Hoosen T, Lutchman Z, Mkhasibe N, Ngcobo N, Sivapersad S a. School of Pharmacy and Pharmacology, University of KwaZulu-Natal, Durban, South Africa b

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1 Identifying perceptions of the University of KwaZulu- Natal graduates on the relevance and adequacy of the Pharmacy curriculum to current pharmacy practice a Naidoo P, (MMedSci), a Govender T, PhD b Hoosen T, Lutchman Z, Mkhasibe N, Ngcobo N, Sivapersad S a School of Pharmacy and Pharmacology, University of KwaZulu-Natal, Durban, South Africa b Final year students at the School of Pharmacy and Pharmacology, University of KwaZulu-Natal, Durban, South Africa Abstract Correspondence to: Ms P Naidoo, naidoopj@ukzn.ac.za Keywords: pharmacy curriculum; pharmacy education; relevance; pharmacy practice; UKZN graduates This article has been peer-reviewed Background: Pharmacy, like every other profession, is undergoing radical changes. The knowledge and skills base required by the profession are affected by external changes including patient demographics and expectations, emerging disease state priorities, technological developments, regulatory requirements and development in other professions. Pharmacy education therefore needs to timeously and effectively respond to professional and social change to ensure optimal education and training of pharmacists. It remains the responsibility of staff at academic institutions to ensure that the curriculum and teaching and learning methodologies are relevant to the demands of the profession and that they undergo regular review. Feedback from graduates of a programme, who are at the forefront of current practices and challenges of the profession, is one of the approaches critical in evaluating a curriculum for review and change to enhance pharmaceutical education. The aim of this study was therefore to determine the content relevance and adequacy of and skills training in the BPharm curriculum at the School of Pharmacy and Pharmacology, University of KwaZulu-Natal (UKZN), according to the perceptions of its own graduates. Methods: A cross sectional descriptive study was conducted. A structured questionnaire was developed and administered to UKZN graduates. The sample population of 323 included graduates that qualified between to determine their perceptions towards the pharmacy curriculum in relation to current practice. The list of graduates together with their contact details was obtained from the Faculty of Health Sciences. However, some of the details were no longer relevant and these graduates were thereafter excluded and a valid sample of 152 traceable graduates was obtained. Thereafter, the questionnaires were hand delivered, ed or faxed as per the participant s request after obtaining their consent. Data was collected and captured electronically and analysed using the Statistical Package of Social Sciences (SPSS) for Windows version 15. Ethical clearance was obtained from UKZN Faculty of Health Science Ethics Committee (FECHSC 043/08). Results: The response rate was 57%, with 69% of respondents being females. The majority of respondents graduated in the year 2007 and the mean age range of the participants in years was 24 to 27. The majority of respondents indicated that all modules in the current programme were relevant to their practice (72.7% 100%). However, while relevant, the respondents also reported that the various modules were inadequate in meeting their practice needs (5.7% 4%). It was also established that there were several areas in the curriculum that were lacking. Only a minority of respondents felt adequately equipped in categories such as complementary and alternative medicines (26.5%), traditional healing (10.6%), drug utilisation review (31.8%), overall pharmacy management (14.5% 41.2%) and screening (54.9%), whilst over 90% of the graduates felt they were particularly adequately equipped in areas such as communication, reconstitution of medicines and Pharmacy laws. Except for computer skills (.2%), Research (74.7%), Pharmacy Laws (82.8%), First Aid (77.0%), the study also showed that skills acquisition in all the other indicated subject areas from the University during their training was low (1.1% 54.0%). Overall, 58.1% of graduates felt that their training at university equipped them with the knowledge and skills required to perform their tasks confidently. Conclusions: The findings of the study have highlighted the importance of obtaining feedback from graduates to improve the curriculum. It specifically confirmed a need for the School of Pharmacy and Pharmacology (UKZN) to make specific amendments to the curriculum of the BPharm programme at UKZN in terms of content, to consider introducing new modules and also to explore alternative teaching methodologies within the current constraints of large student numbers and poor resources to enhance skills acquisition in students during their training. 36

2 ORIGINAL RESEARCH Introduction Pharmacy has emerged as dynamic, information driven, patient-orientated profession whereby the pharmacist, through his or her competence and skills, is committed to meeting the health care needs of the people of South Africa. 1 To be effective health care team members, pharmacists need skills and attitudes enabling them to assume many different functions. The various pharmacy schools in South Africa as well as the South African Pharmacy Council (SAPC) are continually challenged to make significant changes in undergraduate pharmaceutical education and training, so that present and future graduates can meet current and future expectations of pharmacy practice. The SAPC has developed unit standards for entry-level pharmacists and these are expressed as outcome statements of the competencies required. 2 In terms of these standards, the pharmacist should be able to: Organise and control the manufacturing, compounding and packaging of pharmaceutical products Organise the procurement, storage, and distribution of pharmaceutical materials and products Dispense and ensure the optimal use of medicines prescribed to the patient Provide pharmacist-initiated care to patients and ensure the optimal use of medicines Provide education and information on health care and medicines Promote community health and provide related information and advice, and Participate in research to ensure the optimal use of medicine 1 Pharmacy, like every other profession, is undergoing radical changes. Clearly then, the knowledge and skills base required are affected by external changes, including patient demographics and expectations, emerging disease state priorities, technological advancements, regulatory requirements and developments in other professions. Various professional and educational reasons for revising a pharmacy curriculum were also highlighted by Enslin et al. 3 These included: the information explosion in pharmacy, changes in practice methods within pharmacy, the need to train the pharmacist for the 21 st century in which rapid change needs to be dealt with and to encourage life-long learning. Pharmacy education therefore needs to timeously and effectively respond to professional and social changes to ensure optimal education and training of pharmacists. Although the outcomes are specified by the SAPC, curriculum development is, nevertheless, led individually by higher education institutions. It therefore remains the responsibility of staff at these institutions to ensure that the curriculum and teaching and learning methodologies are relevant to the demands of the profession and that they undergo regular review. Curricula evaluation may occur on different levels i.e. with an individual module and programme assessment, within broader school or institutional changes and within more global changes at a national level. 4 It also includes various approaches to curricular evaluation such as content relevance (knowledge, skills and attitude), teaching and assessment methodologies, learning outcomes achievement, performance monitoring, staff and student perceptions and feedback from graduates and employers. For example, El-Awady et al 5 evaluated pharmacy programmes in terms of student perspectives on specific aspects of the curriculum, Kapol et al 6 evaluated the curricula content based on competency standards while Ho et al 7 used an outcomes based approach to measure the effectiveness of a curriculum for revision. The BPharm programme at the School of Pharmacy and Pharmacology, University of KwaZulu-Natal (UKZN) is one of the most popular programmes in the University and receives in excess of applications annually for approximately 90 places in its first year. The programme is taught mainly by the didactic approach in a discipline (Pharmaceutical Chemistry, Pharmaceutics, Pharmacy Practice and Pharmacology) based manner. The BPharm progamme is covered in a period of four years in a semesterised modular structure. The development of the current content and delivery of the programme have been extensively informed by the competencies and objectives established by the SAPC, feedback from stakeholders, government health authorities and recent research developments. The impetus for this project arose from a need to review the BPharm curriculum at UKZN to ensure relevance to the changing patterns of practice within pharmacy for pharmacists to optimally fulfil their roles in the health care team. Feedback from graduates of a programme, who are at the forefront of current practices and challenges of the profession, is one of the approaches critical in evaluating a curriculum for review and change. A search for any published studies or grey literature to date on the relevance and adequacy of the pharmacy curriculum to current practice amongst graduates of University of KwaZulu-Natal (UKZN), or the previous University of Durban-Westville (UDW), as well as amongst students of other universities in South Africa did not yield any results. The aim of this study was therefore to determine the content relevance and adequacy of skills training in the BPharm curriculum at UKZN, according to the perceptions of its own graduates. Methodology A cross sectional descriptive study was undertaken. The sample population included interns, community service pharmacists and pharmacists that graduated from UKZN or the former University of Durban-Westville (UDW) between the years A list of contact details of pharmacists, interns and community service pharmacists who qualified from UKZN or the former UDW was obtained from the Faculty of Health Sciences. The sample population comprised 323 graduates. Graduates that could not be contacted through the details given were subsequently excluded from the study, 37

3 giving a valid sample of 152 traceable graduates that worked in the KwaZulu-Natal (KZN) province. A structured questionnaire that contained both closed- and open-ended questions was developed. It contained three sections: demographic data in the first section, closed-ended questions in the second section and open-ended questions in the third section. Section two included, amongst others, questions on the course content in terms of relevance, adequacy and skills obtained. The open-ended questions probed their suggestions for improvement of the curriculum and for additional course content incorporation or deletion. The questionnaire was piloted amongst six pharmacists to clear ambiguity, ensure clarity of questions and to determine the time taken to complete the questionnaire. Copies of the questionnaire were distributed via fax and , however most were personally delivered. Ethical clearance was obtained from UKZN Faculty of Health Science Ethics Committee (FECHSC 043/08). The study was explained to participants and a consent form was completed prior to administration of the questionnaire. Participation in the study was voluntary and participants were given the option to withdraw from the study at any time. Anonymity of the participants was maintained throughout the study. Data was collected, captured electronically and analysed using Statistical Package of Social Sciences (SPSS) Version 15 computer software. Frequency tables were generated and responses were tabled and graphed accordingly. Cross tabulations were done using chi square analyses. A p value of 0.05 was regarded as statistically significant. Results and discussion Response rate and demographic profile Of the 152 graduates that comprised the sample size, 87 graduates completed the questionnaires giving a response rate of 57%. Possible reasons for not achieving a 100% response rate were primarily due to time constraints as there was a short space of time in which data collection could be carried out and the participants busy work schedules which also hindered completion of the questionnaire. The majority of respondents were female (69%), within the age range of years (50.6%) and had graduated in 2007 (%). The race and nationality of the respondents were: South African of African origin (20.9%), South African of Indian origin (76.7%), South African of European origin (1.2%) and other (1.2%). Figure 1 shows that the majority of the respondents work in the public hospital sector (68.6%) with over 25% in the private sector (community pharmacies and private hospitals), while only 1.2% were in the pharmaceutical industry. The relatively low placement of respondents in the latter sector may be due to the smaller number of pharmaceutical companies in KZN as compared to the other provinces in South Africa. Table I highlights the modules currently taught in the BPharm curriculum and presents the perceptions of the graduates in terms of relevance and adequacy. Whilst the majority of Figure 1: Current distribution of UKZN graduates in the various sectors of pharmacy: Perceptions of graduates on Pharmacy curriculum Community Private hospital Industry Wholesale Public hospital Other respondents felt that the current modules were relevant to their current practice (72.7% 100%), it was of significance to note that many felt that the modules were still inadequate in meeting their current practice needs (5.7% 4%). The three modules highlighted with the highest inadequacy were Introduction to Pathology (4%), Zulu Communication Skills (43.6%) and Pharmacy Logistics Economics and Management (%). Therefore, whilst the current modules are all relevant to the programme, it is necessary for academics to examine the extent to which the content within these modules is meeting the needs of the current practice of pharmacy. It would be necessary to take cognisance of the data in Table II to strengthen the adequacy of the modules. Respondents were also asked to evaluate the adequacy of their skills in relation to their current practice and to state specifically where that skill was obtained (Table II). Whilst over 90% of the graduates felt they were particularly adequately equipped in areas such as pharmacy laws, communication and reconstitution of medicines, only a minority of respondents felt adequately equipped in categories such as complementary and alternative medicines (26.5%), traditional healing (10.6%), various aspects of pharmacy management (14.5% 41.2%), drug utilisation review (31.8%) and screening (54.9%). Further, except for computer skills (.2%), pharmacy laws (82.8%), first aid (77.0%), research (74.7%) and analytical calculations (69.0%), the study also showed that skills acquisition from the university during their training in all the other subject areas had been low (1.1% 54.0%). Although the BPharm programme at UKZN is taught mainly using the didactic approach, several strategies are currently incorporated into the programme to enhance skills development, active learning, problem solving and student engagement. These include an experiential training programme, ward round visits, laboratory sessions, seminar presentations and problem based sessions within modules. Clearly, these appear to be inadequate and the School of Pharmacy and Pharmacology (UKZN) would need to explore alternative approaches, within the constraints of large 38

4 Table I: Responses to the relevancy and adequacy of the modules currently taught in the Pharmacy curriculum (n = 87) Module Relevant % Irrelevant % Adequate % Inadequate % Pharmacology Pharmaceutical Care Health Law and Ethics Pharmacy Calculations Pharmacy Logistics Economics and Management Physical Pharmacy Pharmaceutical Technology Introduction to Pathology Zulu Communication Skills Institutional Pharmacy Pharmaceutical Chemistry Biopharmaceutics Research Project Advanced Drug Delivery Pharmaceutical Analysis Sterile Products Medicinal Chemistry Community Studies student numbers and limited resources, to facilitate skills development. Table II also highlights the importance of the internship training in skills acquisition especially in areas such as communication, reconstitution of medicines, stock taking and pharmacist initiated therapy. The subject areas rated the highest in terms of inadequacy and low skills acquisition during their university training are discussed below. Complementary and alternative medicines It was established in the study that only 26.5% of respondents felt adequately competent in complementary and alternative medicine (CAM). When comparing the reported adequacy of skills in CAM amongst graduates across different years of qualification, it was established that students in the year 2006 were better equipped (56.8%) in their knowledge of CAM. In comparison to this, only 9% of respondents that graduated in 2005 felt adequately equipped in the area of CAM (p = 0.048). Since there was no change in the programme, this could possibly be due to the fact that the use of CAM was gaining more prominence in the market place especially with its use in HIV/AIDS and other chronic conditions, and that individual lecturers may have been emphasising aspects of CAM post 2005 within existing modules. The results of this study correlate with those of Tiralongo and Wallis, where it was established that pharmacists generally rated their knowledge relating to CAM as inadequate and were not confident in answering patient queries. 8 They also stated that more than 50% of the world s population uses CAM, mostly in combination with conventional medicine. In addition, more than complementary medicines have been submitted for evaluation to the complementary medicines committee according to the Medicine Regulatory Authority (MRA) of South Africa. 9 It has also been highlighted in the literature that pharmacists are frequently cited as accessible to patients and one of the most trusted health care professionals and that patients routinely ask them for advice about a variety of CAM-related practices. For this reason, many believe that pharmacists must be better educated regarding CAM. 10 Within the South African context, respondents were also specifically asked about traditional healers, another group of alternative therapists. Only 10.6% of respondents felt that their skills were adequate for their participation in the area of traditional healing, with only % indicating skills obtained from the university. There are an estimated indigenous traditional healers in South Africa, that includes witch-doctors and herbalists, and up to 60% of South Africans consult them. 11 Owing to this large proportion of South Africans that are seeking alternative forms of therapy, the National Drug Policy aims to encourage traditional healers to work more closely with the formal health sector, particularly in programmes such as immunisation monitoring and AIDS 40

5 ORIGINAL RESEARCH management. 12 Therefore, pharmacists with their extensive knowledge of disease states and treatment modalities can play an important role in optimising patient management and drug therapy in collaboration with traditional healers. Pharmacy management In various specific areas required for management of a pharmacy, e.g. SARS/VAT returns, human resources, financial management, medical aid claims, ICD 10 codes and managed health care, the majority of respondents (58.8.5%) indicated inadequate skills to meet current practice needs. Further skills acquisition at the university in these areas was very low (1.1% 26.4%). This finding is supported by Calomo, 13 who stated that a major focus of the educational curriculum within the schools of pharmacy was the quality of patient care whereas the business aspect was Table II: Perceptions of respondents of their current skills to meet practice needs, and the place of skills acquisition Place of skills acquisition Subject matter n Adequate (%) Inadequate(%) University(%) Internship(%) Workplace as a pharmacist (%) Pharmacy Laws/Regulations Communication Skills Reconstitution of Medicines Patient Counselling Computer Skills Research First aid Analytical Calculations Stock Taking Procurement of Drugs Drug Manufacturing Pharmacist Initiated Therapy Therapeutic Drug Monitoring Pricing Regulations incl SEP Drawing up of Standard Operating Procedures Screening Family Planning Managed Health Care Drug Registration Drug Utilisation Review Medical Aid Claims Line Opening / Clearance ICD 10 codes Opening up of a New Pharmacy Complementary Medicine Human Resource Management Budget Management SARS, VAT and VAT Returns Traditional Healing

6 often neglected. Knowledge of pharmacy management is required in every sector of pharmacy. Knowledge and skills in areas including budget management, procurement, stock taking, ICD10 codes, medical aid submissions and human resource management are important to ensure the efficient provision of cost effective pharmaceutical health services. Drug utilisation review (DUR) The rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their individual requirements, for an adequate period of time, and at the lowest cost to them. 14 One of the aims of the National Drug Policy is to ensure the rational use of drugs by promoting rational prescribing, dispensing and use of drugs to support the informed and appropriate use of drugs by the community. 12 Pharmacists, with their extensive training in this area, must be at the forefront of meeting these objectives. Yet only 31.8% of respondents felt that their DUR skills were adequate, with only 19.5% of respondents indicating that the skills required were obtained from the university. Screening The SAPC requires that pharmacists meet the health care needs of the people of South Africa by being the provider of essential clinical services, including screening and referral services. While 54.9% of graduates felt that their skills were adequate, only 12.6% of respondents obtained these skills from the university. According to the Good Pharmacy Practice (GPP) guidelines, a pharmacist that provides screening and monitoring services must comply with GPP and must be competent in order to provide patients with such services. The SAPC, together with the pharmacy schools, had undertaken a study to quantify these procedure codes. The aim was to determine the activity time for the services for which a pharmacist may levy a fee, the cost of providing services in a pharmacy and the number of persons required to provide these services in pharmacies. These services include, amongst others, dispensing of prescriptions, counselling, and measurement of blood pressure, glucose and cholesterol. The results of this project will be submitted to the Director General in the National Department of Health for publication in the national health reference price list. In order for pharmacists to provide these services as a profit component of community and hospital pharmacies, current and future pharmacists would need to have sufficient knowledge and skills in order to conduct such tests and provide sound advice to patients. Other Some of the other significant areas perceived by the respondents as those in which their skills were inadequate due to low skills acquisition at university included drawing up of standard operating procedures, medicine registration and line opening/closing. This finding illustrates the inadequacy of the provisions of Unit Standard 1 and 2 for pharmacists as prescribed in terms of section 33 of the Pharmacy Act 53 of This may be due to the fact that the School is not adequately covering aspects of industrial/manufacturing pharmacy in the current curriculum. This is compounded by the fact that there are limited experiential training opportunities due to the limited number of pharmaceutical companies within the vicinity of UKZN. In addition to considering the introduction of a module on Industrial Pharmacy, the School needs to explore securing further vacation jobs for students in the industry, inviting pharmacists from the industry to deliver presentations on various aspects of industrial pharmacy and devising assignments that create a simulated industrial environment to enhance their knowledge and skills as manufacturing pharmacists. Further concern pertains to the provisions of Unit Standards 3 and 4 in the curriculum as these form part of a core function of pharmacy practice i.e. communication skills, patient counselling, therapeutic drug monitoring, reconstitution of medicines and pharmacist initiated therapy. More than 55% of the graduates reported that they did not obtain these skills from the university. Academics may need to reconsider the teaching and assessment methods to ensure that the skills are optimally acquired before the graduates are declared competent. Response to BPharm programme for preparation to perform tasks Respondents were also asked whether their education and training at the School of Pharmacy and Pharmacology (UKZN) adequately equipped them to perform their tasks with confidence. Although 58.1% of respondents felt that the university had equipped them adequately, a vast number of respondents (41.9%) felt poorly equipped to perform their tasks with confidence. There appeared to be a significant correlation between the year that respondents qualified and their attitudes towards their university training (p = 0.034). It was apparent from the results obtained that the majority of graduates that qualified in 2006 (92.6%) felt that they could perform their tasks with confidence due to their university training. In comparison a smaller proportion of respondents that graduated in 2003 (%) felt adequately equipped to perform their tasks with confidence. One of the possible reasons may be the following: In 2002, the School undertook a curriculum review process. Amongst other interventions, the content of several existing modules was revised to address developments in the profession. Therefore, the 2006 graduates were exposed for a longer period to the revised modules than the 2003 graduates. The open-ended questions on suggestions for improvement to the curriculum only yielded responses that indicated a need for modules to cover the content emphasised as lacking in Table II and no new subject matter and/or modules were recommended for addition or deletion. Limitations of the study Some of the limitations of this study are the following: Since this is a self-reported study, the reliability of self reporting is 42

7 ORIGINAL RESEARCH difficult to substantiate as information was collected and analysed based on what the graduates reported. Also, as a cross sectional study, the direction of the association may not be causal. The results of this study may, in addition, not be relevant to all UKZN BPharm graduates since the sample size was small and confined to the province of KZN within the period only. Conclusions and recommendations This study showed that the majority of the respondents felt that all the modules in the current curriculum were relevant to their practice needs. However, the modules were also indicated as being inadequate in terms of meeting their current practice needs. Some of the modules with higher percentages of being inadequate were the Zulu Communication Skills, Introduction to Pathology and the Pharmacy Logistics Economics and Management modules. The main areas in which the graduates indicated their skills as being inadequate in terms of their current practice needs were pharmacy management, complementary and alternative medicines, traditional healing, drug utilisation review and screening. In most areas, the study also identified low skills acquisition during their university training. This study also identified a need for the possible development of a new module to address aspects pertaining to industrial pharmacy practice. The findings of the study have highlighted the importance of obtaining feedback from graduates to improve the curriculum. It specifically confirmed a need for the School to make specific amendments to the curriculum of the BPharm programme at UKZN in terms of content, to consider introducing new modules and also to explore alternative teaching methodologies within the current constraints of large student numbers and poor resources, to enhance skills acquisition by students during their training. These interventions will contribute to improving the quality of graduates to optimise pharmaceutical services provision in the country. References: 1. PSSA Pharmacy Law Compendium, Volume 1, 2005, Lexis-Nexis, PRE 53, 54, Enslin G, Haavik C, Lowes M, Moola F, Summers B, Summers R. Pharmaceutical education in the South African multicultural society. Am J Pharm Educ, 2001;65: Enslin G, Lowes MMJ, Summers B, Summers RS. A fresh approach to pharmacy education: the collaborative BPharm degree of Medunsa and Technikon Pretoria. Pharmaceutical Journal, 1999;263: Anderson HM, Anaya G, Bird E, Moore DL. A review of educational assessment. Am J Pharm Educ, 2005;69:Article El-Awady EE, Moss S, Mottram D, O Donnell J. Student perspectives on pharmacy curriculum and instruction in Egyptian schools. Am J Pharm Educ, 2006;70:Article Kapol N, Maitreemit P, Pongcharoensuk P, Armstrong EP. Curricula based on Thai pharmacy competency standards. Am J Pharm Educ, 2008;72:Article Ho SSS, Kember D, Lau CBS, Yeung MYM, Leung DYP, Chow MSS. An outcome based approach to curriculum development in Pharmacy. Am J Pharm Educ, 2009;73:Article 14, (Pg. 1 9). 8. Tiralongo E, Wallis M. Integrating complementary and alternative medicine education into the Pharmacy curriculum. Am J Pharm Educ, 2008;72:Article Registration of complementary medicines. Available at (Accessed 10/06/2008). 10. Choudary V, Harris IM, Kingston RL, Rodriguez R. Attitudes towards complementary and alternative medicine among Pharmacy faculty and students. Am J Pharm Educ, 2006;70: Indigenous Healing in Southern Africa. Available at izangoma/part1.asp (Accessed 05/10/2008). 12. National Drug Policy. Available at drugsjan1996.pdf (Accessed 15/08/2008). 13. Calomo JM. Teaching management in a community pharmacy. Am J Pharm Educ, 2006;70:Article Guidelines for implementing drug utilization review programs in hospitals. Available at htm&language= english&module=drugs (Accessed 03/09/2008). 43