Navigating Competence: Beyond the Flat Earth

1. Navigating competence:Beyond the flat earth, competency icebergs and career doldrums David Webb NZHPA Conference September 30, 2007

2. Never ascribe to malice that which can be adequately explained by incompetence Napoleon Bonaparte,1815

3. East and South East England

4. He came back….. From a patient’s point of view Professionals’ competence is not negotiable[BRI Inquiry] Technical competence is of key importance [Picker Institute] Round Earth

5. Fuzzy concepts • Competence • Overarching capacity • Competences • Functional, the what • Competencies • Qualities, the how

6. Professional competence Habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served Epstein and Hundert, 2002

7. National Occupational Standard

8. Competence approaches Reductive Shopping lists Job specific Central control Adequacy Generic/cognitive approaches Abstract Subject fragments Performance deficit Provider autonomy Isolated excellence Critical accounts

9. Competency iceberg Effective and persistent behaviour Knowledge Skills Abilities Values, attitudes and beliefs

10. Novice-to-expert Dreyfus & Dreyfus 1986 5 stage progression From adherence to intuitive grasp Reliable metric to identify expert? Reflective practice Schön 1983 Learning from experience Necessary and sufficient? Cause or effect? Alternative departures

11. Deployed Performance Experience Bundled Competencies Integration Developed Knowledge, Skills and Abilities Education and training Characteristics and Traits Innate Components of performance

12. McNamara Fallacy • First step • Measure what can easily be measured • Second step • Disregard what can’t be easily measuredor give it an arbitrary quantitative value • Third step • Presume what can’t be measured easily isn’t important • Fourth step • Say what can’t be measured easily doesn’t exist

13. Does it make a difference?

14. General Level Framework (GLF) McRobbie et al 2001

15. GLF structure

16. Performance improvement

17. Controlled trial 30 control pharmacists 74 intervention pharmacists Matched for gender, age, experience, qualifications Observations Baseline, month-6, month-12 Delivery of patient care Significant changes 25 behavioural indicators Evaluation of GLF in hospital Antoniou et al 2005

18. Performance attainment .7 .6 .5 .4 .3 Group Cumulative attainment active .2 control .1 0.0 Months 0 2 4 6 8 10 12 14 (log rank p=0.0048)

19. Community pharmacy I would like to thank you all for your help with this project. Without it I still wouldn’t have started my CPD ..identified areas for CPD. Helps to have competencies as a prompt...you need to know what you need to be able to do I think I was doing lots of the skills but never put them together into a sequence step by step to actually realise that was how I was working Mills PhD thesis 2007

20. 4.0 Intervention (n=69) Non-intervention (n=31) 3.5 patient carecluster (mean + 95% CI) Self-assessed performance in the delivery of 3.0 2.5 Baseline 4 months 12 months 8 months Performance improvement

21. Undergraduate & preregistration General post-registration Higher level Phase 1 Higher Level Phase 2 1 Advanced Practitioner Consultant Pharmacist General Level Advanced & Consultant Level Professional Development Frameworks Practice development model

22. Advanced/Consultant Level Framework • Development • Literature review • Expert and consensus development panels • ACLF design • 34 competencies in 6 clusters • Foundation, excellence & mastery • Premise • Attainment identifies level of practice • Generalisable Meadows et al 2004

23. Clusters Competencies Expert professional practice Expert skills and knowledge, Patient care responsibilities, Reasoning and judgement, Professional autonomy. Building working relationships Communication, Teamwork and consultation. Leadership Vision, motivation, governance, Strategy, innovation, Service development. Management Planning, performance, change, Priorities, resources, standards, Risk. Education, training, development Mentorship, role model, delivery, CPD, practice linkage, policy. Research and evaluation Critical evaluation, protocol review, Evidence creation, development, Supervision, partnerships.

25. Practice levels Specialist-in-training Experienced practitioner Leading-edge practitioner Evidence To substantiate assessment Sample (n=390) Cancer 69 Mental health 69 Critical care 36 Primary care 84 Paediatrics 53 MI 43 Other 36 Self assessment using ACLF

26. Mastery Excellence Leading-edge respondents Expert professional practice Expert skills and knowledge, Patient care responsibilities, Reasoning and judgement, Professional autonomy. Building working relationships Communication, Teamwork and consultation. Leadership Vision, motivation, governance, Strategy, innovation, Service development. Management Planning, performance, change, Priorities, resources, standards, Risk. Education, training, development Mentorship, role model, delivery, CPD, practice linkage, policy. Research and evaluation Critical evaluation, protocol review, Evidence creation, development, Supervision, partnerships.

27. Excellence Foundation Experienced practitioner respondents Expert professional practice Expert skills and knowledge, Patient care responsibilities, Reasoning and judgement, Professional autonomy. Building working relationships Communication, Teamwork and consultation. Leadership Vision, motivation, governance, Strategy, innovation, Service development. Management Planning, performance, change, Priorities, resources, standards, Risk. Education, training, development Mentorship, role model, delivery, CPD, practice linkage, policy. Research and evaluation Critical evaluation, protocol review, Evidence creation, development, Supervision, partnerships.

28. Competency profiles

29. Aims Ensure highest level of expertise is available to those patients who need it Strengthen professional leadership Retain experienced pharmacists in practice Responsibilities Expert practice Research, evaluation and service development Education, mentoring and overview of practice Professional leadership Consultant pharmacist posts

30. Practice beyond initial registration • Annotation to the professional register • Supplementary and independent prescribers • 1,241 SPs • 142 IPs • Regulation of advanced practice? • Risk perspectives? • Systems for recognition of expertise • Approval of consultant pharmacist posts • Accreditation of pharmacists with special interests

31. Training infrastructure College system Undergraduate & preregistration General post-registration Higher Level Phase 2 PG enabling programmes General Diploma Masters Adv Practice Research Degree Pharmacist development model Higher level Phase 1 1 Consultant Pharmacist Advanced Practitioner GLF ACLF PharmacistRegisteredband 6 Pharmacist Specialist band 7 Pharmacist Advanced band 8a/b Consultant Pharmacist band 8b/d

32. Training infrastructure College/faculty system Undergraduate & preregistration General post-registration Higher Level Phase 2 PG enabling programmes General Diploma Masters Adv Practice Research Degree Pharmacist development model Higher level Phase 1 1 Consultant Pharmacist Advanced Practitioner GLF ACLF PharmacistRegisteredband 6 Pharmacist Specialist band 7 Pharmacist Advanced band 8a/b Consultant Pharmacist band 8d/d

33. Performance assessment Assessment Strategies Does Performance Mini-CEX, mini-PAT, CbD Experience Shows OSCE, simulation Competencies Integration Knows Knowledge, Skills and Abilities MCQ, MEQ Education and training Characteristics and Traits after Miller 1990

34. Training infrastructure Undergraduate & preregistration General post-registration Higher Level Phase 2 PG enabling programmes General Diploma Masters Adv Practice Research Degree Pharmacist development model College system Higher level Phase 1 1 Consultant Pharmacist Advanced Practitioner GLF ACLF PharmacistRegisteredband 6 Pharmacist Specialist band 7 Pharmacist Advanced band 8a/b Consultant Pharmacist band 8d/d

35. Curriculum design

36. Land ahoy • Professional coherence • Higher level practice in community pharmacy • Careers in research, teaching and management • Higher level practice • Consistent and equitable recognition • Clarity for, and safety of, the public • Infrastructure • To bridge education and service provision • General professional development for all?

37. Graham Davies Ian Bates Denise Farmer Duncan McRobbie Lizzie Mills Sotiris Antoniou Laura Obiols Naomi Meadows Roger Fernandes With thanks to DH Steering Group, GHP, UKCPA, CPP and E&SE England Specialist Pharmacy Services. Members of Specialist/Practice Interest Groups and CPP Faculties Funding NWL WDC, NSC WDD and Department of Health (scoping higher level practice)

38. Antoniou S, Webb DG, McRobbie D et al. A controlled study of the general level framework: results of the South of England competency study. Pharmacy Education 2005: 5: 201-7 Dreyfus HL, Dreyfus SE. Mind over Machine. Oxford: Blackwell, 1986 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002; 287: 226-235 McRobbie D, Webb DG, Bates I, et al. Assessment of clinical competence: designing a competence grid for junior pharmacists. Pharmacy Education 2001; 1: 67-76 Meadows N, Webb DG, McRobbie D et al. Developing and validating a competency framework for advanced pharmacy practice. Pharm J 2004; 273: 789-792 Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65(suppl): S63-S67 Schön DA. The Reflective Practitioner: how professionals think in action. London: Temple Smith, 1983 Downloads: www.codeg.org www.postgraduatepharmacy.org Bibliography