacy
practice.
Results
The analyses of Australian community pharmacist education
models from the four groups of pharmacists are presented
together, as identified themes overlapped. There were 15
pharmacists in total (nine female and six male), working in
five of the seven states and territories.
This study identified both negative and positive areas
which, from the participant pharmacists’ perspectives, had
substantial impacts on the extent to which a model of CE
could deliver effective outcomes in terms of good pharma-
ceutical practice and patient outcomes.
Negative impact on effectiveness of CE
Affordability
Lack of affordability was seen by participants to affect phar-
macists’ ability to engage in the most suitable CE. This was
particularly the case for pharmacists requiring a diverse range
of skills, or who had family commitments. A strong associa-
tion was made between this issue and the fact that there were
multiple education providers for community pharmacists.
Participants commonly indicated that they had to be selective,
and sometimes make compromises, in choosing which educa-
tion to undertake so that the amount spent on professional
development did not become excessive:
“With our two [professional] societies . . . they’re the two organi-
sations that you can subscribe to. But again costs are a factor and
IJPP.book Page 315 Thursday, November 1, 2007 6:55 PM
December 2007, The International Journal of Pharmacy Practice
I’ve found that I cannot subscribe to both – I’ve had to make a choice
over the last couple of years. It’s really difficult to afford both.”
“This year I have decided to venture away from [one CE organisa-
tion] because it wasn’t providing what I needed and because of the
cost of what I’ve been spending on CE this year . . . I have to agree
about the economics of education. I, likewise, have a young family
and can’t spend several thousand dollars a year on education.”
Poor co-ordination of activities
Some participants held the view that CE required central
co-ordination for promotion of activities. Even if CE is avail-
able, pharmacists reported that they were sometimes unaware
of it because of difficulties keeping in touch with the numer-
ous organisations involved, thus creating difficulty in
planning appropriate CPD activities. It was suggested that
such a coordinating role was uniquely suited to pharma-
cist-accreditation bodies:
“I didn’t know that a person could get it [Rural Health Education
Foundation broadcasts] beamed to their house with a satellite dish. That
was an interesting thing and I’m sure that a lot of other pharmacists don’t
know about that. So we have to tell them about possibilities that exist”
“I could see it as part of the role of the board [to promote educa-
tional opportunities]. I mean the boards obviously know all the regis-
tered pharmacists in each state . . . [and] are moving towards making
CE almost compulsory. So, seeing it from that point of view they
would need then to make sure that each pharmacist receives adequate
communication.”
“Moving to Queensland has really left quite a big hole, in that I
haven’t really received communication [from CE organisations] . . .
newsletters don’t seem to be coming out as frequently here and I think
I’ve had one communication through the pharmacy board up
here. . . . So, I’m feeling particularly isolated at the moment.”
Positive impact on effectiveness of CE
Reaccreditation requirements
The impact of pharmacist reaccreditation requirements on
uptake of CE was also discussed. There was general approval
of the decision by Australian registration/reaccreditation
authorities to adopt portfolio-based CPD as the standard for-
mat for reaccreditation assessment. It was felt that such a pro-
cess would facilitate greater efforts from pharmacists to make
their CE relevant to tangible professional development. The
following statements typify feelings about the mixed merits
of points-for-attendance reaccreditation systems which cur-
rently predominate in Australia, and the potential for improving
their practice through maintenance of CPD portfolios:
“What I’ve noticed is that sometimes it seems that lectures are put
on just for the sake of putting lectures on and as we’ve heard, some
of those are a bit lacking. However, in a sense it’s good as it has
forced people to go to those lectures because when I go, I think ‘Oh,
that’s a couple of points whacked up. That’s good!’ But often they’re
not going with the intention of learning anything, they’re just going
so that the pharmacy board doesn’t come knocking!”
“I know that when the [professional development] portfolio was
introduced it just made me a little more focused on really getting a
learning outcome when I was finding something out, as distinct from
315
if I was just checking out what was happening and what was new.
You have to go just that little bit further if you want to justify it as a
learning outcome by recording it in your portfolio.”
“I like keeping the portfolio and being able to see what you have
worked through and what you’ve done has been successful for you.”
Participants already engaged in the maintenance of CPD port-
folios for accreditation purposes highlighted the need for clar-
ity about how this process works. While there was
acknowledgement that accreditation authorities need to use a
‘big stick approach’ with some pharmacists to motivate pro-
fessional development, a collaborative approach was consid-
ered far more productive in facilitating outcomes for most
pharmacists. Without engagement of the profession by
accrediting bodies to produce clarity in the CPD process, it
was felt that pharmacists would become overly concerned
with documentation requirements rather than the desired
learning outcomes:
“Well, we have this document to fill in but no-one knows yet how
much detail to provide. It would be nice to get back from the board
real examples where; ‘Here’s one we don’t think is satisfactory and
here’s one that’s really fantastic and here’s an example of one that’s
OK and just passes the grade’. It doesn’t have to be too hard – just
write down what you’ve done!”
“I would like to see too that the pharmacy board has a group of
people who go out – as I have never heard of this – and come out
to my pharmacy and say; ‘Hi guys. Let me talk you through this
process’.”
Impact of work environment
Participants from a couple of focus groups discussed the
impact of their personal working environment on their moti-
vation to learn and the applicability of CE. A number of phar-
macists spoke of having needed a fresh ‘challenge’ – such as
medication management through conducting formal medicine
reviews, such as home medicines review (HMR) – to moti-
vate them to undertake professional development. Excessive
workload in some roles, and a lack of other formally recog-
nised programmes that employ the broader capabilities of
pharmacists were also cited as limiting factors in being able
to apply CE towards practice:
“For me to do the accredited review [HMR training] . . . I think it
gave me the impetus to see me through the next 10 or 20 years of
pharmacy – because it had been very much ‘The wheels are beginning
to fall off pharmacy and it’s getting pretty boring’. So pursuing that as
part of CE has given me a whole new professional focus on pharmacy.”
“I’ve actually completed a couple of speciality courses as well.
One of those I did a few years ago was asthma – 4–5 years ago. It
was perhaps a bit too premature for the time in that the last page was
basically doing a medication plan which was not in vogue back then – so
it didn’t quite gel.”
“Irrespective of what the doctors think, we are the drug experts. If
the government capitalise on that, then there would be more incen-
tive for pharmacists to go out and extend their knowledge further.”
“The problem is that pharmacy is linked to the provision of drugs
and there are certain areas [of practice] which are difficult to provide
IJPP.book Page 316 Thursday, November 1, 2007 6:55 PM
316 The International Journal of Pharmacy Practice, December 2007
for consumers because pharmacists, in general, are not remunerated
for it. It’s almost like an add-on service because we are all nice
people and we want to do the best by the community.”
Good patient outcomes were identified by a number of partic-
ipants as the primary desired consequence of CE, and also the
most rewarding aspect of pharmacy practice. The difficulty
cited with community pharmacy practice in this regard was
that pharmacists often did not get to observe these patient out-
comes owing to the episodic nature of the practitioner–client
relationship:
“One of the frustrating things about the community work you do is
that you spend a lot of time solving people’s problems when they
come and ask you a question. But you rarely get feedback to say that
that information was great or worked – because they don’t come
back specifically to tell you. But when they do come back and say;
‘That rash I had last week – well, it’s gone!’ – that’s really
rewarding.”
Increased confidence
The paucity of objective clinical outcomes perhaps adds to
the importance of other stated beneficial effects of CE. Partic-
ipants repeatedly referred to the importance of ‘confidence’
that resulted from attendance – both in terms of being able to
advise patients correctly, in terms of being able to make a
meaningful contribution to their medical colleagues, and in
terms of maintaining a general sense of professionalism:
“Any increase in your knowledge gives you more confidence in
what you’re doing and gives you more awareness of what’s going on
around you clinically and so on.”
“No matter how you feel about a seminar or meeting – whether it
was successful or not successful, I think that the more confidence
that you can come away with the better. We gain confidence, we gain
knowledge. We might not see it at the end of the day but in our over-
all practice I think it shines through well.”
Opportunity for professional interaction
An additional perceived benefit from attendance-based CE
was the opportunity to interact with the profession. This was
mentioned particularly by the focus group of younger phar-
macists as a means of assimilating into professional net-
works, discussing practice issues with peers, and more
generally in rural areas as a way of maintaining a network of
peers to establish consensus on various issues:
“Certainly in the rural areas where you might be a sole pharmacist
in the town, people thoroughly enjoy having a meeting with other
pharmacists from other areas and just chatting about drug [issues].
So, it may not be the content of the education that’s important but it’s
just that they can get out and talk to other pharmacists.”
Discussion
This study was able to identify several substantive issues,
positive and negative, relating to the professional environ-
ment of community pharmacists, which are capable of modi-
fying the applicability and value of CE from the perspective
of practitioners. Such findings strongly corroborate the
principles described by Holland and Nimmo’s theoretical
model for change in pharmacy practice,11 and also the obser-
vations of other healthcare settings.2–4,12 While the findings
are valid as an exploration of issues, the generalisability of
findings is limited because of the nature of the participants.
These particpants volunteered to participate in this research
and were therefore likely to be motivated towards undertak-
ing CE, and very probably more predisposed towards main-
taining professional standards and innovations such as the use
of CPD portfolios. Perhaps unsurprisingly, research has
shown pharmacists who actively engage with CE to be more
favourably disposed towards it.8 Therefore this study may not
accurately reflect the views of pharmacists who are less moti-
vated to engage in CE, and possibly other groups within the
profession. Equally, this study related specifically to the
experiences of pharmacists involved in Australian primary
care, and so the perspectives of hospital and other pharma-
cists were not sought or considered.
Pharmacists indicated that accreditation bodies can play an
important part in creating a suitable environment for practice-
based outcomes. This would be achieved by managing the
co-ordination of CE activities and their promotion to pharma-
cists, by working with pharmacists to facilitate greater under-
standing of the professional development process and
requirements, and by exercising legislative powers where
necessary to ensure maintenance of professional competencies
and standards. This suggested collaborative approach is very
much in keeping with the adult learning principle of maintain-
ing an environment of mutual respect.13 Consultations during
the UK experience of introducing portfolio-based accreditation
also indicated a great value in having a collaborative and facil-
itated approach to its implementation.14 Competency at under-
taking medication reviews appears to be a significant driver of
desire to undertake CE and CPD among participants. The cur-
rent dearth of formal recognition or remuneration for many
other enhanced primary care services in community pharmacy
may be hindering professional development.15 Research has
demonstrated the effect of financial incentives as a means of
influencing the practices of doctors;16,17 it may be that phar-
macists are reluctant to invest time and resources into CE for
which there is limited scope of application in practice due to a
lack of financial remuneration. Wider delivery of chronic disease-
management programmes in particular might provide more
meaningful, objective and patient-focused indicators of
performance in practice, thus reducing reliance on proxy mea-
sures of CE benefit such as self-confidence and increased drug
knowledge. The burdensome dispensing load of many Austral-
ian community pharmacists may also impede the ability to
convert educational experiences into practice outcomes.15
The substantial costs of CE incurred by pharmacists may
reduce the effectiveness of delivery models for a number of
reasons. Evidence from general practice suggests that this
encourages ad hoc uptake of education based on what is avail-
able for an acceptable price to participants, with less reference
to their educational needs;18 this reduces the relevance and
applicability of CE. Low affordability may encourage a reli-
ance on industry-subsidised and industry-provided education
whose merits and motives have been questioned,19,20 hence the
importance of government funding for independent sources of
drug information such as the NPS in Australia. Even increased
 IJPP.book Page 317 Thursday, November 1, 2007 6:55 PM
December 2007, The International Journal of Pharmacy Practice
funding of NPS educational activities is not a complete solu-
tion, and it needs to be part of an overall strategy. Selective
governmental funding of CE by organisations with a particular
mandate will possibly have the following effects:
• the absence of a holistic approach to CE (for example,
pharmacists are unlikely be taught about interpersonal
counselling skills by organisations dedicated to rational
prescribing)
• professional bodies, whose CE revenue often cross-
subsidises policy and advocacy roles, may find them-
selves unable to compete for members with subsidised
organisations without ancillary roles or associated costs.21
Indeed, the existence of multiple CE providers may be creat-
ing diseconomies of scale in CE provision and contributing to
a lack of affordability. Therefore it is essential that all con-
cerned stakeholders collaborate to ensure that CE is organised
in a manner that guarantees affordability and a needs-driven
approach.
It is interesting to note the value placed on attend-
ance-based CE by some rural and newly qualified pharmacists
as a means of developing and maintaining peer networks
within the profession. A survey of Flemish pharmacists also
found this to be a moderately motivating factor for
attendance.10 The actual formation of such networks may be
important for professional development because peer-assisted
learning has been shown among pharmacists to facilitate faster
diffusion of innovation and have a substantial role in shaping
professional attitudes towards competencies and professional
development.22 We should be particularly mindful of this need
to retain peer engagement as the profession increasingly uti-
lises distance-learning options as a solution to poor CE access
in rural areas.23–25
Conclusion
There are numerous factors relating to the broader profes-
sional environmental which appear to have an impact on the
relevance, applicability and effectiveness of CE models in
pharmacy practice. These relate especially to the reaccredita-
tion system in place, to the community pharmacy work set-
ting, and to the degree of collaboration between all
stakeholders in the planning, promoting and funding of CE.
The introduction of professional portfolio assessments by
accreditation authorities and the development of cognitive
pharmacy services may act as motivation for pharmacists to
undertake more effective CE.
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