the pharmacist registration examination · pdf filethe pharmacist registration examination...

The Pharmacist Registration Examination

Rebecca Elvey (BA, MA (Econ)) Research Associate

Samuel D Jee (BSc) Research Assistant Penny Lewis (PhD, MRPharmS) Research Associate Harsha Parmar (MRPharmS) Teaching Fellow Ellen I Schafheutle (PhD, MRes, MSc, MRPharmS) Lecturer in Law & Professionalism in Pharmacy Mary Tully (PhD, MRPharmS) Clinical Senior Lecturer Sarah Willis (BA, MA) Research Fellow Jason Hall (PhD, MSc, BSc, PGCE, MRPharmS) Senior Lecturer

School of Pharmacy and Pharmaceutical Sciences 1st

The University of Manchester Floor Stopford Building

Oxford Road Manchester M13 9PT

Correspondence Dr Jason Hall [email protected] 0161 275 2720

mailto:[email protected]�

The Pharmacist Registration Examination – September 2010 i

Abstract

The aim of this study was to review the registration examination and compare

it with alternative methods of assessing professional competence. We carried

out the following three pieces of work. Firstly, we reviewed the procedures for

registration of selected other health professionals (optometry, medicine,

dentistry) within Great Britain to determine the range of methods employed for

assessing suitability for registration. Secondly, we reviewed the procedures

for registration of pharmacists in a selection of English speaking countries

outside Great Britain to determine the range of methods employed for

assessing suitability for registration. Thirdly, we mapped out the registration

examination questions against the pre-registration syllabus.

There were differences between the professions and differences between

countries in terms of the training and assessment of candidates seeking to

obtain professional registration. Pharmacy was the only profession in our

review with formal written examinations at the end of the postgraduate pre-

registration training period whilst the other professions relied on practice

based assessments to a greater extent. In pharmacy in GB the supervisor and

assessor functions were not separated which was not the case in most other

professions or countries. Our assessment of the registration examination

suggests that it particularly focuses on the assessment of knowledge which

means that particular emphasis and importance rests on the regular

performance reports to assess a broad range of competences and

understanding.

The Pharmacist Registration Examination – September 2010 ii

Acknowledgements We would firstly like to give thanks to the General Pharmaceutical Council

(GPhC)/Royal Pharmaceutical Society of Great Britain (RPSGB) who funded

this research and provided us with pharmacy registration examination data.

This research started in May 2010 when the RPSGB was the regulator in

Great Britain and was completed after 27th

September 2010 when the GPhC

became the pharmacy regulator.

Many thanks go to Professor Val Wass from the School of Medicine at Keele

University (formerly from the School of Medicine at the University of

Manchester) for her advice about registration requirements in medicine and

other healthcare professions in Great Britain and abroad.

We are also very grateful to our expert panel consisting of:

• Ian Smith – Boots Teacher Practitioner University of Manchester; Boots

Pre-registration coordinator for north of England

• Alison Littlewood – Lead Pre-registration Facilitator, NHS north west;

• Professor Chris Dickinson – Optometry Programme Director, University

of Manchester;

• Andrea Owen – University Medical Assessment Partnership (UMAP).;

and

• Iain Mackie – Head of School of Dentistry, University of Manchester

The expert panel offered their time and expertise about registration

requirements in pharmacy, medicine and other healthcare professions in

Great Britain and abroad. We would particularly like to thank Ian Smith and

Alison Littlewood for helping members of the research team with the

registration examination mapping exercises.

The Pharmacist Registration Examination – September 2010 iii

Contents 1 Introduction ............................................................................................... 1

1.1 Membership of a profession ................................................................ 1

1.2 Membership of the pharmacy profession ............................................ 2

1.3 Aims of this study ................................................................................ 3

1.4 Layout of this report ............................................................................ 4

2 Comparing registration of pharmacists in GB with registration requirements

for other GB healthcare professions and for pharmacists abroad .................... 5

2.1 Introduction ......................................................................................... 5

2.2 Method ................................................................................................ 5

2.3 Results ................................................................................................ 7

2.3.1 Pharmacy ..................................................................................... 7

2.3.2 Optometry .................................................................................. 12

2.3.3 Medicine ..................................................................................... 16

2.3.4 Dentistry ..................................................................................... 22

2.3.5 Summary/comparison of the different professions ..................... 28

2.3.6 Australia ..................................................................................... 32

2.3.7 New Zealand .............................................................................. 37

2.3.8 Canada ....................................................................................... 38

2.3.9 USA ............................................................................................ 43

2.3.10 Summary/comparison of the different countries ...................... 48

3 The effectiveness of the pharmacist registration examination ................ 51

3.1 Introduction ....................................................................................... 51

3.2 Method .............................................................................................. 51

3.3 Results .............................................................................................. 53

3.3.1 Closed book examination paper ................................................. 53

3.3.2 Open book examination paper ................................................... 57

3.3.3 Summary/Comparison of the closed and open book papers ...... 62

4 Discussion .............................................................................................. 64

4.1 Registration requirements for other healthcare professions in the UK.. 64

4.2 Registration requirements for pharmacists in selected other countries .66

The Pharmacist Registration Examination – September 2010 iv

4.3 The effectiveness of the pharmacist registration examination:

mapping of examination questions against syllabus & knowledge versus

understanding ............................................................................................. 68

5 Recommendations .................................................................................. 72

6 References ............................................................................................. 73

Appendices 7.1 Appendix 1: Comparison of registration requirements for healthcare

professionals in GB ........................................................................................ 77

7.2 Appendix 2: Comparison of registration requirements for pharmacists

in GB and abroad ........................................................................................... 80

7.3 Appendix 3: Coding of the registration examination syllabus ............ 82

7.4 Appendix 4: Mapping of closed and open book registration

examination questions to knowledge and/or understanding and examination

syllabus .......................................................................................................... 88

List of tables Table 3.1: Number of times syllabus entries were assessed in the closed

book examination ........................................................................................... 54

Table 3.2: Number of times syllabus entries assessed knowledge and/or

understanding (number of questions) in the closed book ............................... 57

Table 3.3: Number of times syllabus entries are assessed in the open book

examination .................................................................................................... 59

Table 3.4: Number of times syllabus entries assessed knowledge and/or

understanding (number of questions) in the open book ................................. 61

The Pharmacist Registration Examination – September 2010 1

1 Introduction

1.1 Membership of a profession

Members of a profession tend to have a monopoly on their area of expertise

or practice and many have a restricted title. Membership of a profession may

bring a number of rewards such as job security, above average salary,

interesting work and respect from society. Such benefits make membership

attractive and there is usually competition1

for entry.

Historically, members of professions were generally keen to preserve the

social standing and reputation of their profession and sought to guard entry to

their profession.2

Entry to a profession was usually via the successful

completion of a period of study at a higher education institution on an

approved programme of study and in some cases following a period of

apprenticeship and further assessment.

More recently, the motive for controlling entry to the health professions has

been to promote health, safety and wellbeing of patient and the public.3 Many

of the health professions either have their own regulator, or are jointly

regulated by the Health Professions Council (HPC), which deal with entry to

their profession. Within the UK the Council for Healthcare Regulatory

Excellence (CHRE) is the organisation that oversees the regulators for nine

health professions including medicine, dentistry, optometry and pharmacy.4

They review how the health profession regulators carry out a range of

activities including education and training, fitness to practise and registration.


1.2 Membership of the pharmacy profession

To become a pharmacist in Great Britain (GB), it is a requirement to

successfully undertake a four-year full time Master of Pharmacy (MPharm)

degree course in a UK university. This is followed by 52 weeks of pre-

registration training, usually in one of the main pharmacy sectors (i.e.

community or hospital), but sometimes split between more than one sector

(e.g. between the pharmaceutical industry and hospital pharmacy). Besides

entrance to the pre-registration year via an MPharm degree, a one-year

Overseas Pharmacists Assessment Programme (OSPAP) diploma is also in

place and is offered at five schools of pharmacy in GB. The latter needs to be

passed by internationally trained pharmacists from outside the European

Economic Area (EEA) before they are eligible to enter pre-registration training.

All pre-registration applicants have to sign declarations of good conduct and

good health, agree to abide by the Standards of conduct, ethics and

performance5

(previously the RPSGB Code of Ethics) and pay the appropriate

fee.

The pre-registration training itself involves a minimum of 26 weeks (and

usually 52 weeks) of supervised practice in employment in a clinical

(pharmacy practice) environment. Outcomes of training are assessed using

two distinct methods. Firstly, trainees must demonstrate competence in

eleven areas of practice by providing evidence that they have complied with

performance standards related to these eleven areas.6

A pre-registration tutor

acts as supervisor and also assessor for compliance with the standards in a

series of assessments made during the training year (at 13, 26 and 39 weeks)

leading up to a final assessment at the end of the year. The second aspect of

assessment is the formal registration examination, a uniform test for all pre-

registration trainees, set centrally by the General Pharmaceutical Council

(GPhC), and previously the Royal Pharmaceutical Society of Great Britain

(RPSGB). A trainee cannot sit the examination until their tutor has signed

them off as fit to undertake the examination at the 39 week assessment and

provided the trainee has completed at least 45 weeks of pre-registration

training.


The requirement for pharmacists to undertake a 12-month period of pre-

registration training prior to registration has been in place for a long time. The

system of pre-registration competencies and the completion of a related

portfolio, as well as a written exam, has been in place for a number of years.

Nevertheless, we have little insight into the effectiveness of current

arrangements for in practice training and assessment, or the effectiveness of

the written exam. Nevertheless, similar arrangements for in practice training

are in place in the education of other healthcare professions, or pharmacists

in other countries. Further insight may also be gained from exploring how

current assessment maps against the existing examination syllabus.6

1.3 Aims of this study

The aim of this study was to review the registration examination and compare

it with alternative methods of assessing professional competence

In order to meet the research aims we carried out the following pieces of work

that together contribute to this report:

• A review of the procedures for registration of selected other health

professionals (optometry, medicine, dentistry) within Great Britain to

determine the range of methods employed for assessing suitability for

registration

• A review of the procedures for registration of pharmacists in a selection

of English speaking countries outside Great Britain to determine the

range of methods employed for assessing suitability for registration

(section 2)

• Mapping out examination questions against the pre-registration

syllabus1

(section 3)

1 Previously this was the preregistration standards, but this was not feasible (c.f. section 2)


1.4 Layout of this report

As there were two main parts to this study each part is presented in turn, with

an individual ‘introduction and method’, ‘results’, and ‘summary’ section.

Following this an overall discussion highlights some of the key issues raised

from the findings from each part of the study. Based on these findings,

recommendations related to assessments are then made.


2 Comparing registration of pharmacists in GB with registration requirements for other GB healthcare professions and for pharmacists abroad

2.1 Introduction

There are a range of healthcare professions in GB, each having different

requirements set out for prospective registrants to fulfil so they can be placed

on the register. Differences also exist in registration requirements for

pharmacists in other countries. It is useful to gain insight into these different

requirements, as they may shed light on which aspects of, or approaches to,

training, supervision and assessment the registration bodies for those

professions or countries consider to be particularly effective. This could inform

potential changes

to achieve a more effective means of assessment and

registration in GB pharmacy.

This part of the study aims to:

• compare the methods used for assessing the suitability for registration

as a pharmacist in GB, with methods used by optometry, medicine and

dentistry in GB;

• compare the methods used for assessing the suitability for registration

as a pharmacist in GB to a selection of English speaking countries with

similar systems/policies outside GB: Australia, Canada, New Zealand

and the USA.

2.2 Method

For each profession, and for each country, we reviewed the training

programmes and assessment methods in place for each profession prior to

full registration as a health professional, in order to answer the following

questions:


• Who conducts the assessment?

• Where is it assessed?

• When is it assessed?

• What is assessed?

• How is it assessed (by what methods)?

Numerous internet searches were carried out to identify relevant websites

relating to the regulatory and professional bodies and training/educational

organisations (such as professional societies and colleges) of health care

professions in Great Britain as well as identifying similar organisations for the

pharmacy profession abroad. Some of these websites included:

• The Royal Pharmaceutical Society of Great Britain (prior to split):

http://www.rpsgb.org

• General Optical Council: http://www.optical.org/

• General Medical Council: http://www.gmc-uk.org/

• General Dental Council: http://www.gdc-uk.org/

• Australian Pharmacy Council: http://www.pharmacycouncil.org.au/

• New Zealand Pharmacy Council:

http://www.pharmacycouncil.org.nz/cms_display.php

• The Pharmacy Examining Board of Canada:

(http://www.pebc.ca/EnglishPages/General/HomePage.html)

• National Association of Boards of Pharmacy in the USA:

http://www.nabp.net/

The websites were examined for documentation pertaining to registration

which mainly consisted of registration programme training curricula,

workbooks and similar materials. The documents were read and the relevant

information was extracted. Members of the expert panel summarised relevant

information regarding registration and helped identify relevant documents and

websites.

http://www.rpsgb.org/�

http://www.optical.org/�

http://www.gmc-uk.org/�

http://www.gdc-uk.org/�

http://www.pharmacycouncil.org.au/�

http://www.pharmacycouncil.org.nz/cms_display.php�

http://www.pebc.ca/EnglishPages/General/HomePage.html�

http://www.nabp.net/�


2.3 Results

This section reviews the different methods used to train and assess an

individual to prove that they are qualified to register to practise in their

discipline. Specifically, pharmacy in GB will be compared to optometry,

medicine and dentistry. A comparison table of the registration processes for

these professions is provided in appendix 1. This section of the report also

provides details about the different methods used, and requirement laid out,

for a pharmacist to register in a selection of other countries besides GB:

Australia, New Zealand, Canada and USA. A comparison table of the

registration processes of countries is available in appendix 2.

Findings for healthcare professionals including pharmacy To provide the main comparator, this section will begin by setting out the

requirements for registration as a pharmacist in GB.

2.3.1 Pharmacy

2.3.1.1 Basic training requirements and different types of registration

In the main, pharmacy undergraduate degree programmes consist of a four-

year Masters course, the MPharm, although a five-year sandwich course is

also available. Following attainment of the MPharm degree, pharmacy pre-

registration trainees undertake a one-year pre-registration post, most

commonly in either a community or hospital pharmacy practice setting, usually

with two weeks ‘cross sector’ experience. After successful completion of the

pre-registration year, and passing the required assessments, trainees can

apply for registration as a pharmacist with the GPhC.

2.3.1.2 Details of training and assessment methods

Information presented in this section was taken/adapted from the 2009/10

version of the pre-registration trainee workbook (previously available from the

RPSGB website) 2009/106, unless otherwise indicated. During the course of

this programme of work the GB pharmacy regulator changed from the RPSGB


to the GPhC. The most up to date version of the workbook is available from

the GPhC website7

. When referring to the current regulations reference will be

made to the GPhC and when a historical perspective is taken the RPSGB will

be referred to.

People involved in the assessment of pre-registration trainees

Pre-registration training can only be undertaken in premises approved by, and

registered with, the GPhC. Each pre-registration trainee is assigned to a pre-

registration tutor. The pre-registration tutor is the key contact for trainees

during their pre-registration year. The tutor assesses whether or not the

trainee has reached the standard of competence required and makes the final

decision as to whether the trainee is a fit and proper person to be registered.

Requirements for being a tutor include being:

• a practising pharmacist and have been working in the field of pharmacy

in which they wish to tutor for at least three years

• able to work for a minimum of 28 hours a week over a minimum of four

days with the trainee

In community pharmacy, for example, there is usually a one-to-one

relationship of tutor to trainee. In some training sites that employ several

trainees, there may not be enough pharmacists, who meet all of the criteria to

be tutors, to enable every trainee to have their own tutor. In these cases one

of the tutors or the pre-registration manager will take on the role of tutor for

more than one trainee.

Currently, the GPhC does not specify any compulsory training for tutors, but

states that tutors ‘have an ethical obligation to be adequately and

appropriately trained, prepared and experienced to take on the role’. GPhC

issues distance learning materials as part of the tutor workbooks and other

material sent to tutors. The materials also contain references to other sources

of information and guidance and tutors should follow these up. Most large


employers will also run in-house training for tutors. Some universities run

‘training for trainers’ courses (previously available from the RPSGB website).8

Besides the tutor, there are also other individuals that play a role in the

training of pre-registration trainees. In the workplace these are trainers and

mentors. The GPhC does not specify requirements for those fulfilling these

roles, but, as stipulated in the pre-registration trainee workbook:

• trainers are often pharmacists but may be other pharmacy personnel.

Trainers have the greatest input when a tutor has responsibility for

more than one trainee and when a trainee is working away from the

tutor's place or section of work (primarily this relates to different

sections of a hospital pharmacy or different parts of a hospital trust).

Trainers may then undertake some of the roles of the pre-registration

tutor;

• a mentor is a person who is able to guide and support the trainee in a

non-judgemental way, for example, a recently registered pharmacist or

a more experienced colleague. Trainees, along with their tutors, are

encouraged to identify a suitable person, either within the workplace or

elsewhere, to be their mentor.

2.3.1.3 Assessment – what is assessed and how

Skills and behaviours are assessed in the workplace by the pre-registration

tutor or trainer. Knowledge is assessed by satisfactory performance and

behaviour whilst in the workplace, and in the registration examination.

To successfully complete the pharmacy pre-registration year, trainees have to

demonstrate competence in the ‘pre-registration standards’. These standards

are set out in the pre-registration workbook. The performance standards are

grouped into three areas – personal effectiveness, interpersonal skills and

medicines & health. The standards can be assessed in any order and the

timing of assessments is agreed between the tutor and trainee. Trainees must

collect evidence which demonstrates their competence against each standard

and build up a portfolio of evidence. Evidence of the trainee’s competence


against each standard is then assessed by the tutor. There are three staged

assessments (every 13 weeks). The tutor acts as an assessor and completes

progress reports for each assessment, which are submitted to the GPhC.

Competence in the pre-registration standards is confirmed through the three

progress reports plus a ‘final declaration’ completed by the pre-registration

tutor.

Observation is the main method of assessment against the performance

standards. As stated in the pre-registration trainee workbook, there are

different types of observation that can be used:

• Formal observation – the assessor observes the trainee undertaking a

particular activity and then provides feedback. If performance is of the

required standard the assessor records this, if not, they will discuss

areas for improvement with the trainee. Trainees should be observed

on more than one occasion to ensure consistent performance.

Observation can be undertaken for a short period i.e. whilst

undertaking a particular task, or over a longer period i.e. over a week of

giving advice over the pharmacy counter, or of fielding queries in the

medicines information centre.

• Informal observation - tutors and others will observe trainees in the

workplace and can give the trainee feedback and highlight areas where

improvement is needed; this is an ongoing, formative process.

• Role play, case study, simulation – tutors, trainers or study day

facilitators can provide ‘mock’ situations for trainees to deal with.

Where the tutor is not involved, others can provide a report for the

portfolio. Video evidence showing how the trainee performs in certain

tasks e.g. preparing aseptic products, demonstrating how to use an

appliance may also be used.

In addition to observation, other forms of evidence are collected by trainees to

show how they meet the performance standards and are filed in the portfolio,


with an annotation to show which standards they relate to. The main forms of

evidence as noted in the pre-registration trainee workbook are:

• testimonials - statements provided by a person who has worked with

the trainee and observed their performance. Trainees are encouraged

to ask others who provide training for them when their tutor is absent,

to complete testimonials for the tutor to review;

• projects and assignments that the trainee can write up to show what

they did and what they learned in a certain area, as demonstration of

competence in that area;

• records of evidence – brief notes of work situations e.g. diaries or

notebooks of work experiences, conversations and so on that are

cross-referenced to the relevant performance standards;

• prior experience – e.g. a valid first aid certificate or a workbook/portfolio

from undergraduate work experience. Evidence from this source is

most likely to be appropriate for 'technical' areas;

• other documentation - examples of other evidence could include copies

of medicines administration records; copy of a problem prescription

with notes of action taken.

The pre-registration workbook does not specify what type of or how much

evidence is required for each competency, but states that trainees ‘probably

need to produce a minimum of five pieces of evidence for each standard’ to

satisfy the tutor of their competence. One piece of evidence, e.g. the record of

observation of a particular scenario, could be used to demonstrate

competence against more than one standard.

The registration examination

Besides performing adequately in accordance with the tutors’ performance

reports and subsequently being signed off, pre-registration trainees also have

to pass the registration examination. Trainees are eligible to sit the registration

examination after a satisfactory 39-week Progress report and after completing

45 weeks of training. The registration examination assesses knowledge and


understanding by asking candidates to analyse and evaluate practise-based

problems. There are two papers in the examination both of which use multiple

choice questions (MCQs). In the first paper candidates should attempt all 90

questions in 90 minutes and the examination is closed book. In the second

paper candidates should attempt all 80 questions in 150 minutes and the

examination is open to selected reference sources (British National Formulary

– BNF, Drug Tariff and Medicines Ethics and Practice – MEP). Twenty of the

questions in the second paper are calculation style and electronic calculators

are not permitted in this examination. Trainees must achieve 70% across all

questions and 70% in the calculation style questions.

2.3.2 Optometry


Following a three-year undergraduate degree, pre-registration optometrists

undertake a one-year ‘Scheme for Registration’ (SfR) post in a high street or

hospital practice, usually with some ‘cross-sector’ experience. The SfR is run

by the College of Optometrists.

Optometry students are required to register with the General Optical Council

(GOC) from the start of their undergraduate training. After successful

completion of the pre-registration year, and passing the required

assessments, trainees can apply for full registration. The GOC also holds

registers for specialty practitioners and corporate bodies. Registrants with a

specialty entered against their name in the opticians register are qualified to

perform additional duties to those of a normal optometrists or dispensing

optician. Once qualified, optometrists can develop their interests in specialist

areas.9 There are currently three specialties for which optometrists can be

registered: ‘Additional Supply’, ‘Supplementary Prescribing’ and ‘Independent

Prescribing’. Following completion of a training course and approval by the

GOC, a register entry is added to the registrant’s record allowing them to

practise their specialty.



Information presented in this section has been taken/adapted from The SfR

handbook10

unless otherwise indicated.

People involved in the assessment of pre-registration optometrists

The supervisor is the key contact for the pre-registration optometrist and is

responsible for supporting them throughout their SfR training. Supervisors

work with trainees on a day-to-day basis, directly supervising them on the

premises. Supervisors must have been practising optometry for at least three

years. No formal training is provided.

The SfR competency assessments are conducted by two separate

independent assessors – one for each stage of the assessments. Assessors

are appointed by the College of Optometrists.

Assessment – what is assessed and how

The core activity of trainee optometrists’ work is carrying out sight tests on

patients, and this is done from the start of their training. At first the trainee is

only expected to see ‘simple’ cases, and the supervisor checks their work

closely. As they progress, the trainee is expected to see more complex cases,

and supervisor makes fewer checks on their work. The assessment

framework specifies particular ‘patient episodes’ that a trainee must see

during the pre-registration year.

During the year, the trainee keeps a ‘logbook’, where they record:

• details about each patient seen – this consists of a table where

information about each case is entered into a row;

• a weekly dispensing summary for spectacles;

• any additional comments, unusual occurrences or ‘learning points’.


The trainee has monthly reviews of their work with their supervisor. During the

review the supervisor checks the logbook and patient records and completes

a review sheet which provides the assessor with an overview of the trainee’s

professional development. The supervisor also gives the trainee a score for

each competency.

To successfully complete the SfR, trainees have to satisfy the assessors with

their level of ‘competence’ in their work. The skills required are set out as a

number of ‘competencies’ falling under categories such as ‘communication

skills’, ‘professional conduct’ and ‘ocular examination and technique’11

which

the trainee has to pass. These are assessed through a process of ‘work

based assessment’, which has two stages.

Stage 1 of the work-based assessment involves the assessment of 75

competencies over a minimum of three visits (usually quarterly throughout the

year). For the assessment of competencies, direct observation is the preferred

method, and is compulsory for 13 specified skills. Where direct observation is

not compulsory, or as a second form of evidence, anything relevant from the

following ‘evidence types’ is acceptable:

• examples of patient records

• logbook signed by supervisor, ophthalmologist or hospital optometrist

• witness testimony

• case scenarios provided by assessor

• questioning by assessor

• field plots

• images provided by assessor

• keratometry readings taken

• prescription interpretation

• referral letters

• verification of supplied spectacles


During the assessments, the Stage 1 assessor:

• observes the trainee carrying out procedures with patients (e.g. a

routine eye examination on a presbyopic patient) – these are planned

with the trainee and they book in appropriate patients in advance so

that the assessor can observe them during the assessment;

• discusses cases from the logbook with the trainee;

• discusses with the trainee the records they have provided as evidence

and ask them questions about photographs of abnormal eye conditions

or visual field plot results which he or she will provide.

Demonstration of the understanding of some skills can be assessed by the

assessor discussing cases with the trainee – where possible these will be

‘real’ cases the trainee has seen, otherwise the assessor will use hypothetical

scenarios. The assessor will review evidence from patient records and

witness testimonies. The assessor will require at least two, and preferably

three, pieces of evidence before they will be satisfied of a trainee’s

competence in any area.

When the Stage 1 Assessor has judged the trainee to be competent in all 75

Stage 1 competencies, they enter Stage 2 of the work-based assessment

process and are allocated a Stage 2 Assessor who is different from the first

assessor.12

The Stage 2 Assessor judges whether the trainee has maintained

their competence in all eight core subjects by assessing:

• the trainee’s ability to carry out an eye examination on a presbyopic

patient - by undertaking this on a simulated patient

• the trainee’s ability to fit soft contact lenses and provide aftercare to a

soft lens wearer – by undertaking these on a simulated patient

• The over-arching competencies – by having case-based discussions

The assessor also confirms that the trainee has completed the GOC’s

refractions and dispensings (spectacles) requirement of a minimum of 350

refractions and 250 dispensings (spectacles).


The final assessment

Once assessed as competent by the Stage 2 assessor, trainees may enter

the final assessment. This is now an Objective Structured Clinical

Examination (OSCE) comprising 14 stations. (This is new for trainees starting

from June 2009, and was previously a two-day final assessment in

examination conditions). Candidates must pass the OSCE before being

eligible for registration with the GOC.

2.3.3 Medicine


Medical undergraduate degree programmes consist of a five-year degree

course, the Bachelor of Medicine (MBChB). Following attainment of the

MBChB degree, medical trainees enter a two-year ‘foundation training’

programme, during which they are called ‘foundation doctors.’ Provisional

registration with the GMC is required from the start of foundation training.

Successful completion of the first year of foundation training (F1), and passing

the required assessments, allows trainees to apply for full registration with the

GMC. This is followed by a second year of foundation training (F2).

Successful completion of this does not lead to any change in registration

status. After the F2 year, doctors can go on to undertake either GP training or

specialist training, leading to registration as a GP or specialist (consultant).13


Information presented in this section is taken/adapted from the Foundation

curriculum 2010 14

, unless otherwise indicated.

People involved in the assessment of pre-registration doctors

There is an educational supervisor who is a trainer that is selected to be

responsible for the overall supervision and management of a specified


foundation doctor’s educational progress during a training placement or series

of placements. Local education providers must ensure that educational

supervisors have adequate support and resources to undertake their training

role. This will include training in equality and diversity.

There is also a clinical supervisor who is a trainer that is selected and

appropriately trained to be responsible for overseeing a specified foundation

doctor’s clinical work and providing constructive feedback during a training

placement. Clinical supervisors may change on a day-to-day basis depending

on the rota for each foundation doctor. A clinical supervisor will usually be the

consultant or principal in general practice to whom a foundation doctor is

directly accountable for their clinical work. Some training schemes appoint an

educational supervisor for each placement. The roles of clinical and

educational supervisor may then be fulfilled by the same person.

Other people are also involved in the assessment of trainee doctors; some of

the assessment methods used on the foundation programme specify who can

be involved (for example, see the ‘multi-source feedback’ tool outlined below).

The foundation curriculum states that:

Within any attachment an individual assessor is unlikely to build up a coherent

picture of competences, let alone performance of an individual foundation

doctor. To prevent any individual having undue influence over a doctor’s

progression the educational/clinical supervisor’s overall assessment and

judgement of the foundation doctor must be based on multiple assessments

by many observers.


Foundation year one takes place entirely in secondary care settings, usually

with three, four-month attachments in medical and surgical settings. Most

learning takes place in clinical areas, but there is protected time for

educational activity.


The foundation programme is designed to work through a process of

continuous assessment, with a formative approach. The programme

curriculum emphasises that assessments should be spread evenly throughout

the year and that assessments should be followed by constructive feedback.

The foundation curriculum states that:

"Feedback is a key component of the interactions between supervisors and

foundation doctors. Giving and receiving feedback and engaging in

constructive conversations about learning, successes, difficulties and

progress are all part of an effective professional learning environment.

Improvement in clinical practice will only happen if regular review leads to

constructive feedback. Unscheduled assessments are a good opportunity for

immediate feedback. This is particularly true of Direct Observation of

Procedural Skills (DOPS) and mini-Clinical Evaluation Exercise (mini-CEX)

which may be opportunistic. It is essential that trainers provide, and

foundation doctors receive, structured feedback.”

The foundation doctor, with the support of the supervisor(s), is responsible for

arranging assessments, having them signed off and recording results. The

evidence should be used to stimulate immediate or early feedback and to

provide a basis for discussion with the clinical and/or educational supervisor.

Foundation doctors undertake assessments and document them in their e-

portfolio. The GMC requires demonstration of competence in a series of

procedures in order for a provisionally registered doctor with a licence to

practise to be eligible for full registration. These are recorded and signed off in

a log book, which is found in the e-portfolio. A completed log book is also

required for successful completion of the foundation programme.

There are five main assessment methods used during the foundation year:

1) Multi-source feedback

2) Direct observation of doctor/patient encounter

3) Case-based discussion


4) Developing the clinical teacher

5) Final assessment

1) Multi-source feedback:

• usually takes place at least once a year; Deaneries have the option of

increasing the frequency;

• incorporates Team Assessment of Behaviour (TAB) which consists of

the collated views from a range of co-workers (previously described as

360-degree assessment). It will be mapped to a self-assessment tool

with identical domains. It is suggested that both F1 and F2 TAB be

taken in the first four months of the year’s training. If there is a risk of

‘rater fatigue’, i.e. overburdening of a small number of colleagues, then

F2 TAB could be undertaken in the second four months of training. If

there are concerns about any foundation doctor, TAB can be repeated

in the last four months of training;

• for each assessment, the foundation doctor should nominate 15 raters.

A minimum of 10 returns are required. No other foundation doctor can

be a rater. The recommended mix of raters/assessors is as follows:

• 2–8 doctors more senior than F2, including at least one

consultant or GP principal;

• 2–6 senior nurses (band 5 or above);

• 2–4 allied health professionals;

• 2–4 other team members including ward clerks, secretaries and

auxiliary staff.

2) Direct observation of doctor/patient encounter

Two tools can be used to assess doctor/patient encounters: the Direct

Observation of Procedural Skills (DOPS) and the mini-Clinical Evaluation

Exercise (mini-CEX).


The DOPS is a structured checklist for assessing the foundation doctor’s

interaction with the patient when performing a practical procedure. Foundation

doctors may submit up to three DOPS as part of the minimum requirements

for evidence assessing doctor-patient encounters; there should also be a

minimum of six mini-CEX per annum. Different assessors should be used for

each encounter wherever possible and each DOPS could represent a different

procedure and may be specific to the specialty. Although DOPS was

developed to assess procedural skills, its primary purpose in foundation years

is to assess the doctor/patient interaction.

The mini-CEX is a structured assessment of an observed clinical encounter.

Foundation doctors should complete a minimum of six mini-CEXs in F1 and

another six in F2. These should be spaced out during the year with at least

two mini-CEX completed in each four month period. A different assessor

should be used for each mini-CEX wherever possible, including at least one of

consultant or GP level, per four month placement. Each mini-CEX must

represent a different clinical problem, sampling one of the acute care, chronic

illness, psychiatric care, etc. (categories listed in the Syllabus and

competences).

Foundation doctors are required to undertake a minimum of nine observed

encounters in both F1 and in F2. At least six of these encounters each year

should use mini-CEX.

3) Case-based discussion (CBD)

The CBD a structured discussion of clinical cases managed by the foundation

doctor. Its strength is assessment and discussion of clinical reasoning. A

minimum of six CBDs should be completed with at least two CBDs undertaken

in any four month period. Different assessors should be used for each CBD

wherever possible. Assessors should have sufficient experience of the area

under consideration, typically higher specialty training, with variations between

specialties. Each CBD must represent a different clinical problem, sampling


one of the acute care, chronic illness, psychiatric care etc (categories listed in

Syllabus and competences).

4) Developing the clinical teacher

Foundation doctors need to demonstrate the knowledge, skills, attitudes and

behaviours to undertake a teaching role. Some of the competencies required

of a clinical teacher include undertaking teaching in under or post-graduate

education in a one-to-one setting, assessing students and other non medical

colleagues in training and contributing to the assessment or review of

students and other colleagues with whom they work. A form is used to aid the

assessment of a foundation doctor’s skill in teaching and/or making a

presentation.

5) Final assessment

Towards the end of a placement, the foundation doctor and educational

supervisor will meet again for an overall assessment. They will review the e-

portfolio and the results of assessments made during the placement. This

process will involve reviewing evidence from colleagues who have observed

the doctor’s performance in practice and/or in individual assessments. This

should include a ‘sign off’ document confirming satisfactory performance and

progress. It should detail any outstanding issues that still need to be

addressed.

The educational supervisor’s role includes having an overview of the

foundation doctors’ assessments. The results of these assessments will be

drawn together and included in a formal structured report by the educational

supervisor. This will cover the overall performance of the doctor in a

placement. Whilst workplace-based assessments (WPBAs) will be taken into

account, the overall judgement will include a triangulated view of the doctor’s

performance. This includes the doctor’s attendance and participation in

educational activities, appraisals, and the assessment process as well as the

recording of all of these activities in an e-portfolio.


The outcome of the final assessment discussion should be agreed by both the

foundation doctor and the educational supervisor and recorded in the doctor’s

e-portfolio ‘end of placement review’ form. Placement reports put together in

an annual report will form the basis of the foundation training programme

director/tutor’s recommendations of satisfactory completion of F1 and the

foundation programme.

2.3.4 Dentistry


On completion of a five-year Bachelor of Dental Surgery (BDS), dental

graduates can apply for full registration with the General Dental Council

(GDC). Full registration allows the practice of dentistry without supervision.

This means that it is legal for a dentist to practise privately with no further

training following their BDS; however, many dentists will continue with further

training before practice. The GDC also holds 13 ‘specialist lists’ for particular

branches of dentistry.15

Once registered, dentists can undertake further

training in specialist areas to allow them to apply for registration on the 13

‘specialist lists’ held by the GDC. Any registered dentist can work in a

particular field of dentistry (such as orthodontics or oral surgery), but only

those on a specialist list can call themselves a 'specialist'.

In October 2005, the Department of Health asked the General Professional

Training (GPT) Liaison Group UK to take forward the development of a

curriculum for foundation programmes in dentistry in the UK. The proposed

two-year dental foundation programme is broadly comparable to the

structured two year GPT programme which has been available for a

proportion of graduates in the UK.

The proposed curriculum for dental foundation training was published by the

Committee of Postgraduate Dental Deans and Directors (COPDEND) which

sets out a two-year foundation programme. The first year is equivalent to the


one year ‘vocational training’ and is spent in primary care, providing NHS

general dental services. The remainder of the two year programme can be

completed in a variety of primary and secondary care settings. The

COPDEND policy statement specifies that the aim of dental foundation

training is: ‘To enable the acquisition and demonstration of dental foundation

training competences, the evidence of which could, in the future, contribute to

that required for a first validation with the GDC following initial registration.’

The curriculum was formally launched by the Chief Dental Officer (England)

on 15 November 2006.


People involved in the assessment of pre-registration dentists

The Bachelor of Dental Surgery (BDS):

The BDS is a five year course provided by higher education institutions. The

GDC specified ‘learning outcomes’ which must be achieved in order to

register as a dentist and the GDC accredits BDS programmes. There is

variation between the BDS courses in the different dental schools, but they all

meet the requirements for the outcomes. The examinations and any other

assessments that have to be passed as part of the BDS can therefore be

called ‘professional examinations’ in the sense that they are the gateway to

registration.

Foundation training:

The proposed curriculum (described above) states that: Individuals

responsible for judging the performance of dental foundation programme

trainees should be appropriately qualified, have relevant expertise and be

adequately prepared for their role through training.



The Bachelor of Dental Surgery (BDS):

For the BDS, the GDC defines the overarching outcomes that span four

domains.16

The overarching outcomes should be demonstrated throughout

education and training.

Overarching outcomes:16

Upon registration with the GDC the Registrant will be able to:

• Practise safely and effectively, making the high quality long term care

of patients the first concern

• Apply an evidence-based approach to learning, practice, clinical

judgment and decision making

• Accurately assess own capabilities and limitations, demonstrating

reflective practice, in the interest of high quality patient care and act

within these boundaries

• Recognise the role and responsibility of being a registrant and

demonstrate professionalism throughout education, training and

practice in accordance with GDC guidance

These four domains are; clinical, communication, management and leadership

and professionalism. Registrants must be able to demonstrate a variety of

outcomes that include activities such as describing, explaining, discussing,

recognising, implementing, managing, assessing, monitoring and evaluating.

The GDC state that assessments must be ‘rigorous, appropriate and reliable

as a gateway for students to become qualified to practise independently’, but

it is open to each HEI as to how they perform the assessment.16

Foundation training:

The proposed curriculum states that the type of assessment used should

reflect the stage in training (i.e. postgraduate). Also, the dental foundation


programme is more focussed on assessing ‘performance outcomes’ and less

on the achievement of individual competencies. The curriculum states:

…it is recommended that within postgraduate dental training, assessment

should be at the highest level of Miller’s pyramid wherever possible i.e. what

the practitioner ‘does’. At this level, we are looking at the assessment of

‘performance’ rather than ‘competence’, which is an appropriate approach for

training within the workplace where the integration of individual competencies

into the ‘whole task’, and a consistent approach to practice is required for the

delivery of high quality patient care. 17

The curriculum outlines to a number of assessment methods which are

considered potentially appropriate for dental foundation training. These are

outlined below.

Workplace-based assessment using observation of performance:

Assessment methods using direct observation of performance in the

workplace frequently have high validity. There are two main approaches to

scoring performance – checklists and the use of global ratings. In brief,

methods using checklists are usually specific to the task being assessed. The

task is divided procedurally into stages or skills and the evaluator identifies

whether or not each stage has been performed correctly. The advantages of

this approach are that very detailed and structured feedback can be provided

on individual tasks. This may be particularly useful at earlier stages of

professional development such as undergraduate training, the mastery of

more complex tasks at postgraduate training, or for targeted training when

addressing poor performance. The use of global ratings to measure observed

performance has been shown to have many advantages at the postgraduate

level, including more flexibility, and enhanced validity. Ratings are usually

provided along a scale (e.g., 6, 8 or 9 points) with performance descriptors,

and across several broad areas of performance that may be clinically-

orientated (e.g. ‘history taking’, ‘clinical judgement’) or generic (e.g.


‘professionalism’, ‘communication skills’). The majority of methods that are

currently being piloted, in postgraduate dental education, use global ratings.

LEP (Longitudinal Evaluation of Performance)

The LEP uses global ratings on a 9-point scale (1-3 = ‘Need Improvement’, 4-

6 = ‘Satisfactory’, 7-9 = ‘Superior’ performance) to score trainees’

performance in several clinical and generic areas. This approach was adapted

from the mini-CEX, specifically for use within postgraduate dental training (VT

and GPT). Evaluation of the LEP to date has indicated high validity and a

positive educational impact. Specific features of the tool include:

• high flexibility (can be used across the whole curriculum)

• continuous assessment

• judgements are made against a reference point that is the standard

expected upon completion of the training, allowing the demonstration of

progress and the identification of strengths and weaknesses at an early

stage.

• high quality feedback for trainees and trainers.

• a ‘no penalty’ approach to assessments where scores are awarded in

the ‘need improvement’ range, reducing the likelihood of leniency/halo

effect and the potential for demotivation of trainees.

Mini-CEX (Clinical Evaluation Exercise)

Developed in the U.S.A. by Dr John Norcini, this tool has had wide

international success, and was one of the first methods of this kind, from

which many others (including the LEP) have been developed. Evolving from

the more detailed and time consuming ‘CEX’, the mini-CEX was designed to

take a ‘snapshot’ of performance and enhance feasibility and flexibility within

the workplace. Recent changes to the tool, for its use within medical

foundation programme pilots, include the move from a 9-point to a 6-point

scale, with descriptors highlighting that evaluators judgements are made


against the standard expected upon completion of F1 or F2. Previously,

judgements were made in relation to the trainee’s current stage in training.

DOPS (Direct Observation of Procedural Skills)

Originally developed and evaluated by the Royal College of Physicians,

DOPS is a method similar to the mini-CEX that has been designed specifically

for the assessment of practical skills. This tool uses the same rating scale and

descriptors as the mini-CEX used in medical foundation programme pilots, but

against areas that resemble more of a structured checklist for practical

procedures.

CbD (Case-based discussion)

Also being used within medical foundation pilots, CbD allows case

presentation and subsequent discussions with evaluators/trainers to be

recorded. CbD assesses clinical judgement and the application of knowledge

with regard to patient care. It is also used in the USA for poorly performing

doctors, as it allows the decisions and thought processes of practitioners to be

probed by the evaluator.

PAQ (Patient Assessment Questionnaire)

Designed specifically for the assessment of dentists in postgraduate training,

the PAQ has good validity and reliability in primary care (vocational training)

and is now being piloted in the SDS and HDS. The PAQ asks patients to

anonymously provide ratings on a 5-point scale (poor, fair, good, very good

and excellent) for areas of communication skills and professionalism. This

data can be triangulated with that from other assessments such as the LEP, to

compare the trainers and patients views of these areas of performance.


Mini-PAT/Min e-PAT (Peer Assessment Tool)

A method of multi-source feedback for trainees, the mini-PAT is also being

piloted at present in medical foundation programmes. Multi source feedback

can assess multiple components of performance.

Dental VT/GPT ‘Test of Knowledge’

Used alongside the LEP and PAQ in Scotland, within the system of

assessment for satisfactory completion of VT and GPT, this test is computer-

based and focuses on aspects of knowledge that are developed within this

training such as health and safety in practice, practice organisation, NHS rules

and regulations etc. It does not include clinically related questions that may

have previously been assessed at an undergraduate level.

2.3.5 Summary/comparison of the different professions

By comparing pharmacy, optometry, medicine and dentistry in GB we have

been able to draw out some of the similarities and differences between the

processes of registration between these healthcare professions. All of the

training programmes use portfolios and there is a focus on ‘continuous

assessment.’ The trainee collects pieces of evidence and has to record these

and ‘map’ them onto the competencies that they have to achieve. With all the

postgraduate training programmes, trainees spend most of their time in a

practice setting. The amount of time they spend in university varies, for

example pharmacy pre-registration trainees attend ‘study days’ at the

university whereas optometry trainees do not come to the university for

anything. There are, however, a number of differences in terms of the

implementation of formative and summative assessments.

In pharmacy, the specific assessment methods for each competency are less

strictly prescribed than they are in the medical foundation programme. For

example, the medical foundation curriculum states that ‘competence 2.1 –

Eliciting a history’ is assessed via mini-CEX and CBD. Throughout the

curriculum most competencies have methods of assessment specified. In the


pharmacy pre-registration workbook, the focus seems to be more on providing

proof that a competence has been ‘met’, and the workbook specifies forms of

documentary evidence that can be used, but is less specific about the actual

assessment tools that can be employed.

There is less specification in the assessment tools that pharmacy trainees

could be ‘subject’ to for example, the final assessment for all optometry

trainees is an OSCE, whereas the pharmacy pre-registration programme does

not specify that trainees will be assessed through OSCEs. However, in

practice, they may take part in OSCEs as part of a university study day, and

the results from this could form part of the evidence used to achieve the

competencies.

In terms of the timings of assessments, the pharmacy and optometry

programmes are similar in that they have scheduled quarterly assessments,

whereas medical foundation trainees are responsible for organising their own

assessments, by finding suitable cases and asking colleagues to assess

them. This puts more onus on the trainee to manage their own time (and

learning).

In terms of who assesses the trainee, pharmacy pre-registration trainees have

a tutor who acts as their supervisor on the work premises and also takes the

role of the assessor (through performance reports). In optometry there is a

supervisor on the premises, but an independent assessor goes in quarterly to

‘sign off’ the trainee’s evidence against the competencies. Medical foundation

trainees are ‘formally’ assessed by a greater range of people. For example,

for team-based assessment, there are recommendations on who should be

included in this, including other health care professionals. Furthermore, there

is a clinical as well as an educational supervisor. While a pre-registration

trainee could potentially include a testimonial from a nurse who had observed

their work on a hospital ward as evidence in their portfolio, this is not a

requirement in medicine. The process of obtaining feedback from a wider

range of colleagues is much more formal and established in medicine.


Pharmacy is the only profession with formal written examinations at the end of

the postgraduate pre-registration training period, although if we include the

methods of assessment used on the BDS, then pharmacy and dentistry have

the most similar assessment methods in place – trainees are assessed using

written examinations in MCQ format (dentistry also has short answers).

The training programme for dentistry is unique among the professions

included in this review in that a bachelor degree, which is not ‘graded’ but

simply awarded with a ‘pass’, allows registration with the regulatory body.

Therefore, postgraduate trainees are already members of the profession from

the start of their postgraduate training. At the moment, dental vocational

training is not formally assessed, although a curriculum for dental foundation

training has been published, which sets out the assessment methods that are

likely to be used for this. However, whereas doctors must successfully

complete their F1 year to be eligible for full professional registration, this is not

the case for dentists. 18

The proposed foundation programme for dentistry has been designed to

follow the medical training model in that it is a two year practice-based

programme, using many of the same assessment tools. However a key

difference is that whereas the majority of medical postgraduate training takes

place in hospitals, it is compulsory for dentists to complete a year of

postgraduate training in primary care. (The majority of dentists practise in

general or personal dental practice.) Also, the dental foundation programme is

more focussed on assessing ‘performance outcomes’ and less on the

achievement of individual competencies.

Pharmacy and dentistry have only one ‘level’ or type of registration, whereas

medicine has four types on three levels – provisional (F1), full and then GP or

specialist (following specialist training). Student optometrists have to register

with the GOC from the start of their undergraduate training, and then apply for

full registration after passing the scheme for registration. While all practising

pharmacists have to undertake continuing professional development to

maintain their registration, and there are ‘higher’ qualifications which


pharmacists can undertake, such as the hospital diploma, there is only one

level of professional registration.

With medicine, trainees have to successfully complete their F1 year to be

eligible for full registration. However, the assumption is that their ‘training’ will

not stop there, as the F2 curriculum sets out a further year of competencies

that doctors must achieve, with the aim of going on to specialist training,

which leads to specialist registration. This model provides a clear path that

medical trainees follow which suggests a higher level of practice, and

eventually (on completion of specialist training) a higher level of registration.

For example, the foundation curriculum states: ‘A key feature of the F2

curriculum is that all doctors must develop competencies at a significantly

higher level than those acquired in the F1 year’.14


Findings for pharmacy in countries outside GB

This section of the report focuses on pharmacy registration requirements for a

selection of countries outside GB, specifically: Australia, New Zealand,

Canada and USA. These were selected as they are English speaking and

have similar healthcare systems and particularly arrangements for pharmacy

education and training, and registration.

2.3.6 Australia


Australian pharmacy undergraduate degree programmes consist of a four-

year bachelor’s degree, the BPharm. Following attainment of the BPharm

degree, the graduate must register with the Pharmacy Board of Australia and

undertake a period of supervised practice of 1824 hours (e.g. 38 hours per

week for 48 weeks) and also pass an examination. They can then apply for

‘general registration’.

Previously, there was a registering authority (a Pharmacy Board) in each state

and territory of Australia that was responsible for registration and regulation of

pharmacy within that jurisdiction. As of 1st July 2010 the state registering

authorities were decommissioned and all registration and regulation issues

are now the responsibility of the newly established Pharmacy Board of

Australia. Registrants have national registration that enables them to work

anywhere in Australia without having to re-register (and pay a fee) in each

state they wish to practise. This is part of the Intergovernmental Agreement on

the Australian health workforce, which has created a single national

registration and accreditation system for 10 health professions (chiropractors,

dental care practitioners, medical practitioners, nurses and midwives,

optometrists, osteopaths, pharmacists, physiotherapists, podiatrists, and

psychologists).19

The internship year (the year following the BPharm – similar to the pre-

registration year in Great Britain) is generally undertaken in a hospital or


community setting; a small number undertake their training in an industry

setting. Graduates of the BPharm in Australia are required to hold provisional

registration in order to complete an internship. Interns must complete

supervised practice and pass the Board Registration Examination.


People involved in the assessment of pre-registration trainees

The Pharmacy Board of Australia stipulates the following requirements for

supervised practice:

• each period of supervised practice is undertaken under the direction

and/or supervision of a preceptor approved by the Board for a minimum

period of 152 hours;

• it must be under the direct supervision of a pharmacist who holds

general registration (not necessarily the approved preceptor).

Note that some of the assessment methods outlined below include additional

specifications for the training of those carrying out certain types of

assessment.


Supervised practice is undertaking pharmacy practice under the direct

supervision of a pharmacist who holds general registration (a preceptor), while

the pharmacist is providing pharmacy services in pharmacy premises or other

circumstances as determined by the Board.

Previously, each state had its own ‘Intern training programme’. The

Pharmaceutical Society of Australia is the largest provider of Intern training

programmes in Australia, and has now developed a National Intern Training

Program. The National Intern Training Program will be rolled out in most

states and territories of Australia in 2010 and 2011.20 At the time of writing,


there was no guidance available specifying the detail of this national

programme. Without this, a description of the pharmacy intern programme

was taken from a paper by Marriott et al. in the American Journal of

Pharmaceutical Education.21

Requirements of the intern programme include:

• completion of an accredited education programme such as that

provided by the Pharmaceutical Society of Australia, Monash

University, and others;

• passing the competency-based pharmacy board examinations. The

structure of the pharmacy board examination used to vary somewhat

between states but generally took the form of an oral examination at

the end of the internship and could involve an OSCE;

• pass a law and ethics examination;

• a calculations examination;

• an Australian Pharmacists Competency Assessment Test (APCAT);

• a demonstration of satisfying the competency standards for

pharmacists in Australia (see below).

The competency standards are grouped into eight ‘functional areas’:

•

•

practise pharmacy in a professional and ethical manner

•

manage work issues and interpersonal relationships in pharmacy

practice

•

promote and contribute to optimal use of medicines

•

dispense medicines

•

prepare pharmaceutical products

•

provide primary health care

•

provide medicines and health information and education

apply organisational skills in the practise of pharmacy


The competency standards for pharmacists in Australia documentation22

outline six ‘suggested’ assessment methods for the required competencies

which are outlined below.

1) Supervisor observation

(Following training) Supervisors observe the trainee in the workplace to

assess competence. A prepared checklist over a period of time, taking into

account varying conditions in the workplace, is often used. Appraisals of

aspects of competency may also be conducted. Appraisal can include:

•

•

application to work;

•

quality of work;

•

attitude to clients;

•

attitude to co-workers;

personal behaviour/professional attitude.

2) Written assignments/examinations

Written assignments/examinations can include practice-based reports, open-

book assignments and written examinations. These are outlined below:

Practice-based reports Can include case studies relating to:

• prescriptions;

• primary health care;

• consumer medication records;

• reports of extemporaneous preparations undertaken.

(In industrial placements, involvement in manufacturing process of products

may be reported.)

Open-book assignments

A series of practice-based questions covering broad areas of competence to be

answered and submitted for assessment.


Written examinations

Practice-based questions may be closed- or open-book and can be in the form of:

• short answers;

• multiple-choice questions;

• essays.

3) Oral interview

The oral interview is an interview that consists of practice-based questions.

Prescription and primary care cases can be used to assess:

• knowledge;

• communication skills;

• application of theory to practice;

• professional decision making, judgement and attitudes.

An oral interview relies on experienced practitioners who are trained

assessors for objectivity, reliability and validity. Preferably, two assessors

should examine together and come to an agreed interpretation of the

candidate’s competence with reference to the Performance Criteria and pre-

established decision rules.

4) Objective structured examination

The objective structured examination is a series of stations structured to each

assess an aspect of competence. The objective structured examination is a

method of assessing practical and clinical skills which brings together several

testing methods. There are two broad categories of stations:

• At procedure stations an activity or practical procedure is carried out

e.g. dispensing a prescription; counselling a ‘consumer’. (A marker with a

checklist and scoring card notes the candidate’s performance.)

• At question stations written answers to open-ended or multiple choice

questions are given. After a given period, candidates move on to the next

station in response to a given signal. The time allowed should be the


same for each station to simplify the rotation. All candidates rotate

through the same stations.

5) Practical examination

The practical examination focuses on candidates’ ability at dispensing

simulated prescriptions for proprietary and/or extemporaneous preparations

under examination conditions.

6) Evidence of prior learning

This is assessed by having candidates provide evidence of aspects of

competency previously assessed satisfactorily by other sources. Evidence

may include:

• certification of courses successfully undertaken;

• record of hours of practical training undertaken;

• log book of practical experiences.

2.3.7 New Zealand


Pharmacy undergraduate degree programmes in New Zealand consist of a

four-year bachelor’s degree, the BPharm. Graduates must then register as an

intern with the Pharmacy Council of New Zealand and complete a minimum of

44 weeks practical training in a pharmacy alongside an intern programme run

by the Pharmaceutical Society of New Zealand (named EVOLVE)23

. The

EVOLVE Intern Programme runs concurrently with the practical training period

and is the training and assessment that occurs around that work experience.

Successful completion of these allows application for full registration as a

pharmacist.



People involved in the assessment of pre-registration trainees in New Zealand

All New Zealand graduate interns must undertake supervised practice, under

an approved preceptor pharmacist in an approved site. Preceptors must:

• be pharmacists with three years post-registration experience

• have completed the training for a preceptor as currently required by the

Pharmacy Council. Currently this is Workplace Assessor Training Unit

Standard 4098 on the New Zealand Qualifications Authority (NZQA)

framework; ‘Use standards to assess candidate performance’. (The

NZQA is a national organisation that oversees qualifications.)


The EVOLVE Intern Programme24

, run through the Pharmaceutical Society of

New Zealand, is an achievement based programme based on a set of

competence standards that describe the knowledge, skills and attitudes

required of a newly registered pharmacist. The preceptor conducts three

assessments during the year, against the competence standards.

The final assessment

Trainees attend an Assessment Centre where they are assessed by trained

assessors.25

The final assessment involves an oral interview conducted by

two assessors and a five station OSCE assessing application of clinical

knowledge and professional competence for a range of practice scenarios.

2.3.8 Canada

There are 12 regulatory authorities with responsibility for the registration or

licensing of pharmacists within their areas in Canada – one for each province

or territory, apart from Nunavut, which is included within the remit of the


Northwest Territories Department of health and social services. This

department specifies that to be ‘licensed’ pharmacists must have passed the

Pharmacy Examining Board of Canada (PEBC) examination, but there are no

other requirements regarding practical experience etc. No other details about

registration of pharmacists in the territories were found.


The number and type of registration categories varies between provinces, for

example, Alberta has five: clinical, associate (non-practising), retired, student

(undergraduates) and provisional (interns) while Ontario has three: student,

intern and registered pharmacist.

The National Association of Pharmacy Regulatory Authorities (NAPRA) has a

‘national model licensing programme’ which sets core requirements for initial

licensure of pharmacists. These are:

• a degree in pharmacy (BSc); Canadian undergraduate degree

programmes consist of a four-year course, however, these require

completion of a one-year ‘pre-pharmacy’ university course to be

undertaken before entry;

• passing the ‘Pharmacist Qualifying Examination’ set by the PEBC;

• pharmacy jurisprudence requirements – assessed by a ‘jurisprudence

examination’ set by the provincial regulatory authority;

• practical experience/training period, during which time the professional

competencies are assessed.

There are also language fluency requirements, but applicants who have

received an accredited Canadian or American university degree in pharmacy

will not be required to undergo further testing unless a ‘trigger’ suggests that a

test for language proficiency is necessary.



People involved in the assessment of pre-registration trainees in Canada

For structured practical training, each pre-registration trainee or candidate is

supervised and assessed by a recognized preceptor. To be recognized as a

preceptor, the pharmacist must:

• be a member in good standing of a Provincial or Territorial Regulatory

Authority;

• have at least 12 months experience as a licensed pharmacist;

• hold a ‘practising’ or ‘active’ licence and be practising in a patient care

setting with direct patient interaction;

• have undertaken a preceptor training program offered by an accredited

university or the Regulatory Authority.26


The profession of pharmacy is regulated on a provincial level. The provincial

regulatory authorities are directly responsible for granting pharmacist licenses,

assessing the competency of pharmacists and ensuring public safety.

NAPRA defined a set of seven competencies required of pharmacists at the

point of licensure. Each competency has a number of elements, of which

there are 37 in total. 27

1) Patient Care

2) Professional Collaboration and Team Work

3) Ethical, Legal and Professional Responsibilities

4) Drug, Therapeutic and Practice Information

5) Communication and Education

6) Drug Distribution

7) Management Knowledge and Skills


In early 1998, NAPRA's National Licensing Standards Committee (NLSC)

identified 19 of the 37 Competency Elements as being optimally assessed

through a structured practical training program. It was recommended that

these particular competencies require observation of performance to

determine the ability of the pre-registration trainee or candidate and that

further, the observations should occur over a period of time to ensure that

performance can be sustained. Accordingly, a structured practical training

framework was developed.

The framework for assessing competencies states that:

The structured practical training experience and assessment should ideally be

incorporated into the undergraduate academic program. However, it is

acknowledged that the Canadian Council for Accreditation of Pharmacy

Programs' (CCAPP) current minimum criterion of 16 weeks practical training

experience may not provide sufficient time to assess all the required

competencies. In such cases, an internship program administered and

supervised by the Provincial Regulatory Authority would be required. The total

practical training experience with assessment could be carried out through a

partnership arrangement between the Provincial Regulatory Authority and the

Faculty, determined on a province-by-province basis.

Programs should be focused on measuring or assessing the actual attainment

of competencies, which is not directly related to time spent. Therefore, the

group's further suggestion that the total time required for completion of a

structured practical training program prior to licensure be not less than 24

weeks (840 hours) is offered as an example. Using this example, the following

schedule of internship training is offered as a possible option to consider for

candidates enrolled in accredited in-province and domestic pharmacy

programs.

The candidate might complete 280 hours of practical experience over eight or

more weeks during the first three years of enrolment, as follows:


• Year 1: 70 hours over at least 2 weeks



Practical experience obtained over an extended period of time allows for

integration with the didactic program and can result in an optimal learning

opportunity. In Year 4 the period of structured practical training might be 560

hours over sixteen weeks, scheduled in blocks of at least 140 hours/four

weeks duration and involve sites that offer different types of experiences.

In practice, each pharmacy regulatory body has its own provincial

requirements. Before gaining a license to practise, trainees may gain practical

experience which is included within their undergraduate programme, or they

may be required to undertake an ‘internship’ which takes place after they have

graduated. The requirements for how much time is required in each of these

types of training varies between provinces.

For example, in Alberta, the undergraduate degree programme includes 900

hours of structured practical training (SPT). After graduating, trainees must

complete 100 of SPT as an intern and follow the Post-Graduate Structured

Practical Training and Evaluation Guide for Alberta Pharmacist Interns which

assesses the entry to practice competencies of the pharmacist intern in a

structured, 100 hour timeframe while practising in a typical practice setting. In

Ontario, in the fourth year of the degree programme, undergraduates

participate in 16-weeks of supervised training in field placements where they

apply in-class learning and are evaluated with university-affiliated pharmacists

in actual pharmacy settings. Following graduation, to register with the Ontario

College of Pharmacists, graduates must successfully complete a minimum 12-

week SPT internship while registered with OCP as an intern.

The jurisprudence examination

Provincial requirements vary, but the examinations are generally based on the

regulatory body’s standards and policies, and Federal and Provincial acts and

their regulations, which control the production, distribution, advertising, sales

https://pharmacists.ab.ca/Content_Files/Files/PostGrad100HourEvalGuide.pdf�

https://pharmacists.ab.ca/Content_Files/Files/PostGrad100HourEvalGuide.pdf�


and use of drugs in a particular province and assess the pre-registration

trainee knowledge, ability to interpret and apply all legislation that impacts on

current pharmacy practice. For example, in Alberta, the ethics and

jurisprudence examination is undertaken online, at a testing centre, is closed

book, in MCQ format and lasts for two hours. In Ontario, alternatively, the

examination is a written, MCQ format, lasting two and a half hours.

The PEBC examination

This examination has two parts, a written component in MCQ format and an

OSCE. Part I consists of two MCQ papers, taken in two sittings over two

consecutive days. Each sitting (examination period) is 3.75 hours in length.

Part II is a 16-station (plus four rest stations) OSCE, undertaken over a

maximum of six hours, with breaks. The examinations are undertaken on the

same days throughout the whole of Canada.

2.3.9 USA


Each of the 51 states in the USA has its own board of pharmacy, and there

are some variations in requirements for registration between states, however,

generally, these are:

• Attainment of a Doctor of Pharmacy (PharmD) - there are pre-

pharmacy requirements which precede entry to the PharmD, which

usually involve at least one year of university education;

• passing the North American Pharmacist Licensure Examination

(NAPLEX) examination;

• passing a jurisprudence examination (44 states and the District of

Columbia require that applicants pass the Multistate Pharmacy

Jurisprudence Examination (MPJE), while those states that do not

require the MPJE have their own law examination);

• fulfilling practical experience requirements.


The categories of ‘licence’ vary between states but include student, intern,

‘standard’ and speciality categories.


People involved in the assessment of pre-registration trainees in the USA

According to standard number 14 of the accreditation guidelines stipulated by

the Accreditation Council for Pharmacy Education (ACPE)28

, throughout the

practical training (i.e. practice based experience) of a pharmacist in the USA

there is a preceptor on site that can work with the trainee. According to the

guidelines a ‘Preceptor should hold full, shared, adjunct, or other defined

positions in the college or school and should be well versed in the outcomes

expected of students and the pedagogical methods that best enhance

learning. In this regard, the college or school must ensure that preceptors

receive orientation, especially for first-time preceptors prior to assuming their

responsibilities, ongoing training, and development. Preceptors should provide

close supervision of and significant interaction with students. The student-to

preceptor ratio for the pharmacy practice experiences should be adequate to

provide individualized instruction, guidance, supervision, and assessment.’


The NAPLEX

The NAPLEX was designed to measure a candidate’s knowledge of the

practice of pharmacy. It is one component of the licensure process and is

used by the boards of pharmacy as part of their assessment of a candidate’s

competence to practise as a pharmacist. The 185-question examination tests

a prospective pharmacist’s ability to measure pharmacotherapy and

therapeutic outcomes, prepare and dispense medications, and implement and

evaluate information for optimal health care. Many of the questions are asked


in a scenario-based format. For example, a patient profile is provided, and the

candidate must answer a series of questions related to the profile.

The NAPLEX is computer-based and uses adaptive technology to deliver

selected-response and constructed-response questions. Computer adaptive

testing (CAT) successively selects questions so as to maximize the precision

of the examination based on what is known about the examination from

previous questions. From the examinee's perspective, the difficulty of the

examination seems to tailor itself to his or her level of ability. For example, if a

candidate performs well on an item of intermediate difficulty, they will then be

presented with a more difficult question. Or, if they performed poorly, they

would be presented with a simpler question. Compared to static tests, with a

fixed set of items administered to all examinees, computer-adaptive tests

require fewer test items to arrive at equally accurate scores.29

The Multistate Pharmacy Jurisprudence Examination (MPJE)

The MPJE combines federal- and state-specific questions to test the

pharmacy jurisprudence knowledge of prospective pharmacists. It serves as

the pharmacy law examination in participating jurisdictions. Each board of

pharmacy approves questions applicable in that state or jurisdiction. The

MPJE is a two-hour, computer-adaptive examination that consists of 90

multiple-choice test questions. The MPJE tests candidates on:

• legal aspects of pharmacy practice, including responsibilities with

regard to the distribution and dispensing of pharmaceuticals and for the

care of patients;

• licensure, registration, certification, and operational requirements;

• regulatory structure and terms of the laws and rules that regulate or

affect pharmacists, pharmacies, manufacturers, and distributors.30


Practical experience requirements

Requirements are set by each state pharmacy board. There may be slight

differences in the requirements for the number of hours spent in practice.

The ACPE is the national agency for the accreditation of professional degree

programs in pharmacy and providers of continuing pharmacy education. The

ACPE specifies a number of ‘Professional competencies’ and ‘Outcome

expectations’ for PharmD programmes.28

Professional competencies that

must be achieved by graduates through the professional degree program

curriculum are the ability to:

• Provide patient care in cooperation with patients, prescribers, and other

members of an inter-professional health care team based upon sound

therapeutic principles and evidence-based data, taking into account

relevant legal, ethical, social, cultural, economic, and professional

issues, emerging technologies, and evolving biomedical,

pharmaceutical, social/behavioural/administrative, and clinical sciences

that may impact therapeutic outcomes;

• Manage and use resources of the health care system, in cooperation

with patients, prescribers, other health care providers, and

administrative and supportive personnel, to promote health; to provide,

assess, and coordinate safe, accurate, and time-sensitive medication

distribution; and to improve therapeutic outcomes of medication use;

• Promote health improvement, wellness, and disease prevention in

cooperation with patients, communities, at-risk populations, and other

members of an inter-professional team of health care providers.

These professional competencies must be used to guide the development of

stated learning outcome expectations for the pre-registration curriculum. To

anticipate future professional competencies, outcome statements must

incorporate the development of the skills necessary to become self-directed

lifelong learners. These competencies can, however, be difficult to assess.


The issue of ‘pharmacy’ competencies and their assessment has received

attention from those concerned with the assessment of pre-registration

trainees in the USA. A paper by Ried and colleagues reports work undertaken

to develop a standardised performance measure for ‘practical experiences’ at

three colleges in Florida.31

Each college had used a different tool for

assessing students' clinical competencies. This was burdensome and

confusing for the preceptors. In response, some preceptors developed and

used their own forms instead of the colleges' forms. This lead to faculty from

the state's three colleges of pharmacy collaborating to develop a standardized

assessment tool: the System of Universal Clinical Competency Evaluation in

the Sunshine State (SUCCESS).

Graduates must possess the basic knowledge, skills, attitudes, and values to

practise pharmacy independently at the time of graduation. In this regard, the

college or school must ensure that graduates are competent to:

• provide patient-centred care, through the ability to design, implement,

monitor, evaluate, and adjust pharmacy care plans that are patient-

specific; address health literacy, cultural diversity, and behavioural

psychosocial issues; and are evidence-based;

• manage a successful patient-centred practice (including establishing,

marketing, and being compensated for medication therapy

management and patient care services rendered);

• provide population-based care, through the ability to develop and

implement population-specific, evidence-based disease management

programs and protocols based upon analysis of epidemiologic and

pharmacoeconomic data, medication use criteria, medication use

review, and risk-reduction strategies;

• manage human, physical, medical, informational, and technological

resources, through the ability to ensure efficient, cost-effective use of

these resources in the provision of patient care;

• manage medication use systems, through the ability to apply patient-

and population-specific data, quality improvement strategies,

medication safety and error reduction programs, and research


processes to minimize drug misadventures and optimize patient

outcomes; to participate in the development of drug use and health

policy; and to help design pharmacy benefits;

• promote the availability of effective health and disease prevention

services and health policy through the ability to apply population-

specific data, quality improvement strategies, informatics, and research

processes to identify and solve public health problems and to help

develop health policy.

To be capable of the above, pharmacy graduates also must be able to:

• communicate and collaborate with patients, care givers, physicians,

nurses, other health care providers, policy makers, members of the

community, and administrative and support personnel to engender a

team approach to patient care;

• retrieve, analyze, and interpret the professional, lay, and scientific

literature to provide drug information and counselling to patients, their

families or care givers, and other involved health care providers;

• demonstrate expertise in informatics;

• carry out duties in accordance with legal, ethical, social, economic, and

professional guidelines;

• maintain professional competence by identifying and analyzing

emerging issues, products, and services.

2.3.10 Summary/comparison of the different countries

This section draws out some of the similarities and differences between the

training and registration procedures for pharmacy across the different

countries.

Our research has found that the length of time required to become a qualified

pharmacist is typically five years. In the USA it may also take six years if a

pre-pharmacy course is carried out for two years prior to the four year doctor

of pharmacy. The way that these years are formatted differs between the


countries that were compared. For example, the systems existent in GB,

Australia and New Zealand generally require students to complete a

pharmacy degree, followed by a year of supervised practice. The USA seems

somewhat different, in that practice experience is integrated more with links to

colleges and schools of pharmacy, and courses may indeed differ depending

on the college or state one is training in. In Canada there appears to be more

integration of practice into the earlier years of the course rather than

segmenting the educational (taught in university/college) and practical side of

pharmacy.

Findings from this research also highlight differences in terms of the people

who are involved in the practical training of pre-registration trainees. There is

at least one individual that is intimately involved in the training and

assessment of pre-registration pharmacists: a tutor or ‘preceptor’ with a

required amount of experience in practising pharmacy. Although there is an

indication that these individuals may receive some orientation and support in

their role as a preceptor (as stipulated in the accreditation guidelines of the

USA), New Zealand demands the most requirements of their preceptors. This

includes ensuring they have a minimum of three years post-registration

experience and have completed preceptor training in accordance with the

pharmacy council. One year of practice experience seems to be the norm in

the other countries that were examined, though in GB the tutor also needs

three years experience in the field they are working and tutoring in.

The amount of assessment taking place within each of the pre-registration

systems between the countries varied. In comparison to the GB system,

Australia New Zealand, Canada and the USA appear to have in place a wider

range of measures to assess competences and performance. The newly

formed National Intern Training Program that is being rolled out in Australia21

has a comprehensive range of assessments including observations from

supervisors, written examinations, oral interviews, and practical examinations,

to name but a few. In New Zealand and Canada there are observation

assessments that take place throughout the practice training such as OSCEs.

In the USA there was more emphasis on examination-based assessment


such as the NAPLEX and MPJE. As with the USA, a written examination-

based assessment – as opposed to a more practical assessment such as an

OSCE – is the final assessment for pre-registration trainees in GB. However,

while the GB examination is paper based, the NAPLEX and the MJPE are

administered using ‘computer-adaptive’ technology. This means that all

candidates do not answer the same questions; the examination papers sat by

pre-registration trainees during the month of testing (June or September) will

be the same.

Assessing the competencies of practical-based experience may create

problems for some preceptors monitoring pre-registration trainees as has

been found in research in the USA.31 Other work has demonstrated similar

findings. For example, Hill et al. conducted a review of the assessment

methods of an Advanced Pharmacy Practice Experiential (APPE) Program. 32

The review of the school’s assessments methods suggested that the existing

forms were cursory and did not allow for detailed assessment of students’

competence in performing clinical responsibilities. They lacked objective

criteria, were not competency related, did not require midpoint grading, and

provided little guidance to preceptors in grading. After reviewing assessment

instruments from several other pharmacy schools as well as guidelines

published by the Accreditation Council for Pharmaceutical Education and the

American Association for Colleges of Pharmacy, the authors decided to

develop a competency-based assessment process with detailed grading

rubrics. Studies such as this highlight some of the complexities of assessing

practice-based placements in pharmacy.

Lastly, there are some differences between the countries examined in terms

of regulatory boards. Canada, for example, has 12 regulatory authorities. In

the USA there are also a number of pharmacy boards which may create

problems in terms of consistency in the training and development of future

pharmacists. These countries do however outline general guidelines for

subordinate authorities in terms of requisites for the registration of

pharmacists. One could argue that a national system of regulation, such as in

GB may provide a more consistent means of regulating registration.


3 The effectiveness of the pharmacist registration examination

3.1 Introduction

The registration examination takes place twice per year (in June and

September) and consists of written closed and open book papers which

assess knowledge and understanding using MCQs. In the closed book paper

candidates attempt 90 questions in 90 minutes. In the open book paper –

open to selected reference sources (BNF, Drug Tariff and Medicines Ethics

and Practice) – candidates attempt 80 questions in 150 minutes. Twenty of

these questions require calculations, though electronic calculators are not

allowed to be used.

The aim of this part of the study is to assess how effective the closed and

open book examinations are in assessing pre-registration trainees in a range

of competencies, knowledge and understanding.

3.2 Method

It was initially proposed that the questions from past papers of the registration

examination would be mapped against the pre-registration performance

standards, and, the questions in the registration examination would be

reviewed to determine what they were assessing in terms of competencies,

knowledge and/or understanding. Initially, a number of questions from the July

2009 examination were mapped against the pre-registration performance

standards,6

by a pharmacist member of the research team (PL). This involved

assigning the relevant performance standards, of which there are 76, to each

examination question. However, this task proved unsuccessful as few

questions mapped straightforwardly onto a performance standard directly.

As a result of this, PL met with two members of the expert panel (IS & AL) to

discuss and review the mapping already undertaken. (These members of the

expert panel are from The University of Manchester and have specialised

knowledge and experience in pre-registration training and assessment in


community and hospital pharmacy respectively.) Following this joint reviewing

of the examination questions, in terms of what performance standards were

being covered, PL and the expert panel concluded that many of the

examination questions underpinned some the performance standards but did

not directly examine them. Following consultation with the commissioner at

the RPSGB, it was therefore decided to map the examination questions onto

the examination syllabus instead6

– of which there are 35 elements.

The elements were coded and mapped by another pharmacist member of the

research team (HP). Each element was coded (see appendix 1) and

subsequently mapped to the examination questions from the open and closed

book papers in June 2008, September 2008, June 2009 and September 2009.

In order to ‘map’ a question onto the examination syllabus, the content of each

question was analysed and then mapped onto the appropriate element(s) of

the syllabus. For example, if a question assessed the action and use of a

drug, as well as assessing knowledge on the side effects of the drug, it was

mapped onto both elements 14 and 17 of the examination syllabus (i.e.

actions and uses of a drug and adverse effects of medicines, respectively).

The coding of the four examination papers was tabulated in order to obtain

descriptive statistics about what elements of the examination syllabus could

be mapped to the registration examination. If the content of the question did

not map onto the examination syllabus, it was recorded as ‘did not map’ (see

appendix 4). Questions that were missing from the examination papers

obtained from the RPSGB were also accounted for when tabulating the data.

The questions in the registration examination were also reviewed to determine

what they assessed in terms of knowledge and/or understanding. Definitions

of knowledge and understanding were obtained from the Oxford English

Dictionary:33

Knowledge:

• Acquaintance with a fact; perception, or certain information of, a fact or

matter; state of being aware or informed; consciousness (of anything).

• Acquaintance with facts, range of information,


Understanding:

• To comprehend; to apprehend the meaning or import of; to grasp the

idea of.

• Comprehension of something

The content of each question was analysed by two members of the research

team (PL and HP), and once again, where necessary, members of the expert

panel were consulted for advice in this exercise. In order to classify a question

that assessed knowledge, knowledge was interpreted as ‘facts and concepts

that pre-registration trainees would know from their undergraduate degree and

pre-registration experience’. In order to classify a question that assessed

understanding, understanding was interpreted as ‘the ability to use and apply

knowledge and concepts to answer a question correctly’. In some cases, a

question could be classified as assessing both knowledge and understanding.

The classification of the four examination papers was tabulated in order to

obtain descriptive statistics about the assessment of knowledge and/or

understanding in the four examination papers. If the content of the question

did not map onto knowledge and/or understanding, it was recorded as ‘did not

map’ (see appendix 4).

In some instances questions had been removed by the RPSGB from some of

the examination papers due to errors / problems with specific questions, and

these were noted and recorded as ‘removed from paper’ (see appendix 4).

3.3 Results

This section reviews the findings from both the closed book and the open

book examination papers in sequence.

3.3.1 Closed book examination paper

This section of the report focuses on the closed book registration examination

paper in 2008 and 2009. Table 3.1 displays the number of times the


examination syllabus entries were covered in the closed book examinations

between June 2008 and September 2009.

Table 3.1: Number of times syllabus entries were assessed in the closed book examination

Element of examination (codes 1-35)

June 2008

Sept. 2008

June 2009

Sept. 2009 total

1 RPSGB Code of Ethics 6 10 5 4 25 2 Clinical governance 1 1 1 3 6 3 Continuing Professional Development in pharmacy 1 1 1 0 3 4 Principles of audit 2 2 2 1 7

5 Roles & training requirements for pharmacy support staff 0 0 0 0 0

6 Sale and supply of medicines 14 14 14 15 57 7 Conditions for operating a registered pharmacy 0 0 1 0 1 8 National Health Service 0 0 1 1 2 9 Health and safety 0 0 0 1 1 10 Environmental Protection 1 2 0 2 5 11 Consumer protection 0 0 0 0 0 12 Data protection and health records 1 0 2 1 4 13 Evidence-based practice 4 0 12 8 24 14 Action and uses of drugs 56 25 37 44 162 15 Non-prescription remedies 12 8 13 12 45 16 Differentiating minor illness from more serious disease 6 9 11 9 35 17 Adverse effects of medicines 13 16 11 9 49 18 Contra-indications 4 4 12 8 28 19 Drug interactions 4 5 6 7 22 20 Counselling requirements 5 5 4 5 19 21 Optimising patients' drug therapy 1 0 13 1 15 22 Interpretation of test results 2 2 2 0 6 23 Health promotion and disease prevention 5 1 7 4 17 24 Calculation 1 1 1 3 6 25 Dilution 0 0 1 0 0 26 Formulation and preparation 0 0 0 0 0 27 Good dispensing practice 0 2 1 0 3 28 Special Handling Requirements 0 0 0 0 0 29 Stability of dispensed preparations 1 2 1 0 4 30 NHS funding for pharmacy services 3 4 4 3 14 31 Prescribing guidelines, data and formularies 0 1 0 2 3 32 Operating procedures in primary and secondary care 0 0 1 3 4 33 Quality Assurance of stock 0 0 1 0 1 34 Responding to adverse drug reactions 1 0 0 2 3 35 NHS complaint procedures 0 0 0 0 0


The examination syllabus entry that was assessed most frequently in all of the

four closed book papers (2008-09) was syllabus entry 14 (‘action and uses of

drugs’). Its assessment ranged between 26 and 56 times amongst the set of

89/90 questions (one question had been omitted from the June 2009

examination paper). The other most commonly assessed syllabus entries

were syllabus entries 6 (sale & supply of medicines), 17 (adverse effects of

medicines), and 1 (RPSGB Code of Ethics)

One question (question 58) in June 2008 did not fall into any of the

examination syllabus entries and could therefore not to be mapped. In

September 2008, five questions (14, 30, 31, 32, and 61) did not map well onto

any of the examination syllabus entries and could therefore not be mapped.

3.3.1.1 Areas of duplication of assessment

As noted above, in all examination papers, from June 2008 to September

2009 inclusive, the examination syllabus entry that was been assessed most

frequently was syllabus entry 14. Across the four examinations, the mean

number of times this element was assessed in the closed book paper was 41,

in comparison to the overall mean for the other entries which was 4.1. In

addition to this particular element of the syllabus, many questions mapped

onto other codes as well at the same time. Those syllabus entries that were

frequently mapped to questions that also mapped onto syllabus entry 14 were:

• Evidence-based practice (code 13)

• Non-prescription remedies (code 15)

• Differentiating minor illness from more serious disease (code 16)

• Adverse effects of medicines (code 17)

• Contra-indications (code 18)

• Drug interactions (code 19)

• Counselling requirements (code 20)

• Health promotion and disease prevention (code 23)


3.3.1.2 Areas of under assessment

In comparison to the highly assessed syllabus entries, in particular entries 1,

6, 14, and 17, all other elements of the examination syllabus are consistently

assessed considerably less frequently. The mean number for the assessment

of all elements of the examination syllabus was 4.1 times per examination.

Those entries which were assessed less than four times were therefore

considered to be under assessed (excluding ‘Calculation’ (code 24) which is

not part of the closed book examination). Those that were assessed at least

once but less than four times are:

• Continuing Professional Development (CPD) in pharmacy (code 3)

• Conditions for operating a registered pharmacy (code 7)

• National Health Service (code 8)

• Health and safety (code 9)

• Good dispensing practice (code 27)

• Prescribing guidelines, data and formularies (code 31)

• Quality Assurance of stock (code 33)

• Responding to adverse drug reactions (code 34)

Five elements of the examination syllabus were never assessed in the closed

book examination between June 2008 and September 2009:

• Roles and training requirements for pharmacy support staff (code 5)

• Consumer protection (code 11)

• Formulation and preparation (code 26)

• Special Handling Requirements (code 28)

• NHS complaint procedures (code 35)

3.3.1.3 Differences between years

As can be seen from Table 1, there are differences in the number of times

syllabus entries were examined in the closed book papers in 2008 and 2009.

Five elements from the examination syllabus have only been assessed in the

2009 examination papers:





• Operating procedures in primary and secondary care (code 32)


3.3.1.4 Assessment of knowledge and/or understanding

The closed book paper appears to place the greatest emphasis upon

knowledge alone. In each closed book paper analysed, the number of

questions that assessed both knowledge and understanding is similar, with

the exception of the September 2008 paper. In all papers analysed, the least

emphasis was placed upon understanding alone (see Table 3.2).

Table 3.2: Number of times syllabus entries assessed knowledge and/or understanding (number of questions) in the closed book Element of examination (codes 1-35; K, U, K+U)

June 2008

September 2008*

June 2009*

September 2009

Average 2008/09

Knowledge 49 62 46 52 52 Understanding 1 7 4 1 3 Knowledge and Understanding 40 20 39 37 34

*1 question removed from paper

3.3.2 Open book examination paper

This section of the report focuses on the findings from mapping the open book

examination papers in 2008 and 2009. Tables 3.3 and 3.4 display the amount

of times the examination syllabus entries and knowledge and/or

understanding, respectively, were covered in the open book examination

between June 2008 and September 2009.

Five elements from the examination syllabus have only been assessed in the

2009 examination papers:







3.3.2.1 Areas of under assessment

The elements of the examination syllabus which have a mean result for the

number of times an entry has been assessed of less than three (the average)

are considered to be under assessed. Those that were assessed at least once

but less than three times include:

• Principles of audit (code 4)



• Environmental Protection (code 10)




• NHS complaint procedures (code 35)

There are eleven elements of the examination syllabus that were not

assessed during any of the four open book examination papers in 2008 and

2009:

• Clinical governance (code 2)

• CPD in pharmacy (code 3)



• Consumer protection (code 11)

• Data protection and health records (code 12)

• Dilution (code 25)

• Formulation and preparation (code 26)

• Good dispensing practice (code 27)

• Special Handling Requirements (code 28)

• Quality assurance of stock (code 33)


Table 3.3: Number of times syllabus entries are assessed in the open book examination

Element of examination (codes 1-35) June 2008

Sept. 2008

June 2009

Sept. 2009

Total

1 RPSGB Code of Ethics 4 3 3 4 14 2 Clinical governance 0 0 0 0 0 3 Continuing Professional Development in

h 0 0 0 0 0

4 Principles of audit 0 0 2 0 2

5 Roles & training requirements for pharmacy support staff 0 0 1 0 1

6 Sale and supply of medicines 11 15 11 14 51 7 Conditions for operating a registered pharmacy 0 1 0 0 1 8 National Health Service 0 0 0 0 0 9 Health and safety 0 0 0 0 0 10 Environmental Protection 0 0 1 0 1 11 Consumer protection 0 0 0 0 0 12 Data protection and health records 0 0 0 0 0 13 Evidence-based practice 0 0 3 0 3 14 Action and uses of drugs 29 31 34 38 132 15 Non-prescription remedies 5 1 3 6 15 16 Differentiating minor illness from more serious

di 0 0 1 0 1

17 Adverse effects of medicines 4 4 8 16 32 18 Contra-indications 2 2 3 4 11 19 Drug interactions 3 4 3 2 12 20 Counselling requirements 2 2 2 1 8 21 Optimising patients' drug therapy 0 0 6 1 7 22 Interpretation of test results 3 3 1 0 7 23 Health promotion and disease prevention 1 2 2 3 8 24 Calculation 21 21 20 21 83 25 Dilution 0 0 0 0 0 26 Formulation and preparation 0 0 0 0 0 27 Good dispensing practice 0 0 0 0 0 28 Special Handling Requirements 0 0 0 0 0 29 Stability of dispensed preparations 0 1 0 3 4 30 NHS funding for pharmacy services 4 4 6 4 18 31 Prescribing guidelines, data and formularies 1 0 0 0 1

32 Operating procedures in primary and secondary care

0 0 1 0 1

33 Quality Assurance of stock 0 0 0 0 0 34 Responding to adverse drug reactions 0 3 1 5 9 35 NHS complaint procedures 0 0 0 0 0


3.3.2.2 Questions in the registration examination mapped against the examination syllabus

Just like in the closed book examinations, syllabus entry 14 (‘action and uses

of drugs’) was also assessed most frequently in the open book papers. This

element of the syllabus was assessed between 29 and 41 times in the four

examination papers (mean = 33.5.). The second most frequently assessed

syllabus entry was 24 (‘calculations’), which was assessed between 20 and 21

times in 2008 and 2009. Syllabus entry 6 (‘sale and supply of medicines’)

followed in frequency and was assessed between 11 and 15 times.

In June 2008, five questions (question 49-51 and 61-62) were missing from

the examination paper and were therefore unable to be mapped onto the

syllabus. In June 2009 one question (question 14) was unable to be mapped

onto the examination syllabus as it did not correspond to any of the elements

assessment.

3.3.2.3 Areas of duplication of assessment

Some elements of the registration examination syllabus were being assessed

much more than others; there was clearly some over assessment/duplication

in this respect. The mean result for the number of times an entry was in the

open book papers from June 2008-September 2009 was 3. In all examination

papers from June 2008-September 2009 inclusive, the examination syllabus

entry that was assessed most frequently was entry 14 (‘action and uses of

drugs’). In addition to this particular element of the syllabus, many questions

mapped onto other codes as well at the same time. Syllabus entries that were

frequently mapped to questions that also mapped onto syllabus entry 14 were:

• Adverse effects of medicines (code 17)

• Contra-indications (code 18)

• Drug interactions (code 19)

• Counselling requirements (code 20)


3.3.2.4 Difference between years

Two elements from the examination syllabus were only assessed in 2008.

These were:



Seven elements from the examination syllabus were only assessed in the

2009 examination papers. These were:

• Principles of audit (code 4)


• Environmental Protection (code 10)

• Evidence-based practice (code 13)


• Optimising patients’ drug therapy (code 21)


3.3.2.5 Assessment of knowledge and/or understanding

The open book paper also places the greatest emphasis upon knowledge

alone. In each open book paper analysed, the number of questions that

assessed understanding alone was similar, with the exception of the June

2009 paper.

Table 3.4: Number of times syllabus entries assessed knowledge and/or understanding (number of questions) in the open book Element of examination (codes 1-35; K, U, K+U)

June 2008*

Sept. 2008

June 2009

Sept. 2009

Average 2008/09

Knowledge 39 38 34 32 36 Understanding 19 20 29 20 22 Knowledge and Understanding 17 22 17 28 21

*5 questions missing


3.3.3 Summary/Comparison of the closed and open book papers

Our analysis of four pharmacist registration examination open and closed

book examination questions (from 2008 and 2009) suggests that the closed

book paper assesses a wider range of elements from the examination

syllabus than the open book paper. The mean number of questions based on

‘actions and uses of drugs’ in the four closed book papers analysed was 42,

compared to a mean of 34 in the four open book papers analysed. In the

closed book papers analysed, the entry ‘action and uses of drugs’ was

consistently assessed in conjunction with ‘CPD in pharmacy, sale and supply

of medicines, optimising patients’ drug therapy, interpretation of test results

and calculation’. In the open book papers analysed, the elements that were

consistently assessed in conjunction with ‘action and uses of drug’ were

adverse effects of medicines, contra-indications, drug interactions and

counselling requirements. It should be noted, however, that in the closed and

open book papers, ‘action and uses of drugs’ has never consistently been

assessed with a particular entry. The number of times it is assessed with a

particular element of the examination syllabus is variable. For example, in the

June 2008 closed book paper, it was assessed ten times in conjunction with

‘non-prescription remedies’, but only assessed twice in conjunction with the

same element in the September 2008 paper.

Besides syllabus entry 14, there were a number of other entries which were

assessed frequently in all four reviewed examinations. They were entries 6

(sale & supply of medicines), 17 (adverse effects of medicines), and 1

(RPSGB Code of Ethics) in the closed book examination, and 24

(‘calculations’) in the closed book examination. These syllabus entries are

ones encompassing pharmacists’ keys competencies and roles, so would be

expected to be adequately and sufficiently assessed. Some syllabus entries

were assessed rather less frequently, others were not assessed at all during

one or more of the four reviewed examination papers.

Both the closed and open book papers placed the highest emphasis upon

assessing knowledge alone. The closed book paper assessed knowledge and


understanding to a similar level as knowledge alone, whereas, the open book

paper assesses understanding to a similar level as knowledge alone.


4 Discussion

In this report, we have compared registration requirements for pharmacist

registration in GB with requirements in other countries, as well as

requirements for other healthcare professionals in the UK. We have also

reviewed the final written registration examination required for GB pharmacist

registration in detail, to identify which elements of the examination syllabus

are being assessed, and to what extent, and whether questions assess

knowledge and/or understanding. This discussion section will summarise the

findings from these different parts (see sections 2 and 3) and discuss their

implications.

Our findings from comparing registration requirements for pharmacists

elsewhere (namely in Australia, Canada, New Zealand, and the USA), as well

as other UK healthcare professionals (optometrist, doctor or dentist) have

shown that there are both similarities and differences. Both provide us with a

better understanding of possible different approaches, and also give some

insight into potential benefits and/or drawbacks within these.

4.1 Registration requirements for other healthcare professions in the UK

The training of the healthcare professions in Great Britain we looked at

(dentistry, medicine and optometry) were chosen because they all have an

undergraduate mostly university based degree course, followed by more

practice based training pre- or post graduation. For the purpose of this study,

we focussed on training, supervision and assessment during practice based

learning. None of the other healthcare professional registrations required a

written examination comparable to the GB pharmacist registration

examination, but they were much more focussed on practice based

assessments.

One important finding that is worth noting here was the difference in the

number of individuals or tutors involved in the supervision and assessment of


pre-registration trainees in the different professions. In pharmacy there is one

tutor who is integral to the pre-registration year of a trainee. They serve as

both a colleague and mentor, supervisor, and as an assessor. By assessing

and signing the pre-registration performance reports on the trainee’s

progression, they ultimately dictate to a large extent whether a trainee has

performed to a satisfactory standard and is ready to sit the registration

examination. Likewise, in optometry there is one supervisor who acts as the

key contact for the trainee optometrist during their SfR training. However,

separate external assessors are involved in the assessment of the student.

In medicine, an even larger number of individuals are involved in contributing

towards both the training and measurement of performance (assessment) of

foundation doctors. Trainees are assigned an educational supervisor and a

clinical supervisor, so they essentially have two key points of contact

throughout their foundation training. They will receive feedback and undergo

assessment from them, who in turn draw on regular assessments from other

sources that liaise with the foundation doctors, such as colleagues (doctors

and other healthcare professionals such as nurses) and patients – they

essentially receive ‘multi-source’ feedback.34 This is arguably advantageous

over the one-to-one feedback and supervision more likely to be encountered

for pre-registration pharmacy trainees and optometry students.34;35

Dentistry stands out as somewhat of an anomaly because dentistry graduates

register with the GDC following graduation. Although many dentists do tend to

undergo further training and supervised practice after registering, and this is

indeed a requirement for NHS practice, this is not a registration requirement. It

appears that the system in place within pharmacy is most similar to that in

place within optometry whereas dentistry and medicine have more unique

features.

Our research findings from comparing the registration requirements of

different healthcare professions in GB also highlighted some of the differences

in the amount – and type – of assessment undertaken by pre-registration

trainees from the various healthcare sectors. Pharmacy trainees are subjected


to routine monitoring and quarterly progress reports prior to a final written

examination. This differs from the assessment methods in place in the other

professions. In optometry for example there is an emphasis on students

meeting a number of competencies which are verified through visits from an

external assessor. If proven to be competent students will proceed to the next

stage of the SfR which assesses more practical abilities (e.g. undertaking an

eye examination). The final assessment is an OSCE which again assesses

practical (including communication) skills that are routinely carried out by an

optometrist.

Foundation doctors undergo continuous and regular assessment (and

formative feedback) by multiple (and multidisciplinary) assessors.

Assessments such as the mini-CEX and DOPS are carried out during the

foundation and results are provided and ratified by a number of different

people. This is useful in gaining a broad range of insight into the performance

of a foundation doctor. Other forms of assessment aim to develop other skills

such as becoming a clinical tutor.

Drawing a comparison between dentistry and the other healthcare professions

just described is difficult due to the peculiar system of allowing registration

without a ‘pre-registration’ or ‘foundation’ year of supervised practise. The

BDS course undertaken by dentistry students will, however, assess a range of

practical skills and performance throughout the five year undergraduate

course in a similar fashion. Pharmacy may lack some useful features that are

present in the pre-registration training year in optometry and medicine such as

having independent assessors and more practical assessments overseen by

appropriately trained (and independent) assessors. Pharmacy pre-registration

trainees will inevitably undertake a great deal of work during their pre-

registration year which is monitored and developed by their tutor, but formal

and objective tests seem to be lacking.

4.2 Registration requirements for pharmacists in selected other countries


When we examined the pharmacy registration processes internationally, we

discovered that there were a number of similarities in the way the regulators

control pharmacist registration. Commonly, it takes a total of five years’

training to become a pharmacist in GB, Australia, New Zealand and Canada.

In the USA it often takes more than five years. All candidates studying for their

pharmacy qualification in GB, Australia and New Zealand are required to

undertake a degree in pharmacy followed by a year of supervised practice.

Throughout the degree programme there may be practice-based experience

but the majority of real-world practice will take place in the year following the

degree (i.e. the pre-registration year in GB). In Canada and the USA there

appears to be more variation in terms of the amount of practical experience

that pre-registration trainees undertake according to the province or state they

are training in. There is also no ‘set’ year of practising pharmacy under

supervision after completing a pharmacy degree. It seems that such work

experience in distributed through the period of study.

The idea of distributing practical experience throughout the undergraduate

course is something that is already in place in Bradford University in GB36;

here, students do two six-month blocks of supervised practice at different

stages rather than having a one-year block at the end of their degree.

Perhaps the incorporation of more supervised practice throughout a pharmacy

degree, rather than merged into one year at the end of the degree, provides

students with a better grasp and knowledge of practical experience which is

conducive to learning practical-based subjects in the MPharm. This is indeed

what was recommended in the Pharmacy White Paper.37

Having one individual as a student or pre-registration trainee’s tutor/preceptor

seems to be common place in each country, though the experience and

requirements of these individuals varies. However, as previously discussed,

there may be some subjectivity in assessments of pre-registration trainees if

this comes from one individual acting as a supervisor and an assessor. This of

course may be more of an issue in GB whereby tutors fill in progress reports –

one of the main ways trainees are measured and assessed throughout their

pre-registration training; they do not have external monitors assessing them,


nor do they undergo different assessments, apart from the registration

examination at the end of supervised practice. In New Zealand, and Canada,

for example, OSCEs are used which may be considered a more superior

assessment of someone’s competencies or fitness to practise.38

Perhaps in

GB there can be more assessment during the pre-registration year which will

focus both on areas of practice and additionally on areas which cannot be

feasibly assessed in the registration examination.

4.3 The effectiveness of the pharmacist registration examination: mapping of examination questions against syllabus & knowledge versus understanding

In another part of this study39

, the research team carried out an examination

of the closed and open book examination papers between 2008 and 2009 and

mapped the examination questions against the pre-registration syllabus.

Findings from this research showed that both the open and closed book

examination papers do not place the same amount of emphasis on each

element of the pre-registration examination syllabus. This is clear from our

findings that many questions map onto specific elements such as ‘action and

uses of drugs,’ ‘sale & supply of medicines,’ and ‘adverse effects of

medicines,’ whereas some elements of the syllabus are not covered at all by

any questions. These are areas which are of particular importance in

pharmacy practice, particularly in community and hospital practice, where the

majority of newly registered pharmacists will practise. The elements of the

pre-registration syllabus that went unassessed in both the open and closed

papers were consumer protection (code 11), dilution (code 25), formulation

and preparation (code 26) and special handling requirements (code 28). Our

findings suggest there is an unequal amount of focus on the elements of the

pre-registration examination syllabus in the pre-registration examination

papers. Perhaps it can be expected that some elements may be more

assessed than others, particularly if these are deemed to be very important

aspects of a pharmacist’s future role upon becoming registered.


Our assessment of the registration examination suggests that it particularly

focuses on the assessment of knowledge which is not surprising considering

the aims stated in the pre-registration trainee workbook.6 Assessments have

the ability to direct learning in a particular direction.40

This relatively narrow

focus on the assessment of knowledge in the registration exam means that

particular emphasis and importance rests on the appropriate assessment of a

broad range of competences and understanding in the regular performance

reports.

Indeed, the written registration examination is currently only part of the

registration assessment which is otherwise assessed continuously and signed

off / passed by the tutor in quarterly progress reports. Understanding may be

much better and more appropriately assessed in practice, but how objectively

and independently this is done in different pharmacy sectors and settings

cannot be commented on based on this project. Other healthcare professions

separate supervisory and assessment functions, and others (medicine in

particular) put particular emphasis on not only obtaining regular assessment,

but involving numerous assessors in this process. How effective these

approaches are in the other healthcare professions, and how some relevant

features could be incorporated into pharmacist pre-registration assessment,

would require further study. Equally, the effectiveness, validity and objectivity

of the current assessment using the completion of progress reports by tutors

for pharmacy pre-registration trainees would require further exploration.

In fact, there has been some research over the last decade, which has

highlighted potential problems with in-practice assessments. This has

indicated that some students or trainees in healthcare professions such as

nursing and medicine are progressing through their clinical training without

encountering failure in assessments that measure performances in abilities

they struggle with. Evidence from nursing has demonstrated a ‘failure to fail’

students even though they may be underperforming.41 Assessment of clinical

competency is complex and is generally based on direct observations from a

mentor which will involve subjective value judgements that vary from person

to person.41 There have been findings of nurse mentors passing students on


clinical assessments even when there were doubts about their performance.42

This could be, in part, due to mentors being unprepared to assess the

competency of students in practice placements.42 Further evidence coming

from the medical setting has also demonstrated the ‘failure to fail’ tendencies

mentors may have. A recent study43

has shown that medical tutors may not

fail medical students due a number of factors such as attitudes towards a

student, attitudes about failing a student and motivation to comply with norms,

such as what they think they should do, or what other tutors were doing. In

that study, focus groups were conducted with a number of medical educators

(GPs, hospital doctors and non-clinical tutors) to understand what was behind

the decision process of passing students that may not possess satisfactory

skills and competencies in medicine. Attitudes and beliefs played a major role

in the process whereby, for example, a tutor may not fail a student because

their attitudes toward that student were positive; the student may be well-like

by tutors or was perceived to be aware of their difficulties.

Other factors may play a role in not failing students as another study in

Canada has shown. In this study, conducted by Dudek et al.,44

semi-

structured interviews were conducted with 21 clinical supervisors at the

University of Ottawa. A number of barriers were identified that prevent

supervisors from reporting a trainee who has been performing poorly. These

include lack of documentation (supporting evidence for judgements), lack of

knowledge of what to document, the anticipation of an appeal process, and

lack of remediation options. The failure to fail students who may not be

meeting the necessary requirements for progressing in their chosen field,

such as nursing and medicine, may be widespread. With these issues

appearing to be prevalent in nursing and medicine, it is likely that they are

also occurring in pharmacy.

This research has ultimately identified some possible shortcomings of the

registration examination and its potential implications for the pharmacist

registration process in GB. This research has also considered the registration

systems in place within other healthcare professions in GB and other systems

of pharmacy registration outside of GB and how they may offer a different


approach to assessing and registering pharmacists. With this information, we

are able to make a number of recommendations concerning the registration

assessment of pharmacists in Great Britain. Many of these would need to be

informed by further research, which we also highlight.

At the time of writing, Modernising Pharmacy Careers (MPC) (part of Medical

Education England (MEE)) is reviewing pharmacy undergraduate education

and pre-registration training. They are assessing the content and continuing

relevance of pharmacy training and identifying options for change. Their report

is expected to be published late 2010.


5 Recommendations

We would like to provide the following recommendations to be considered

concerning the pre-registration examination. As stated in our discussion,

these would need to be informed and supported by further evaluation and

research.

• The tutor should continue to undertake formative assessment of the

trainee and provide feedback to support their professional development

• Separate the supervisor (tutor) and summative assessor function to

improve objectivity and consistency between different tutors

• Review who can be a tutor: The training requirements for tutors should

be addressed. Standards for tutors should be developed. Appropriate

training would need to be developed, with which tutors would need to

be accredited, to ensure they can comply with the appropriate

standards.

• Increase the number and type of formative assessments during the

pre-registration year. Increase the number of people and disciplines

involved in these assessments. These assessments should focus on

skills, understanding and competencies central to the practice of

pharmacy.

• The final registration assessment should not just focus on the

assessment of knowledge but should also assess a wider range of

skills and competencies.

• Further training, support and/or mentoring during the first year following

registration could be considered, following the medical model of

foundation 1 & 2 training


6 References

(1) Fazackerley A. Contest hots up for medical places. Times Higher Education Online. 2004.

(2) Larson MS. The Rise of Professionalism: A Sociological Analysis. Berkeley: University of California Press; 1977.

(3) Department of Health. Trust, assurance and safety - the regulation of health professionals in the 21st century. 2010.

(4) Council for Healthcare Regulatory Excellence. Assuring patient safety through regulation. 2009.

(5) General Pharmaceutical Council. Standards of conduct, ethics and performance. Accessed 10/09/10; available from: http://www.pharmacyregulation.org/pdfs/other/gphcstandardsofconductethicsandperflo.pdf

(6) Royal Pharmaceutical Society of Great Britain. Preregistration trainee workbook 2009/10. 2009

(7) Royal Pharmaceutical Society of Great Britain. Preregistration trainee workbook 2010/2011. Accessed 10/09/10; available from: http://www.pharmacyregulation.org/pdfs/preregistrationpharmacists/2ctraineeworkbook201011.pdf

(8) Royal Pharmaceutical Society of Great Britain. Frequently Asked Questions (FAQs) for Pre-registration Tutors. 2010.

(9) General Optical Council. Opticians' registers. 2010. Accessed 15/06/10; available from: http://www.optical.org/en/our_work/Registration/Opticians'_Registers.cfm

(10) The College of Optometrists. Scheme for registration trainee handbook. 2009.

(11) General Optical Council. GOC optometry core curriculum, core competencies and learning outcomes. 2010 Accessed 25/09/10; available from: http://www.optical.org/goc/filemanager/root/site_assets/educational_curricula/goc_optometry_core_curriculum.pdf

(12) Association of Optometrists. Work based assessment visits 2010/11.2010. Accessed 24/09/10; available from: http://www.assoc-optometrists.org/uploaded_files/work_based_assessment_visits_280410.pdf


(13) General Medical Council. The medical register. 2010. Accessed 15/06/10; available from: http://www.gmc-uk.org/doctors/medical_register.asp

(14) Academy of Royal Medical Colleges, Department of Health, NHS Scotland, Department of Health, NHS Wales. The UK foundation curriculum. 2010. Cardiff, Crown copyright.

(15) General Dental Council. Who we regulate. 2010. Accessed 15/06/10; available from: http://www.gdcuk.org/About+us/Who+we+regulate/

(16) General Dental Council. Outcomes for registration. 2010. Accessed 25/09/10; available from: http://www.gdc-uk.org/NR/rdonlyres/4D5C3858-0F32-4EFD-B0E4-A3F79A991D30/0/Learningoutcomesdraftpublication.pdf

(17) Committee of Postgraduate Dental Deans and Directors, Scottish Executive, Department of Health, Department of health Welsh Assembly Government. A curriculum for UK Dental Foundation Programme Training. 2010.

(18) Committee of Postgraduate Dental Deans and Directors. COPDEND Dental Foundation Training Policy Statement . 2010. Accessed 04/06/10; available from: http://www.copdend.org.uk/

(19) Australian Health Practitioner Regulation Agency. Pharmacy Board of Australia. 2010. Accessed 12/07/10; available from: http://www.ahpra.gov.au/Health-Professions.aspx

(20) Pharmaceutical Society of Australia. Intern training programme. 2010. Accessed 12/07/10; available from: http://www.psa.org.au/site.php?id=4291

(21) Marriott JL, Nation RL, Roller L, Costelloe M, Galbraith K, Stewart P et al. Pharmacy Education in the Context of Australian Practice. American Journal of Pharmaceutical Education 2008; 72(6 (Article 131)).

(22) Pharmaceutical society of Australia. Competency standards for pharmacists in Australia. 2010 Available from: http://www.psa.org.au/site.php?id=1123

(23) Pharmaceutical Society of New Zealand. Requirements of the EVOLVE Intern Training Programme. 2010. Accessed 21/09/10; available from: http://psnz.org.nz/public/evolve/documents/RequirementsoftheInternTrainingProgramme.pdf

(24) Pharmaceutical Society of New Zealand. EVOLVE intern programme. 2010. Accessed 21/09/10; available from: http://www.psnz.org.nz/public/evolve/training_an_intern_pharmacist/training.aspx

(25) Royal Pharmaceutical Society of New Zealand. Guidelines for employing an intern. 2010. Accessed 21/09/10; available from:


http://psnz.org.nz/public/evolve/training_an_intern_pharmacist/documents/GuidelinesforemployinganIntern2011.pdf

(26) National Association of Pharmacy Regulatory Authorities. A framework for assessing Canadian pharmacists' competencies at entry-to- practice through structured practical training programs. 2010. Accessed 10/07/10; available from: http://www.napra.org/Content_Files/Files/Framework_for_Assessing_Canadian_Pharmacists_Competencies.pdf

(27) National Association of Pharmacy Regulatory Authorities. Professional competencies for Canadian pharmacists at entry to practice. 2007.

(28) Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 2006.

(29) National Association of Boards of Pharmacy. NAPLEX. 2010. Accessed 12/07/10; available from: http://www.nabp.net/programs/examination/naplex/

(30) National Association of Boards of Pharmacy. MJPE. Accessed 12/07/10; available from: http://www.nabp.net/programs/examination/mpje/

(31) Ried LD, Nemire R, Doty R, Brickler MP, Anderson HH, Frenzel-Shepherd E, Larose-Pierre M, Dugan D. An automated competency-based student performance assessment program for advanced pharmacy practice experiential programs. American Journal of Pharmaceutical Education 2007; 71(6):128.

(32) Hill LH, Delafuente JC, Sicat BL, Kirkwood CK. Development of a competency-based assessment process for advanced pharmacy practice experiences. American Journal of Pharmaceutical Education 2006; 70(1).

(33) Oxford English Dictionary. 2010. Accessed 21/09/10; available from: http://oxforddictionaries.com/

(34) Lockyer J. Multisource feedback in the assessment of physician competencies. Journal of Continuing Education in Health Professions 2003; 23(1):4-12.

(35) Violato C, Lockyer J, Fidler H. Multisource feedback: a method of assessing surgical practice. BMJ 2003; 326(7388):546-548.

(36) Bradford University. Pharmacy MPharm 5 years practice-integrated. 2010. Accessed 23/09/10; available from: http://www.brad.ac.uk/pharmacy/our-courses/undergraduate/pharmacy-mpharm-5-year-practice-integrated/

(37) Department of Health. Pharmacy in England: Building on strengths - delivering the future. 2010.


(38) Sloan DA, Donnelly MB, Schwartz RW, William S. The objective structured clinical examination: The new gold standard for evaluating postgraduate clinical performance. Annals of Surgery 1995; 222(6).

(39) Jee SD, Willis S, Elvey R, Lewis P, Parmar H, Schafheutle EI, Tully M, Hall J. Re-sitting assessments and competence. The University of Manchester. 2010.

(40) Ofsted. Assessment for learning: the impact of National Strategy support. 2008. Accessed 20/09/10; available from: http://www.ofsted.gov.uk/Ofsted-home/Publications-and-research/Browse-all-by/Documents-by-type/Thematic-reports/Assessment-for-learning-the-impact-of-National-Strategy-support

(41) Dolan G. Assessing student nurse clinical competency: Will we ever get it right? Journal of Clinical Nursing 2003; 12(1):132-141.

(42) Duffy K. Failing students: a qualitative study of factors that influence the decisions regarding assessment of students' competence in practice. Caledonian Nursing and Midwifery Research Centre, School of Nursing, Midwifery and Community Health, Glasgow Caledonian University. 2003.

(43) Cleland JA, Knight LV, Rees CE, Tracey S, Bond CM. Is it me or is it them? Factors that influence the passing of underperforming students. Medical Education 2008; 42(8):800-809.

(44) Dudek NL, Marks MB, Regehr G. Failure to fail: The perspectives of clinical supervisors. Academic Medicine 2005; 80 (10 SUPPL.).


7 Appendices

7.1 Appendix 1: Comparison of registration requirements for healthcare professionals in GB

Pharmacy Optometry Medicine Dentistry Years of training required for full registration

5 years 4 years 6 years 5 years

Standard registration training

4 year Master of Pharmacy (MPharm) plus one year pre-registration training post

3 year BsC Optometry plus one year on the ‘Scheme for registration’ (SfR)

5 year Bachelor of medicine, Bachelor of surgery (MBChB) plus 2 year foundation programme

5 year Bachelor of dental surgery (mostly BDS one BChD - Leeds)

Alternative registration training models

5 year ‘sandwich’ course (Bradford) – integrates undergraduate course with pre-registration training

4 year Master of Optometry degree (Manchester) – integrates undergraduate course with pre-registration training

4 year graduate entry and 6 year ‘integrated’ courses available

4 year graduate-entry programmes available

Requirements for entry to registration training MPharm

Must achieve either a 2:2 BsC in Optometry and have a valid Certificate of clinical competency, or (if fail to achieve a 2:2), complete the GOC’s ‘optometry progression scheme’

MBChB BDS entry requirements

Registration categories

One ‘standard’ type of registration for all practising pharmacists. An annotation to the register entry is made for those with prescribing rights.

Two levels: student and full Compulsory ‘student registration’ with the GOC is required from start of BsC throughout training. Full registration upon successful completion of the SfR and the Final Assessment Examination. An additional ‘register entry’ is made for those with supply or prescribing ‘specialty’ rights.

Three levels: provisional, full and specialist Provisional registration – after obtaining MBChB. Full registration - Satisfactory assessment outcomes plus confirmation of overall satisfactory performance during the F1 year. Both surgical and medical attachments are required for GMC registration. After the F2 year, doctors can go on to GP or specialist training, leading to either GP registration or specialist registration. In November 2009, the GMC introduced the licence to practice. To practice medicine in the UK all doctors are required by law to hold both registration and a licence to practice.

One standard type of registration is required for all dentists. There are 13 specialist lists which specialist dentists join.


Pharmacy Optometry Medicine Dentistry

Where the different registration levels allow registrants to practise

Entry onto the RPSGB register allows the registrant to practise as a pharmacist in private practice (community pharmacy or a pharmaceutical company) or for the NHS (hospital or community setting) or other sectors such as the prison service.

Full registration allows the optometrist to practise in private practice, or the NHS (hospital or community setting)

Provisional registration entitles newly qualified doctors to work in F1 Posts in hospitals or institutions approved for F1 service Full registration is required for unsupervised medical practice in the NHS or private practice in the UK Those new to full registration are required to work in an approved practice setting (APS) for 12 months

Registration with the GDC allows a dentist to work in private practice in the UK. (Although this would not be considered ‘good practice’.) In order to work as an associate in general dental service/personal dental service, a dentist must enter their name on the dental list of the PCO – this requires the completion of one year of vocational training (VT)

Where pre-registration training takes place.

Supervised training in employment – the majority take place in a clinical (pharmacy practice) environment usually in either community pharmacy or hospital but with 2 weeks cross-sector experience. There is also a ‘split scheme’ – where time is divided between two sites, and a ‘joint scheme’ with six months in a patient-care setting and the other six in industry, a university or other setting such as the NPA.

High street or hospital practice, usually with a little cross-sector practice (not compulsory but considered good practice).

Year 1 (F1) – all in secondary care settings, usually with three, 4-month attachments in medical and surgical settings. Most learning takes place in clinical areas, but there is protected time for educational activity. Year 2 (F2) Placements usually consist of three 4-month specialty placements, and possibly also embedded ’tasters’ of a week in another specialty. Can be all in secondary care or may include a general practice or academic medicine placement.

Teaching and assessment take place within the university dental school and in Manchester includes some practice in the dental hospital and multi-surgery dental outreach clinics. No time is spent in general dental practice.

Work based experience and how it is assessed

Assessed using: Observation – both formal and informal Role plays, simulations Testimonials Projects or assignments The tutor assesses competence and signs off the trainee against each standard.

he SfR trainee handbook lists the GOC’s 82 competencies. These are assessed through a process of ‘work based assessment’, a two-stage process: The supervisor works with the student, directly supervising them on the premises. Two different assessors visit the workplace to do the stage 1 and stage 2 assessments.

Foundation doctors have a clinical supervisor and an educational supervisor Assessors • assessors must be trained in giving feedback, understand the role of the tool being used, assessment methodology and be competent in the competence they are assessing • most assessors should be supervising consultants, GP principals and doctors in training who are more senior than the foundation doctor, experienced nurses or allied health

For the proposed foundation training, assessments are designed to be work-based assessments. Proposed tools include:

• Longitudinal evaluation of performance (LEP)

• Mini-clinical evaluation exercise (mini-CEX)

• Direct observation of procedural skills (DOPS

• Case-based discussion (CBD) • Patient assessment

questionnaire (PAQ) • Peer assessment tool

(PAT/mini e-PAT)


Pharmacy Optometry Medicine Dentistry professional colleagues • Dental VT ‘test of knowledge’

Other assessment methods

The registration examination assesses knowledge and understanding by asking candidates to analyse and evaluate practice-based problems. A paper examination with two MCQ papers, one closed book (90 questions), one open book (80 questions, 20 of which are calculation style).

The final assessment is conducted at an assessment centre (a university). This is an OSCE with 14 stations (five minutes each).

All assessments are based on performance in the workplace

For the BDS, students are assessed against the learning outcomes. These are divided into generic and specific outcomes – the specific outcomes are areas of knowledge, understanding and competence on which students are assessed. Curricula vary between schools of dentistry. Assessment methods include:

• Written examinations – short answer and MCQ format, to assess knowledge

• OSCEs – to assess clinical competencies and understanding

• Coursework – e.g. researching an illness and producing a report

• Portfolios – students collect evidence of clinical competencies which have to be signed off

• Final examination includes ‘real patient’ and ‘unseen patient’ assessments

Regulatory authority The General Pharmaceutical Council (GPhC) General Optical Council (GOC) General Medical Council (GMC). General Dental Council (GDC)

Training programmes accredited by

The Royal Pharmaceutical Society of Great Britain (RPSGB) The College of Optometrists

Foundation curriculum agreed by the academy of medical royal colleges and the 4 national departments of health.

General Dental Council (GDC) COPDEND


7.2 Appendix 2: Comparison of registration requirements for pharmacists in GB and abroad Great Britain Australia New Zealand Canada USA

Years of training required for full registration

5 years 5 years 5 years 5 years 5-6 years

Standard registration training

4 year Master of Pharmacy (MPharm) plus one year pre-registration training post

4 year Bachelor of Pharmacy (BPharm) plus 1 year of supervised training, during which time an approved intern training course must be completed

4 year Bachelor of Pharmacy (BPharm) plus 1 year

1 year Pre-pharmacy course, followed by a 4 year intern

training programme of Pharmaceutical Society of New Zealand

Bachelor of Science in Pharmacy

1 or 2 year Pre-pharmacy course, followed by 4-year Doctor of Pharmacy (PharmD) (BSc.

Pharm)

Alternative registration training models

5 year ‘sandwich’ course (Bradford) – integrates undergraduate course with pre-registration training

Some graduate-entry MPharm degrees taught in 6 semesters over 2 years

No. Some graduate-entry PharmD programmes available.

Some ‘accelerated programmes’ available.

Registration categories

One ‘standard’ type of registration for all practising pharmacists. An annotation to the register entry is made for those with prescribing rights.

1. general registration 2. limited registration: • postgraduate training or

supervised practice • area of need • teaching or research • in the public interest 3. provisional registration 4. non-practising registration 5. student registration

Two: intern and pharmacist Varies between provinces: generally includes student, intern and ‘general’. Alberta has five.

Varies between states: includes student, intern, ‘standard’ and speciality categories.

Work based experience and how it is assessed

Assessed using: Observation – both formal and informal Role plays, simulations Testimonials Projects or assignments The tutor assesses competence and signs off the trainee against each standard.

Must be assessed as competent in all eight categories of the Competency Standards. • Discussion Papers • Training Day • Health Promotion Project • NPS Pharmacy Practice

Review • CMI Assignment (preceptor

evaluation) • MCQ On-Line Assessment

Module • Workbook including diary

3 assessments against the competence standards during the year Assessed by the preceptor.

monitoring of students’ practice in accordance to competences undertaken by preceptor.

monitoring of students’ practice in accordance to competences undertaken by preceptor.


and intervention records Other assessment methods

The registration examination assesses knowledge and understanding by asking candidates to analyse and evaluate practice-based problems. A paper examination with two MCQ papers, one closed book (90 questions), one open book (80 questions, 20 of which are calculation style).

Australian Pharmacy Competency Assessment Tool (APCAT) Examination • A paper examination with

MCQ format with 120 practice-based questions, some of which are calculation style. Open book examination.

Final oral examination

Pharmacy council final assessment at the end of the year which consists of: • 5 OSCEs assessing clinical

application of clinical knowledge and professional competence for a range of practice scenarios

• An oral interview conducted by 2 assessors,

•

The PEBC Qualifying Examination:

• Part I - written MCQ Part II - OSCE

The NAPLEX - Computer-based examination, uses adaptive technology to deliver selected-response and constructed-response questions, many of which are asked in a scenario-based format

Provincial jurisprudence examinations.

The MJPE tests the pharmacy jurisprudence knowledge of prospective pharmacists. It is a computer-adaptive examination.

Regulatory authority

The Royal Pharmaceutical Society of Great Britain (RPSGB)

The Pharmacy Board of Australia Provincial regulatory authority (usually a ‘College of pharmacy’)

The Pharmacy Council of New Zealand

State pharmacy board

Training programmes accredited by

The Royal Pharmaceutical Society of Great Britain (RPSGB)

Australian Pharmacy Council The Pharmaceutical Society of New Zealand

Degree programmes accredited by

Accreditation council for pharmacy education Canadian Council for

Accreditation of Pharmacy Programs


7.3 Appendix 3: Coding of the registration examination syllabus

Code Examination syllabus entry description 1 RPSGB Code of

Ethics You must be able to demonstrate an understanding of, and be able to interpret, all parts of the Code of Ethics: • the concepts of ethical decision-making, liability, accountability and professional responsibility as described in part 1 • the standards of professional performance described in part 2 • the service specifications described in part 3 • the standards of good professional practice described in the Practice guidance section of The Medicines, Ethics & Practice guide

2 Clinical governance You must be able to demonstrate an understanding of: • the purpose and principles of clinical governance • the application of clinical governance in pharmacy practice

3 Continuing Professional Development (CPD) in pharmacy You must be able to demonstrate an understanding of: • the meaning of lifelong learning • the meaning and principles of Continuing Professional Development • the RPSGB system for undertaking and recording professional development

4 Principles of audit You must be able to demonstrate an understanding of: • the purpose and process of audit and its application in improving practice

5 Roles and training requirements for pharmacy support staff You must be able to demonstrate an understanding of: • the roles commonly undertaken by healthcare staff in their support of pharmacy services • the training and/or qualifications required for such roles


6 Sale and supply of

medicines You must be able to demonstrate an understanding of: • the legal requirements for the sale and supply of medicines and controlled drugs from pharmacies • the legal requirements for the sale and supply of poisons, chemical reagents and spirits from pharmacies • the requirements for the labelling and packaging of all the above substances • the requirements for the supply of supplementary information for all the above substances • the requirements for dealing with medicines returned to the pharmacy

7 Conditions for operating a registered pharmacy You must be able to demonstrate an understanding of: • the requirement to register a pharmacy • the meaning and application of supervision and personal control • the role of the superintendent pharmacist

8 National Health Service You must be able to demonstrate an understanding of: • aspects of NHS legislation of relevance to pharmacy

9 Health and safety You must be able to demonstrate an understanding of: • the employer and employee's legal responsibilities for the health and safety of themselves and others • the principles of risk assessment and management

10 Environmental Protection You must be able to demonstrate an understanding of: • aspects of legislation that pertain to the safe disposal of special and controlled waste from the pharmacy

11 Consumer protection You must be able to demonstrate an understanding of: • aspects of legislation that pertain to the protection of consumers of pharmacy related products and services


12 Data protection and health records You must be able to demonstrate an understanding of: • aspects of legislation that pertain to the keeping and disclosure of data on computer and other recording systems

13 Evidence-based practice You must be able to demonstrate an understanding of: • the principles of obtaining and applying evidence to inform and enhance practice

14 Action and uses of drugs You must be able to demonstrate an understanding of: • the mechanism of action, administration, absorption, distribution, metabolism and excretion of commonly prescribed and purchased licensed medicines • the principle uses of these medicines • correct dosages and dose adjustments for patients with particular needs because of their age or condition

15 Non-prescription remedies You must be able to demonstrate an understanding of: • the actions and licensed uses of medicinal products available without prescription that are commonly used to treat minor ailments

16 Differentiating minor illness from more serious disease You must be able to identify and to demonstrate an understanding of: • the symptoms of conditions that require referral to a medical or other healthcare practitioner • conditions not requiring referral and how they may appropriately be treated by non-prescription medicines, by short -term action that does not involve medication or by lifestyle change

17 Adverse effects of medicines You must be able to demonstrate an understanding of: • the recognised adverse effects of commonly prescribed and purchased medicines

18 Contra-indications You must be able to demonstrate an understanding of:


• the circumstances in which commonly prescribed and purchased licensed medicines are contra-indicated

19 Drug interactions You must be able to demonstrate an understanding of: • the principle interactions that can occur between medicines, prescribed and purchased, and between these medicines and foods or other substances

20 Counselling requirements You must be able to identify and demonstrate an understanding of : • circumstances or situations in which patients or other clients require information • the nature of that information and the most appropriate way to provide it to the individual

21 Optimising patients' drug therapy You must be able to demonstrate an understanding of: • the purpose and principles of medicines management and pharmaceutical care

22 Interpretation of test results You must know, demonstrate an understanding of and be able to interpret: • the normal ranges for blood pressure and key blood components • the normal ranges for therapeutic blood levels of drugs with a narrow therapeutic index • the normal ranges for key parameters of bodily function • the implications of figures outside these ranges

23 Health promotion and disease prevention You must be able to demonstrate an understanding of: • the concepts of health promotion and health education • recommendations for key health parameters • the basis for health improvement programmes • the social, environmental, lifestyle and dietary factors that influence health • how awareness of the stages of behavioural change can help the pharmacist to make interventions appropriate to the individual • actions the pharmacist and pharmacy support staff can take to promote health and prevent disease


24 Calculation

You must be able to: • perform accurately all types of calculations relating to pharmacy practice

25 Dilution You must be able to demonstrate an understanding of: • the correct procedures for the dilution of solid, semi-solid and liquid dosage forms, including selection of the correct diluent

26 Formulation and preparation You must be able to demonstrate an understanding of: • how to develop a suitable formula for preparing sterile and non-sterile products in community and hospital practice • how to apply suitable methods and procedures for the preparation of sterile and non-sterile products in community and hospital practice

27 Good dispensing practice You must be able to demonstrate an understanding of: • the principles and practices involved in ensuring an accurate and efficient dispensing process

28 Special Handling Requirements You must be able to demonstrate an understanding of: • the additional precautions necessary when preparing and dispensing cytotoxic and other products requiring health and safety precautions

29 Stability of dispensed preparations You must be able to demonstrate an understanding of: • the factors affecting the stability of medicinal products (including those dispensed extemporaneously) and the impact of these factors on storage and labelling

30 NHS funding for pharmacy services You must be able to demonstrate an understanding of: • the Drug Tariff, why it is used and how • the procedure for checking the validity of exemptions claimed • the procedure for obtaining the correct charges for prescriptions

31 Prescribing guidelines, data


and formularies You must be able to demonstrate an understanding of: • the purpose of prescribing guidelines and of data from pricing authorities • the purpose of local formularies • the sources of evidence used in the development of prescribing guidelines, data and formularies

32 Operating procedures in primary and secondary care You must be able to demonstrate an understanding of: • the reasons for standardising operating procedures in hospital and community pharmacies • the main areas covered by such procedures/protocols

33 Quality Assurance of stock You must be able to demonstrate an understanding of: • the principles of and methods for assuring the quality of pharmacy products and materials supplied to and from the pharmacy

34 Responding to adverse drug reactions You must be able to demonstrate an understanding of: • the correct actions to take in response to a client reporting an adverse drug reaction, including the national reporting scheme

35 NHS complaint procedures You must be able to demonstrate an understanding of: • the principles of the NHS complaint procedure with reference to complaints about pharmaceutical service


7.4 Appendix 4: Mapping of closed and open book registration examination questions to knowledge and/or understanding and examination syllabus

Tables 7.1 and 7.2 below provide all of the raw data from the mapping exercise that was carried out on the closed and open book examination papers in June 2008, September 2008, June 2009 and September 2009. Table 7.1: Mapping questions from closed book examination to knowledge and/or understanding and syllabus entries

June 2008 September 2008 June 2009 September 2009

Question K, U, KU

Syllabus entry 1-35

K, U, KU

Syllabus entry 1-35

K, U, KU

Syllabus entry 1-35

K, U, KU

Syllabus entry 1-35

1 K 14,15,16 K 17 K 14 KU 14,15 2 KU 14,17,18,1

9 KU 15,18 K 19 KU 14,24

3 KU 14,22 K 30 KU 14, 18 KU 13,14,15,16,20

4 K 13 K 14,15 K 6 K 12 5 K 14,17,18 KU 24 K 14,17,18 K 34 6 KU 14,15,16 U 24 KU 14,15,16 KU 13,14 7 U 24 K 17 U 3 KU 24 8 KU 14,19 K 19 KU 21 KU 14,18,19 9 KU 23 K 14 K 6 K 13,14 10 K 14,29 U 6 KU 14,19,20 KU 13,14,16 11 K 14 K 1 K 13,21,22 KU 13,14,15 12 KU 14,17,19 KU 14,22 K 1 KU 31 13 K 1 K 29 KU 24 K 14 14 K 14 K did not

map KU 13,14,21 K 14

15 K 14,19 K 14,17 K 14,17,19 K 1 16 K 2 U 1 KU 13,14,15,1

6,20 U 2

17 KU 14,17 KU 15,16 U 1 KU 14,17 18 K 16 K 22 K 16 KU 1,6 19 KU 4 K 15 KU 4 K 14 20 KU 14,15 K 14,15 KU 13,14,21 KU 16 21 K 14,17 K 19 K 17 K 14,15 22 K 1 K 17 K 15 K 14,15 23 KU 14,17 K 1,6 K 6 K 14,17 24 KU 14,22 K 23 K 17 KU 24 25 K 23 K 16 K 14 K 8 26 K 14,15 K 19 K 29,33 K 14 27 K 14.17 KU 16 K 20 K 14,17,19 28 K 14,20 KU 16 K 20 K 14,17,19 29 K 14,20 KU 16 K 6 K 14,17,19 30 K 6 K did not

map K 6 K 6

31 K 6 K did not map

K 6 K 6

32 K 6 K did not map

K 6 K 16

33 K 6 K 14,16,17 KU 6,30 K 16 34 K 14 K 14,17 KU 6,30 K 14,15


35 K 14 K 14,17,19 K 30 K 14,15 36 KU 6,30 K 14,20 K 30 KU 6,30 37 KU 6,30 K 14,17,20 KU 14,15,16,1

8,23 KU 6,30

38 KU 6,30 K 6 KU 14,15,16,18,23

K 2

39 K 14,15 K 6 KU 14,15,16,18,23

K 4

40 K 14 K 6 KU 14,15,16,18,23

K 2

41 K 14 K 6 KU 14,15,16,18,23

KU 32

42 KU 14,17 K 14,17 KU 14,17,21 KU 14,17 43 KU 14,17 K 14,17 KU 14,17,21 KU 9,32 44 KU 14,17 K 14,17 KU 14,17,21 K 14 45 KU 14,17 KU 14 K 13,14,21 K 14 46 K 14,15 KU 14 K 13,14 K 14 47 K 14,15 KU 14 K 13,14,18 K 14 48 KU 14 K 6 U 32 K 14 49 K 14 K 6,15 K 13,14 KU 31 50 KU 14 KU 14,17 KU 13,14,21 K 14,15,23 51 KU 6 K 14 K 1,6 K 6 52 K 14 K 6,30 K 14,17 K 14,19 53 KU 14,20 K 6 K 14 K 20 54 KU 14,15,16 K 14 KU 6,7 KU 13,16 55 K 6 K 20 KU 14,15,18 K 23 56 K 14 K 14 KU 13 K 32 57 K 14,15 K 31 KU 22 K 14 58 K did not

map removed from paper

K 14 K 6

59 KU 1 K 1 KU 12 K 6 60 KU 14 U 2 K 1,15 K 6,30 61 K 14,17 K 14 KU 15,16 KU 16 62 K 14,18 K 4 K 14 K 14,18 63 K 1 K 15 K 16 K 1 64 K 14,23 K 1 KU 23 KU 14,18 65 K 14,20 K 16 U 3 K 14,18 66 K 14,18 K 1 K 14,19 K 6,15 67 K 3,14 K did not

map K 17 K 6

68 K 14 KU 3 K 14 K 6 69 K 14,17 K 18 K 8 K 6 70 KU 14,15,16 K 29 K 17 K 14,17 71 K 6 K 17 K 14,15 K 1,32 72 K 6 K 14,18 K 6 KU 6,14,15,16 73 KU 13,14 KU 14,17 KU 13,14,21 K 13 74 K 13,14 KU 27 KU 13,14,21 KU 13,14,17,18,

19 75 KU 13,14 U 1,27 KU 14,19 KU 14,20 76 KU 14,20 KU 17 K 6 KU 22 77 KU 12 K 6,30 K 12 K 14,15,18,19 78 K 6 KU 14,20 KU 14,18,19 K 14,18 79 KU 15 U 1 K 14,18 KU 16 80 KU 23 K 14,18,19 K 14,15 KU 14,15,17 81 KU 14,15 K 4 KU 16 KU 14,20,21 82 KU 16 K 16 KU 17,18 KU 14 83 KU 1 K 6,10 KU 6 KU 14,18 84 K 4 KU 15 KU 1 KU 10


85 KU 14 K 6 KU 4 KU 23 86 KU 1,6 K 6,30 KU 1,27 K 10 87 KU 23 U 1,6,10 KU 25 KU 6 88 KU 6,10 KU 16 K 23 KU 14 89 KU 14,21 KU 1 KU 14,20,21 KU 14,20 90 K 34 KU 14,17 removed from

paper KU 34

Table 7.2: Mapping questions from open book examination to knowledge and/or understanding and syllabus entries June 2008 September 2008 June 2009 September 2009

Question K, U, KU

Syllabus entry 1-35

K, U, KU

Syllabus entry 1-35

K, U, KU

Syllabus entry 1-35

K, U, KU

Syllabus entry 1-35

1 K 14 K 14,20 KU 13,14 K 14 2 K 14 K 17,20 K 14 K 14 3 K 14 KU 14,18 K 14 K 14 4 KU 19,20 KU 14,24 K 1 K 14,20 5 K 14 KU 30 KU 14,21 KU 24 6 K 14 KU 23 K 13 K 23 7 K 6 KU 14 K 6 K 6 8 K 22 KU 14,22 K 6,10 K 14,19 9 K 22 K 19 U 14,21,22 KU 14,18,23 10 U 24 K 14,18 K 14,19 KU 14,17,19 11 K 14 KU 30 K 14,17,18,1

9 KU 14,17,21

12 K 14 KU 14 U 14 K 14,15,17 13 K 15 K 22 U 6,15 K 14,17,18 14 KU 14,19 K 14 U did not

map KU 14,15

15 K 14 K 15 K 14,30 KU 14 16 K 6 K 14 U 14,21 KU 14 17 K 24 K 14 U 6 K 14,18 18 K 14 KU 14 K 13,14 KU 14 19 KU 6 K 23 KU 6 K 6 20 KU 24 K 14 U 14,23 KU 14,17,18 21 K 14,31 K 14,34 K 14 KU 14,17,34 22 K 14,18 K 14,34 K 14,18 KU 14,17,34 23 K 14,20 K 14,34 K 14,20 KU 14,17,34 24 K 14 K 14 KU 6 KU 14,17,34 25 K 6 K 14 U 14 K 30 26 K 6 KU 6 K 14 K 30 27 K 14,17 KU 6 K 14 K 30 28 K 14 K 14 K 14,19 K 14,17 29 K 14,17 K 14 K 14,17 K 14 30 K 14 K 14 K 14 K 14,17 31 K 17 KU 30 K 14 K 6 32 K 14,18 K 6,7 K 14 K 6 33 K 17 K 14,19 K 14,17 K 23 34 KU 14,15,19 K 14,17 K 30 KU 14,17 35 K 6 K 14 KU 6 K 14,15 36 K 14 K 6 K 14 K 6 37 K 6 K 1 KU 14 K 1 38 KU 6 K 14 K 6 K 14 39 K 1 K 6 K 14 K 6 40 K 14 KU 1 K 30 K 14 41 K 6,30 K 6 K 6 KU 1


42 K 14 K 22 K 21 K 6,14,15 43 KU 14,15 K 6 K 20 K 14,15 44 K 1 K 6 K 17 K 1 45 K 23 KU 19 K 14,17 K 14,29 46 K 6 K 6 K 30 KU 6 47 KU 14 K 14 K 14,17 K 6 48 K 30 K 6 K 1,5 K 6,29 49 removed from

paper KU 14 KU 6 KU 14

50 removed from paper

KU 14,17 KU 14,17,34 KU 6,14


K 6,30 KU 15,16,21 KU 1,6

52 KU 30 KU 6 KU 30 KU 30 53 KU 15 KU 14,29 U 23 KU 14 54 KU 14 K 1 KU 6,15 KU 14 55 KU 14,22 KU 14,19 KU 14,21 KU 14 56 KU 30 K 6 KU 4,14 KU 14,29 57 KU 1,14 KU 14,17 KU 14,21 KU 14,15 58 KU 6 KU 6 KU 30 KU 14 59 KU 14 KU 14 KU 14,17,18 KU 6 60 KU 1 K 6 KU 1,32 KU 6 61 removed from

paper U 24 U 24,25 U 24


U 24 U 24 U 24

63 U 24 U 24 U 24 U 24 64 U 24 U 24 U 24 U 24 65 U 24 U 24 U 24 U 24 66 U 24 U 24 U 24 U 24 67 U 24 U 24 U 24 U 24 68 U 24 U 24 U 24 U 24 69 U 24 U 24 U 24 U 24 70 U 24 U 24 U 24 U 24 71 U 24 U 24 U 24 U 24 72 U 24 U 24 U 24 U 24 73 U 24 U 24 U 24 U 24 74 U 24 U 24 U 24 U 24 75 U 24 U 24 U 24 U 24 76 U 24 U 24 U 24 U 24 77 U 24 U 24 U 24 U 24 78 U 24 U 24 U 24 U 24 79 U 24 U 24 U 24 U 24 80 U 24 U 24 U 24 U 24