INTRODUCTION

Continuing professional development (CPD) has become an increasingly significant attribute of most professions, especially those associated with health care.¹ The International Pharmacy Federation declared: “Maintaining competence throughout a career during which new and challenging professional responsibilities will be encountered is a fundamental ethical requirement for all health professionals”.²

CPD is a lifelong learning process that needs continuous pharmacist proficiency through maintenance and enrichment of skills, performance and knowledge.²,³ It aids health care practitioners to remain up to date and competent, thus, fit to practice.⁴ CPD involves any education that helps pharmacists increase their skills, counting any continuing education (CE) whether it's workplace-based or distance learning or electronic learning (1). The role of the CPD process is to incite each health care professional into keeping up with the changes in practice and to ensure that the public confidence in their services they offer are being retained and developed.¹ Core elements of CPD include a pharmacist's self-directed, structured and outcomes-oriented activities for practice-based learning.⁵ This continuing process is based on the 4-stage Kolb learning cycle of identification, planning, implementation/action, evaluation.⁶ CPD is a principal element within a clinical governance context of professional accountability, in the provision of quality service, in the management and reduction of risks, and the continuous enhancement of standards.¹ Most countries with a CE or CPD system request all registered participants to demonstrate annual activity participation (lectures, seminars, congresses, conferences).⁷

Mandatory CPD requirements were implemented in the UAE⁸ in November 2014 and in Qatar⁹ in March 2016, whereas other countries such as Egypt are assessing the degree of readiness and acceptance for CPD in the healthcare sector.¹⁰

In Lebanon, there were no requirements of licensure prior to 2011. Stimulated by developments and initiatives in other countries, the Pharmacy Board of Lebanon (OPL) issued standards for mandatory CE in November 2011, that took effect actually in January 2014.¹¹ As a result, pharmacists practicing in Lebanon are required to document at least 15 credits of CE activity annually, of which at least 5 should be “live” CE.¹¹ Each pharmacist is to submit his/her records for review and monitoring. Failure to meet these standards could lead to disciplinary action up to license suspension. In addition, the OPL is operating in the meantime towards transitioning from CE to CPD.

In many countries, the evolution to a CPD approach and the use of a learning portfolio for documentation and reflection is fairly new for pharmacists. To date there is little published evidence on the impact of such changes and the pharmacists' views and attitudes towards CPD.¹² In 2001, a study conducted in Northern Ireland determined the perceptions of pharmacists on CPD. Barriers to participation were identified as lack of time, remuneration and lack of understanding of CPD.¹³ Another study carried out on a small number of English community pharmacists (n=21) revealed that they needed additional support since they were not fully engaging in CPD.¹⁴ A further study conducted on Scottish pharmacists' views and attitudes to CPD revealed four associated factors: “having positive support in the workplace, having access to resources and meeting learning needs, having confidence in the CPD process and motivation to participate in the CPD process”. Hospital pharmacists reported having more confidence in the CPD process, while community pharmacists were identified as the pharmacy sector that needed most support regarding ability in participation.⁴ In the United States, a study entitled ‘The 5-state CPD pharmacy pilot program' was the first broad-based study evaluating the role of CPD in the pharmacy sector. Its objectives were to find out whether a structured educational intervention would aid pharmacists' utilization of a CPD approach as well as to assess its effectiveness and feasibility for pharmacists.¹⁵

In Lebanon, to the best of our knowledge, to date there is no published evidence regarding pharmacists' views and attitudes towards CE and its transitioning to CPD, particularly those offered by the OPL. In many countries, collection of these views and attitudes in the pharmacy profession has been commonly achieved using questionnaire methodology.⁴ Via this means, studies have found that pharmacists agree with the notion of CPD.¹³,¹⁶ By recognizing areas and identifying sectors where pharmacists' motivation to CPD is high, as well as pinpointing major barriers to participation, possible solutions can be sought for sectors of practice where views and attitude to CPD are less positive.⁴

The primary aim of the present study is to investigate the views and attitudes of pharmacists in Lebanon towards mandatory CE - particularly those offered by OPL- and its transition to CPD. Secondary outcomes include studying the barriers to participation in CPD.

METHODS

Study Design

This is a cross-sectional observational study, using a proportionate random sample of Lebanese pharmacists working in pharmacies from all districts of Lebanon. It was conducted between February and May 2017. A list of pharmacies was provided by the Order of Pharmacists in Lebanon (OPL). Pharmacists working on Lebanese premises were included in the study, whereas pharmacists living outside Lebanon were excluded. The questionnaire was distributed to 800 pharmacists out of a total of 7391 pharmacists living in Lebanon; 591 (73.87%) pharmacists filled and returned the questionnaire.

A sample of 525 pharmacists was targeted to allow for adequate power for bivariate analyses to be carried out. This minimal sample size was obtained by using a total number of registered pharmacists in OPL of 8500, a 39% expected frequency of pharmacists' confidence that the CPD meets their needs¹, and a 5% confidence limits.¹⁷

Study Procedure

The questionnaire used in this study was developed after an extensive literature review and based on previous similar studies in different countries.¹³,¹⁴,¹⁶,^{18 19}-²⁰ Two links, one in English and one in Arabic, were sent via emails as well as via the OPL push notification application simultaneously every 2 weeks. Each pharmacist filled the online questionnaire once.

The questionnaire consisted of 9 parts (A to I), including information about the sociodemographic characteristics of the sample, factors affecting motivation towards CPD, the types of CPD used by the pharmacist, the causes behind using the CPD types mentioned before, and the evaluation of CPD (offered by OPL). Parts (B to E) were skipped by pharmacists who were not involved in practicing CPD yet.

Moving on, the questionnaire comprised questions concerning the attitudes of pharmacists to different elements of CPD (Identification, Planning, and Implementation). Furthermore, the questionnaire assessed the barriers to participation in CPD activities (part G). Finally, the questionnaire asked about future CPD in terms of abiding regulations offered by OPL (part H) and about the types of CPD that were used by the pharmacist (part I).

Motivation, attitudes and barriers scores

Pharmacists' motivation score was calculated using 5 questions by adding the scores for each question, with each question scoring 1 for strongly disagree and 5 for strongly agree. The questions that formed the motivation score were “I feel confident that CPD meets my needs”, “I feel confident that my CPD is preparing me for practice development”, “I have sufficient time to achieve my CPD goals that are mandated by OPL”, “I have sufficient resources (computer access, internet access, 3G/Wi-Fi access, conferences) to achieve my CPD goals” and “I have sufficient enthusiasm to achieve my CPD goals”. The motivation score ranged from 5 to 25, with a higher score indicating more motivation. The attitude score was calculated by adding the score for the following questions: “I feel confident in my ability to assess what I have learned”, “I feel confident in my ability to assess what additional CPD activity may be necessary”, “I feel confident in my ability to assess the benefits of my practice”, “I feel confident in my ability to identify my own learning needs”, “I need some help in identifying my learning needs”, “I am fully aware of resources”, “I am confident about my ability to access resources”, “I have support (encouragement and sufficient time) in my workplace to carry out my CPD plans” and “I have adequate access to suitable CPD resources”. The attitude score ranged from 9 to 45, with a higher score indicating a better/more positive attitude for CPD.

Concerning the barriers score, the same calculation method was used for the following questions: “Accessibility of group learning activities (location/distance)”, “Job constraints (restrictions)”, “Lack of time”, “Cost of participation”, “Lack of relevant learning opportunities”, “Uninteresting subjects or topics”, “Lack of quality learning activities”, “Family constraints (restrictions)”, “Subjects/ Topics are too specialized” and “Low personal priority of learning in relation to other activities”. The barriers score ranged between 10 and 50, with a higher score indicating a higher number of barriers.

Statistical Analysis

Data was analyzed using the Statistical Package of the Social Sciences version 23. Descriptive statistics were calculated for all study variables. This includes the mean and standard deviation for continuous measures, counts and percentages for categorical variables. The Chi-square test was used for bivariate analysis of categorical variables, whereas Student test were used for comparison of means between two groups. ANOVA and Kruskal-Wallis tests were used to compare between three groups or more. Pearson correlation coefficient was used to correlate between quantitative variables. Bonferroni adjustment was used for ANOVA post hoc tests of between groups comparison. Statistical significance was set at p<0.05.

RESULTS

The sociodemographic characteristics of the whole sample are summarized in Table 1, whereas the description of pharmacists practicing CPD can be found in Table 2. It is important to note that 69.3% of the respondents practiced CPD in the past.

Approximately half of the pharmacists that completed the questionnaire agreed that all the factors that were mentioned in the questionnaire motivate CPD, whereas 55.4% agreed that they feel confident that CPD meets their needs. In addition, 62% agreed that they feel confident that CPD is preparing them for practice development, whereas 34.8% agreed that they have sufficient time to complete required CPD credit hours. 76% agreed that they have sufficient resources (computer access, internet access, conferences) to achieve their CPD goals. 57.9% agreed that they have sufficient enthusiasm to achieve their CPD goals (table 3).

Bivariate analysis results for factors affecting the pharmacist's motivation towards CPD showed that a significantly higher percentage of pharmacists aged between 20-30 years thought that available CPD programs did not meet their needs (57.1%), leads to their development (61.9%), had enough time to achieve CPD (43.3%), had sufficient resources (69.2%) compared to all other age groups. A significantly higher percentage of pharmacists aged between 31-40 years strongly disagreed that they had sufficient enthusiasm (51.7%) compared to the other age groups.

A significantly higher percentage of females agreed that they have enough time to achieve their CPD compared to their male counterparts (62.1% vs 37.9%; p=0.043; chi-square). It is of note that no significant difference was found for these 2 variables between males and females concerning the fact that CPD meets their needs, leads to their development, had sufficient resources or sufficient enthusiasm.

A significantly higher percentage of community pharmacists strongly disagreed that CPD meets their needs (42.9%) and leads to their development (52.4%) compared to all other sectors of the pharmacy profession (Table 4).

The most used CPD activities were the live activities (21.6%), computer/internet based activities (47.7%), and interactive workshops (21.3%). Almost 60% of the pharmacists agreed they use the type of CPD because it is at no cost. In addition, more than 70% of them agreed they had easy access to print/online material or because of their interest in learning about a specific topic regardless of the venue (Table 5).

Seventy-eight percent agreed that they feel confident in their abilities to assess what they have learned. 71.6% agreed that they feel confident in their abilities to assess what additional CPD activity may be necessary. 77.6% agreed that they feel confident in their abilities to assess the benefits of their practice. 81.2% agreed that they feel confident in their abilities to identify their own learning needs. 76% agreed that they are fully aware of resources available to them to address their CPD requirements. 76.7 agreed that they are confident about their abilities to access resources (computer access, internet access, 3G/Wi-Fi access, conferences) to address their CPD requirements and 69.6% agreed that they have adequate access to suitable CPD resources (Table 6).

The majority of the pharmacists agreed that accessibility of group learning activities (location/distance) (69.6%), job restrictions (76.3%) and lack of time (80.6%) were the most essential barriers to participation in CPD (Table 7).

We calculated the reliability of each scale to assess the quality of our data. We obtained high Cronbach alphas for all scales as follows: motivation scale (0.858), attitude scale (0.862) and barriers scale (0.797). Based on fairly adequate internal consistency, we believe that the findings were relatively reliable.

The bivariate analyses between the different variables and barriers to participation in CPD showed that a significantly higher percentage of pharmacists aged 20-30 years (58.3%) disagreed that family constraints might be a barrier to participation in CPD (p=0.005), with no significant difference between age and other barriers. Furthermore, no significant difference was found between gender and the current practice site with all barriers online Appendix.

The bivariate analyses showed that motivation was significantly and positively correlated with attitude (r=0.718; p<0.001), but negatively correlated with barriers (r= -0.243; p<0.001), years of experience (r= -0.201; p<0.001) and age (r=-0.236; p<0.001). A significantly higher mean for the motivation score was found in males (13.32) compared to females (12.44) (p=0.036). Neither the marital status nor the monthly salary were significantly associated with the motivation scale (p=0.465 and p=0.889, respectively).

The bivariate analyses showed that attitude was significantly and negatively correlated with barriers (r= -0.120; p=0.021), years of experience (r= -0.144; p=0.004) and age (r=-0.175; p<0.001). A significantly higher mean attitude score was found in males (21.45) compared to females (20.08) (p=0.018). Neither the marital status nor the monthly salary were significantly associated with the attitude scale (p=0.484 and p=0.238, respectively).

The bivariate analyses showed that the barriers score was not significantly correlated with age (r=0.001; p=0.988), the years of experience (r=0.002; p=0.966), gender (p=0.648), monthly salary (p=0.997) but was significantly correlated with the marital status (p=0.021).

No significant difference was found between all sectors of practice concerning attitude and barriers (p=0.209 and p=0.141, respectively). Regarding motivation, a higher motivation score was found in community pharmacists (13.21) compared to their hospital counterparts (10.91) (p=0.015). No significant difference was found between other groups (community vs medical representative (p=0.111) and hospital vs medical representative (p=0.069)).

DISCUSSION

Attitude and motivation have shown to be essential elements in CPD involvement.²¹ Also, in the past, the aspect regarding pharmacists' motivation for participating in CPD has been studied as a key factor to learning.⁴ Within the pharmacy profession, as well as in other healthcare professions' CPD practices, the magnitude of motivation has been acknowledged.²¹ Our results showed that the identification of learning needs was the constituent of the CPD process the majority of pharmacists felt at ease with.¹ Confidence in their capability to recognize their individual training needs was high.¹ These findings are in agreement with a study conducted on Scottish pharmacists' views and attitudes towards CPD¹, although it contradicts previous findings, which state that “general medical practitioners' insights into their own educational needs were also poor”.¹⁵ One explanation is that means for enabling pharmacists to identify their own learning needs proactively ought to be further developed and made accessible.¹ Generally, in our study, motivation and attitude were positive. These findings are in agreement with a study carried out on Texan pharmacists' views, attitudes and preferences related to continuing pharmacy education that revealed approximately 83% of respondents (n=161, response rate 31%) found that currently available CE programs met their educational needs.²² However, a significantly higher percentage of community pharmacists strongly disagreed that CPD meets their needs and leads to their development compared to all other sectors of the pharmacy profession. One explanation for this could be that community pharmacists are not generally involved in teams, and usually work in isolation compared to their hospital and primary care counterparts.²³ Thus the CPD resources and peer support may not be readily available to this sector.⁴ Another explanation could be the frustration that community pharmacists feel towards the pace and intensity of pharmacy practice and how this negatively affects their capability to fully embrace CPD by incorporating learning into their practice.¹²

Within the study, two scores were collated; a motivational score which measured overall motivation towards CPD; and an attitudinal score which measured confidence, ability and support required taking part in the CPD cycle and the reflection process.¹ Our results show that motivation was significantly and positively correlated with attitude. This finding is in agreement with previous studies suggesting that a positive attitude towards CPD is a motivating aspect for efficient performance.²⁴ In addition, by evaluating the motivational and attitudinal median scores, our results show a significant difference between hospital and community pharmacists in the collated motivational median scores but not in the attitudinal score, with the latter proving the more motivated group. This finding is in opposition with other studies where primary care and hospital pharmacists tended to score higher than their community counterparts.¹ However, this may be due to the small number of response from hospital pharmacists encountered in our study. Thus, although community pharmacists' motivation scores were statistically higher than hospital pharmacists, the overall practical significance of these findings is to be limited. The real differences in the scores need to be assessed using larger sample size studies from both sectors in order to tell whether subgroups of highly or poorly motivated pharmacists may explain the overall findings.¹ No significance was found in other sectors of practice regarding motivation or attitude.

According to the majority of respondents, our results show that the essential barriers to participation in CPD include lack of time, difficulties in accessing group learning activities due to distance and job restrictions. Needless to say, these findings re-iterate results shown in previous studies.¹⁶,¹⁸,²⁰,²⁵ In addition, our results show that attitude and motivation were significantly and inversely correlated with barriers to participation in CPD.

In previous studies, the lack of time for CPD¹⁸,²⁶,²⁷ and a high workload¹⁸ were the most commonly reported barriers to participation in CPD. Moreover, lack of information technology support²⁸ and type and location of available courses²⁶ have also been other commonly reported resource barriers to CPD. An important element affecting pharmacists' opinions of CPD was the ease of access to CPD resources.¹⁴,²⁹ Creating networks where pharmacists can talk about their CPD needs and access resources to reach their learning needs may prove helpful.⁴

In our study, the fact that most pharmacists perceived insufficient time to attain their CPD goals was highlighted.¹ Moreover, in England, a study found that pharmacist respondents recognized that they believed that a fraction of working time could be devoted to CPD activities (20). Other healthcare professionals working in medicine and dentistry have defined learning time ‘protected' as their model to provide additional CPD support.¹ The finding in our study that respondents believed they did not have enough time to achieve their CPD goals suggests a similar need, although the idea of ‘protected time' is not likely to be accepted by the workplaces where registered pharmacists are employed.¹

Our results show that motivation and attitude were significantly and negatively correlated with years of experience and age. This finding, not surprisingly, is in line with earlier studies where it was found that older pharmacists were significantly less motivated towards participation in CPD than their younger colleagues.¹⁸,²⁷

Higher significant mean attitude and motivation scores were found in males compared to females, the latter proving to be less motivated and to have less confidence in their ability to participate in CPD. This contradicts previous studies where females carried out significantly more hours of continuing education and CPD¹⁶,¹⁸ or where no significant differences were found between men and women regarding motivation.¹ The fact that our results show a higher motivational and attitudinal score in males versus females could be attributed to different sample sizes and sampling methods to formerly published reports.¹

The most used CPD activities were live in person ones, computer/internet based ones, and interactive workshops. This is due to the fact that these activities carry no cost and are easy to access.

Limitations

Our study suffers from some limitations. The sample size is small. A selection bias is possible because some areas were difficult to reach especially the remote ones. Furthermore, it was not possible to compare the characteristics of responders and non-responders. Additionally, nonobjective understanding of questions is possible, as in all questionnaire-based surveys. An information bias is also possible since the use of a questionnaire in any population may not always be accurate: problems in question understanding, recall deficiency and over or under evaluating symptoms may still be possible.

CONCLUSIONS

Views and attitudes of Lebanese pharmacists towards continuing professional development were assessed in our study, along with their motivation level. Also, the barriers and obstacles to participation in CPD that they encounter while trying to further their education were identified. To date, there are limited data on Lebanese pharmacists' views, attitudes and barriers to participation in CPD; the information from our study contributes to informing the forward pathway for the profession. Generally attitude and motivation to CPD were positive in this study. Moreover, it is apparent that there are different views and attitudes towards participation in CPD among sectors of practice. However, these issues necessitate further study at a larger scale. A large number of pharmacists opted not to fill the questionnaire. Older pharmacists and female pharmacists appear to be the sectors requiring most support to increase not only their motivation to CPD but also their confidence and ability in participating in CPD. Accessibility of group learning activities due to distance and location, job restrictions and lack of time have shown to be the major barriers to participation in CPD. By acknowledging these findings, potential solutions can be sought where views and attitude to CPD are less positive.