A competency framework for clinical pharmacists and heart failure

Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC)

Implantable devices form an integral part of the management of patients with heart failure (HF) and provide adjunctive therapies in addition to cornerstone drug treatment. Although the number of these devices is growing, only few are supported by robust evidence. Current devices aim to improve haemodynamics, improve reverse remodelling, or provide electrical therapy. A number of these devices have guideline recommendations and some have been shown to improve outcomes such as cardiac resynchronization therapy, implantable cardioverter-defibrillators and long-term mechanical support. For others, more evidence is still needed before large-scale implementation can be strongly advised. Of note, devices and drugs can work synergistically in HF as improved disease control with devices can allow for further optimization of drug therapy. Therefore, some devices might already be considered early in the disease trajectory of HF patients, while others might only be reserved for advanced HF. As such, device therapy should be integrated into HF care programmes. Unfortunately, implementation of devices, including those with the greatest evidence, in clinical care pathways is still suboptimal. This clinical consensus document of the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) describes the physiological rationale behind device-provided therapy and also device-guided management, offers an overview of current implantable device options recommended by the guidelines and proposes a new integrated model of device therapy as a part of HF care.

Multiprofessional heart failure self-development framework

OBJECTIVE

Heart failure remains a key public health priority across the globe. The median age of people with heart failure admitted to hospital in the UK is 81 years old. Many such patients transcend the standard interventions that are well characterised and evidenced in guidelines, into holistic aspects surrounding frailty, rehabilitation and social care. Previous published competency frameworks in heart failure have focused on the value of doctors, nurses and pharmacists. We aimed to provide an expert consensus on the minimum heart failure-specific competencies necessary for multiple different healthcare professionals, including physiotherapists, occupational therapists, dietitians and cardiac physiologists.

METHODS

The document has been developed focussing on four main parts, (1) establishing a project working group of expert professionals, (2) a literature review of previously existing published curricula and competency frameworks, (3) consensus building, which included developing a structure to the framework with ongoing review of the contents to adapt and be inclusive for each specialty and (4) write up and dissemination to widen the impact of the project.

RESULTS

The final competency framework displays competencies across seven sections; knowledge (including subheadings on heart failure syndrome, diagnosis and clinical management); general skills; heart failure-specific skills; clinical autonomy; multidisciplinary team working; teaching and education; and research and development.

CONCLUSION

People with heart failure can be complex and have needs that require input from a broad range of specialties. This publication focuses on the vital impact of wider multidisciplinary groups and should help define the generic core heart failure-specific competencies needed to support future pipelines of professionals, who regularly interact with and deliver care for patients with heart failure.

Validation of the specialized competency framework for pharmacists in hospital settings (SCF-PHS): a cross-sectional study

OBJECTIVES

This study aimed to validate the content of the specialized competency frameworks for pharmacists working in hospital settings (hospital and clinical pharmacists) and pilot the frameworks for practice assessment.

METHODS

This online cross-sectional study was carried out between March and October 2022 among a sample of 96 Lebanese pharmacists working in hospital settings. The frameworks were distributed to full-time hospital and clinical pharmacists, who filled them out according to their role in the hospital.

RESULTS

Overall, the competencies were distributed over five domains for hospital pharmacists (fundamental skills, safe and rational use of medicines, patient-centered care, professional skills, and preparedness for emergencies), while for clinical pharmacists, competencies were distributed over seven domains (quality improvement, clinical knowledge and skills, soft skills, ability to conduct clinical research, ability to provide effective education, use information technology to make decisions and reduce errors, and emergency preparedness). Moreover, Cronbach alpha values were appropriate, indicating sufficient to high internal consistency. Pharmacists were highly confident in most competencies, with some exceptions related to research in emergency settings (data evaluation, research, and reporting).

CONCLUSIONS

This study could validate competency frameworks for clinical and hospital pharmacists, with the competencies and their respective behaviors showing an adequate construct analysis. It also identified the domains that require further development, i.e., soft skills and research in emergency settings. Both these domains are timely and needed to overcome the current practice challenges in Lebanon.

What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma?

AIM

To gain consensus on the patient assessment skills required by pharmacist independent prescribers prescribing immunomodulators in myeloma across National Health Service Scotland.

METHODS

This was a two-phase study which used nominal group technique to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks.

SETTING

This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network; West of Scotland Cancer Network and North Cancer Alliance.

SUBJECTS

Participants were invited from each cancer network (South East Scotland Cancer Network, West of Scotland Cancer Network and North Cancer Alliance) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists.

RESULTS

There were five participants in the nominal group technique. Twenty-two out of 31 patient assessment skills gained local consensus, seven patient assessment skills did not gain consensus and two patient assessment skills were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine patient assessment skills were included in the first-round questionnaire and 21 gained consensus. The remaining eight patient assessment skills were included in round two where seven did not achieve consensus and one achieved disagreement consensus.

CONCLUSION

This research outlines 21 patient assessment skills required for pharmacist independent prescribers to prescribe immunomodulators for myeloma patients according to haematology specialists in Scotland. Discussion on patient assessment skills without consensus showed that the pharmacist independent prescribers would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of pharmacist independent prescribers in Scotland. Some patient assessment skills could be transferrable for pharmacist independent prescribers prescribing systemic anti-cancer therapy for other haematological malignancies.

The standards of practice for delivery of polypharmacy and chronic disease medication reviews by general practice clinical pharmacists: a consensus study

Background General practice in the UK is experiencing a crisis. Greater multidisciplinary working is a potential solution. The new general practice contract in Scotland encourages this and includes a new pharmacotherapy service to be delivered by General Practice Clinical Pharmacists (GPCPs). Consensus is lacking for the standards of practice for delivery of pharmacotherapy medication reviews (which are polypharmacy and chronic medication reviews) as part of this service. Aim To identify and validate standards of practice for polypharmacy and chronic disease medication (pharmacotherapy level 3) reviews conducted by GPCPs. Method A two-phased mixed-methods consensus methodology was used. Phase 1: An expert group of GPCPs (n = 4) and clinical pharmacist managers (n = 2) responsible for delivering the pharmacotherapy service used a Modified Nominal Group Technique to generate potential standards. Phase 2: Two-round Delphi survey involving GPCPs with ≥ 1 year of experience of working in general practice (n = 159). Results The expert group identified 44 potential standards of practice for polypharmacy and chronic disease reviews. Practicing GPCPs indicated during the Delphi phase that the 44 standards were applicable to practice. The standards of practice covered seven main categories: skills, environment, qualifications, qualities and behaviours, knowledge, process and experience. Conclusion Practicing GPCPs indicated that the standards identified by the expert group are acceptable and valid for current practice and the delivery of polypharmacy and chronic medication reviews. The application of these standards to practice may help GPCPs and general practices to ensure equitable delivery of patient care.

Stakeholder Engagement in Competency Framework Development in Health Professions: A Systematic Review

Competency framework development in health professions has downstream implications for all relevant stakeholders, from the professionals themselves, to organisations, and most importantly end users of services. However, there is little guidance related to what stakeholders might be involved in the competency development process, and when. This review aimed to systematically review literature related to competency framework development methodology in health, to identify the breadth and purpose of key stakeholders commonly involved in the process. Studies were identified using five electronic databases (MEDLINE, PubMed, CINAHL, EMBASE, and ERIC) and a search of websites of organisations involved in curriculum or regulation using keywords related to competency frameworks. The total yield from all databases was 10,625 results, with 73 articles included in the final review. Most articles were from Australia (30%) and were conducted in the nursing (34%) profession. Unsurprisingly, practitioners (86%) and academics (75%) were typically engaged as stakeholders in competency framework development. While many competency frameworks were described as patient-focused, only 14 (19%) studies elected to include service users as stakeholders. Similarly, despite the multi-disciplinary focus described in some frameworks, only nine (12%) studies involved practitioners from other professions. Limiting the conceptualisation of competence to that determined by members of the profession itself may not provide the depth of insight required to capture the complexity of healthcare and address the needs of important stakeholder groups. Future methodology should attempt to engage a variety of relevant stakeholders such as external health professions and the community to match professional education to health service demands. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=128350.

What are the competency requirements for clinical pharmacist verification of systemic anti-cancer therapy (SACT) prescribed within a clinical trial? A consensus study

BACKGROUND

Since 2005 it has been a legal requirement in Scotland to have a suitably trained pharmacist verify SACT prescriptions. Published information for verification of SACT does not currently cover SACT prescribed within a clinical trial and the additional knowledge this requires. This poses the question of how pharmacists are deemed suitably trained to competently verify SACT prescribed within a clinical trial to ensure patient safety and service efficiency.

AIM

To determine and gain consensus on the competency requirements for clinical pharmacist verification of SACT prescribed within a clinical trial.

METHOD

A two stage process was adopted. Firstly, a Nominal Group Technique (NGT) was conducted with a multi-disciplinary expert panel (n = 7) from National Health Service (NHS) Lothian, part of the South East Scotland Cancer Network (SCAN). Secondly, a national survey was distributed to expert cancer care pharmacists with experience in clinical trial verification across NHS Scotland (n = 86).

RESULTS

Of the 28 competencies proposed, 100% achieved consensus and were deemed important by the expert panel during the NGT. From the national survey, 26 (92.9%) of the competencies achieved national agreement and were considered transferable across Scotland. The final national competencies were split into four categories: general trial background (n = 13); calculations, laboratory results and toxicity assessments (n = 7); administration details (n = 3); prescription and patient details (n = 3). Based on the themes identified during the NGT the final national competencies were further split into two suggested complexity levels; Level 1 (core) and Level 2 (advanced).

CONCLUSION

The competency requirements for clinical pharmacist verification of SACT prescribed within a clinical trial were defined for national use across Scotland. The competencies were split into four categories and two complexity levels. Further work will be required to identify training requirements, develop a training programme to support these and to determine how these competencies should be assessed. In addition, further work could be undertaken to develop a United Kingdom wide competency framework based on the results of this study.

The development, validity and applicability to practice of pharmacy-related competency frameworks: A systematic review

BACKGROUND

Global reforms in the education of health workers has culminated in the implementation of competency-based education and training (CBET). In line with the CBET model, competency frameworks are now commonplace in the health professions. In pharmacy, these frameworks are used to regulate career entry, benchmark standards of practice and facilitate expertise development.

OBJECTIVE

This systematic review assessed the development, validity and applicability to practice of pharmacy-related competency frameworks.

METHOD

PubMed/Medline, CINAHL, Embase, ERIC, Scopus, ProQuest and PsycINFO electronic databases were searched to identify relevant literature. Additional searching included Google Scholar, electronic sources of grey literature, and the Member Organisation websites of the International Pharmaceutical Federation (FIP). The findings of this review were synthesised and reported narratively. The review protocol is registered on PROSPERO with reference number CRD42018096580.

RESULTS

In total, 53 pharmacy-related frameworks were identified. The majority (n = 38, 72%) were from high income countries in Europe and the Western Pacific region, with only three each from countries in South East Asia (SEA) and Africa. The identified frameworks were developed through a variety of methods that included expert group consultation used alone, or in combination with a literature review, job/role evaluation, or needs assessment. Profession wide surveys and consensus via a nominal group, Delphi, or modified Delphi technique were the primary methods used in framework validation. The competencies in the respective frameworks were generally ranked relevant to practice, thereby confirming validity and applicability. However, variations in competency-related terminologies and descriptors were observed. Disparities on perception of relevance also existed in relation to area of practice, length of experience, and level of competence. For example, pharmaceutical care competencies were typically ranked high in relevance in the frameworks, compared to others such as the research-related competencies.

CONCLUSION

The validity and applicability to practice of pharmacy-related frameworks highlights their importance in competency-based education and training (CBET). However, the observed disparities in framework terminologies and development methods suggest the need for harmonisation.

The cardiology training needs of general practice-based pharmacists

OBJECTIVES

As the role of the general practice clinical pharmacist (GPCP) evolves, there has been a shift towards patient-facing roles across multiple conditions. This study aimed to measure the self-reported cardiology training needs of GPCPs.

METHODS

An online survey was developed. Participants were shown a list of statements on cardiac conditions and medication across seven sub-domains. Participants self-reported their knowledge against each statement using a Likert Scale. Participants were considered to require training in that topic where they had 'disagreed', 'strongly disagreed' or expressed a 'neutral' rating in ≥3/7 areas. Participants were shown a list of single statements around cardiology test result knowledge and clinical assessment skills. Respondents who 'disagreed', 'strongly disagreed' or declared a 'neutral' position with the statement were judged to need training in that topic.

KEY FINDINGS

Seventy-three out of 135 (54%) GPCPs responded. Acute coronary syndrome had the highest training requirement (38/73, 52%) within conditions. Fifty-nine out of 73 (81%) required training on sacubitril/valsartan and 57/73 (78%) with ivabradine. Fifty-four out of 73 (74%) and 44/73 (60%) required training on how to interpret natriuretic peptides and troponin, respectively. Fifty-nine out of 73 (81%), 48/73 (66%) and 55/73 (75%) required training on interpreting ECG, echocardiogram and coronary angiography, respectively. Reduced length of experience in general practice (<2 years) was commonly associated with increased training needs.

CONCLUSIONS

There are areas of unmet cardiology training needs within GPCPs that require further support. As the GPCP role evolves, discussion is needed with national pharmacy stakeholders to decide how to incorporate this learning into routine training programmes.

The effectiveness and impact on performance of pharmacy-related competency development frameworks: A systematic review and meta-analysis

BACKGROUND

Competency frameworks for education, training and development are widely used in the health professions, including pharmacy. Published studies suggest that competency frameworks have an impact on professional performance. Professional performance that is consistent with up-to-date knowledge and skills influences health care quality and patient safety. This review assessed the effectiveness of competency frameworks in facilitating improvement in pharmacists' performance.

METHOD

PubMed/Medline, CINAHL, Embase, ERIC, PsycINFO and Scopus electronic databases were searched to identify relevant literature. The findings of the included studies were synthesised qualitatively, and via a meta-analysis. The meta-analysis evaluated the odds of improved competency behaviour as a proxy measure of impact on pharmacists' performance. Study quality was assessed using 12 criteria adapted from the EPPI-Centre guidelines v0.9.7. The protocol for this review is registered on PROSPERO with reference number CRD42018096580.

RESULTS

In total, nine interventional studies were identified for review. The review findings showed observable and significant improvement in pharmacists' performance when competency frameworks are used to appraise performance, identify knowledge gaps, and tailor learning activities. A meta-analysis that involved a total of 348 pharmacists undergoing repeat peer assessment showed pooled odds for improved competency behaviour of 4.41 (95% CI: 1.89-10.29, I² = 83%). Subgroup analyses showed pooled odds with corresponding 95% CI of 6.50 (1.77-23.97, I² = 77%) vs 2.95 (0.59-14.72, I² = 93%) for the studies that were conducted in countries within or outside Europe, respectively; 10.51 (3.73-29.62, I² = 24%) vs 2.39 (0.96-5.95, I² = 87%) for studies with reassessment conducted at ≤6 months from baseline, or more, respectively; 6.68 (1.63-27.45, I² = 88%) vs 2.80 (0.86-9.07, I² = 74%) for studies involving hospital or community pharmacists, respectively; and 2.80 (1.22-6.45, I² = 77%) for studies with low risk of bias.

CONCLUSION

These findings suggest competency frameworks facilitate improvement in pharmacists' performance; however, further evaluative studies are needed.

Development of pharmacy competency framework for the changing demands of Thailand's pharmaceutical and health services

Background

In Thailand, pharmacists are responsible for all activities to ensure access to medicines throughout pharmaceutical supply chain. Competency framework (CF) is an important guidance for professional development and workforce planning.

Objective

This study aimed to explore needs for pharmacy services in pharmaceutical supply chain and competencies of pharmacists to serve those needs. It was the first step for developing evidence-based pharmacy CF within the context of Thailand in 2026.

Methods

A qualitative method using in-depth interviews to gain rich data from practitioners and leaders in all area of practices. 99 key informants from 56 workplaces in Thailand were interviewed during January and March 2016. Data was transcribed verbatim, and thematic analysis was used. Competencies were extracted, followed by several rounds of group discussion among team members to develop an initial framework. The competencies and CF were presented, and recommendations were gained from professional leaders for refining the findings.

Results

The key informants agreed that pharmacist's works and responsibilities have gradually been drifted to support changes in healthcare and pharmaceutical systems. The upcoming pharmaceutical services call for higher standards of practice, larger number of personnel, and skillful pharmacists who have strong foundation in pharmaceutical knowledge as well as an ability to integrate knowledge into practices. Two sets of CFs were established. The general CF comprises five core domains: product focus, patient focus, healthcare system focus, community focus, and personal focus for self-improvement. These general competencies allow practitioners to perform basic professional tasks, including providing information, dispensing, and compounding. The service-specific competency is the integration of general competencies tailored into specific area of practice.

Conclusions

Regarding the professional goal to evolve pharmacists from generalists to specialists for providing higher quality of professional services, the pharmacists are required to demonstrate general competencies and service-specific competencies. The findings serve as the need-based evidence for developing a national CF for pharmacists in Thailand.

Professional development beyond foundation training: a study of pharmacists working in Scotland

Objectives

In Scotland, post-registration hospital pharmacists typically undertake a vocational foundation training programme. Beyond this, there are no mandatory structures for ongoing professional training. To support progression to a more advanced level, competency frameworks are increasingly being used. This study aimed to measure the self-reported competence of pharmacists against a relevant framework and to determine what support was required to enable further professional development.

Methods

An online survey was completed by pharmacists working across six acute hospital sites within NHS Greater Glasgow and Clyde who had completed foundation training between Jan 2013 and Jan 2018. Participants self-reported competency against the Royal Pharmaceutical Society's Advanced Practice Framework Advanced Stage 1 competencies and gave qualitative feedback through free-text questions.

Key findings

Twenty out of twenty-eight eligible pharmacists (71.4%) responded to the survey and three core areas requiring further support were identified: leadership, management and research. Participants reported that a strategic plan for professional development, more opportunities and managerial support were needed to help them develop these areas. Mentorship programmes and postgraduate qualifications were suggested as formats to support development.

Conclusion

Pharmacists working towards advanced practice reported high levels of competence in expert professional practice, collaborative working relationships and education, training and development. While these results are promising, additional support is likely to be needed to cultivate leadership, management and research skills. Future training strategies need to consider this imbalance if we are to achieve national and international workforce goals for the professional development of pharmacists.

Improving medication optimisation in left ventricular systolic dysfunction after acute myocardial infarction

Glasgow city has the highest cardiovascular disease (CVD) mortality rate in the UK. Patients with left ventricular systolic dysfunction after acute myocardial infarction represent a ‘high-risk’ cohort for adverse CVD outcomes. The optimisation of secondary prevention medication in this group is often suboptimal. Our aim was to improve the use and target dosing of ACE inhibitors (ACEI), angiotensin II receptor blockers (ARBs) and beta-blockers in such patients, through pharmacist-led clinics and cardiology multidisciplinary team collaboration. Retrospective audits characterised baseline care. Prospective pharmacist-led clinics were piloted and rolled out across seven hospitals and primary care localities over four Plan–Do–Study–Act cycles. ‘Hub’ and ‘spoke’ clinics utilised independent prescribing pharmacists with different levels of cardiology experience. Pharmacists were trained through a bespoke training programme—‘Teach and Treat’. Consultant cardiologists provided senior support and governance. Patients attending prospective pharmacist-led clinics were more likely to be prescribed an ACEI (or ARB) and beta-blocker (n=856/885 (97%) vs n=233/255 (91%), p<0.001 and n=813/885 (92%) vs n=224/255 (88%), p=0.048, respectively) and be on target dose of ACEI (or ARB) and beta-blocker (n=585/885 (66%) vs n=64/255 (25%), p<0.001 and n=218/885 (25%) vs n=17/255 (7%), p<0.001, respectively) compared with baseline. The mean dose of ACEI (or ARB) and beta-blocker was also higher (79% vs 48% of target dose, p<0.001% and 48% vs 33% of target dose, p<0.001, respectively) compared with baseline. Use of secondary prevention medication was significantly improved by pharmacist and cardiology collaboration. These improvements were sustained across a 4-year period, supported by a novel approach called ‘Teach and Treat’ which linked training to defined clinical service delivery. Further work is needed to assess the impact of the programme on long-term CVD outcomes.

Evaluation of discharge prescriptions for secondary prevention in patients with acute coronary syndromes in Iraq

Background:

Optimal prescribing of secondary prevention medications after acute coronary syndrome (ACS) events has been shown to reduce morbidity and mortality. However, it is unknown whether these medications are optimally prescribed at discharge from acute care in Iraq.

Objective:

To evaluate whether patients with ACS received optimal secondary prevention medications: antiplatelets, statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs), and beta-blockers at discharge from a cardiology unit, and to assess whether statins, ACEI/ARBs and beta-blockers were prescribed at target doses based on the American Heart Association/American College of Cardiology (AHA/ACC) guidelines.

Methods:

Observational retrospective cross-sectional study of patients with ACS admitted to a hospital in Baghdad and survived to discharge between May 2016 and January 2017. Patient-level data and secondary prevention medications at discharge were extracted from routine medical records. Optimal dosing was defined as ≥75%, moderate dosing as 50–74%, and low dosing as <50% of the target dose.

Results:

45.6% (200/439) of eligible patients were included in the study who were aged 25 to 90 years (mean 57.8 years) with 78.0% (156/200) being male. Of those included, 84.5% had a myocardial infarction and 15.5% unstable angina, and the length of hospital stay ranged from 1 to 29 days (median 4 days). In total, 53.5% of patients were prescribed all five secondary prevention medications at discharge, and after accounting for contraindications, 60.0% were treated according to AHA/ACC guidelines. The prescription rate of dual antiplatelet therapy, statins, ACEI/ARBs and beta-blockers was 92.5%, 94.5%, 69.5% and 87.0% respectively. Hypertension, diabetes mellitus and the prescription of oral nitrates were associated with the prescription of optimal secondary prevention therapy. Although 80.9% of patients were prescribed target doses of antiplatelets and statins, only 12.2% and 9.2% were prescribed target doses of ACEI/ARBs, and beta-blockers respectively.

Conclusions:

Approximately one in two patients received the recommended secondary prevention therapy. However, only a minority of patients were prescribed optimal doses of ACEI/ARBs and beta-blockers, in line with guidance. Quality improvement strategies should be implemented, which may include greater involvement of pharmacists within the cardiology multidisciplinary team.