The relevance of the International Pharmaceutical Federation Global Competency Framework in developing a country-level competency framework for pharmacists: A cross-sectional study

Background In the ever-changing roles of pharmacists, the evidence shows that the use of competency frameworks could aid in achieving professional performance development and ensuring a consistent quality pharmacy education. However, there is no national competency framework for pharmacists in Saudi Arabia. This study, therefore, uses an evidence-based method to identify the competencies required to support and facilitate the pharmacists' training and career development. Objective To assess pharmacists' perception of the relevance of the International Pharmaceutical Federation (FIP) Global Competency Framework (GbCF v1) to their own practice. Methods A cross-sectional online survey of pharmacists in different practice settings was conducted between August and November 2020, in Saudi Arabia. The survey was adopted from the GbCF v1. A combination of purposive and snowball sampling was used. The relevance to the GbCF v1 was assessed using a four-point Likert scale. Data were analysed using descriptive and inferential statistics. Results A total of 522 pharmacists participated in the survey. The study showed broad agreement on relevance to practice for 84% of behaviours included in the GbCF v1. The ‘pharmaceutical public health’ cluster scored the highest percentage of relevant responses (91.42%), followed by the ‘professional/personal’ cluster (87.08%), whereas the ‘organisation and management’ cluster scored the highest percentage of ‘not-relevant’ responses (18.40%). The observed non-relevancy was associated with gender, nationality and area of pharmacy practice (p < 0.05). Conclusion The competencies and behaviours included in the GbCF v1 are relevant to pharmacy practice in Saudi Arabia. However, some behaviours of the GbCF v1 require modification to be appropriate for the local needs of the Saudi pharmacy practice. The findings from this exercise will be used as a base to develop a foundation-level competency framework to inform initial pharmacy education development and address knowledge gaps and learning needs required to attain and maintain pharmacists' competence to practise.


Introduction
Pharmacists are critical human resources for health. 1 Their key role within the health system, particularly in optimising safe, responsible and effective use of medicines, underpins the demand for a highly skilled and competent workforce. 2,3 To fulfil their roles, pharmacists must attain and maintain essential competencies relevant to the population health needs in order to ensure a high standard of patient care delivery, thereby helping to improve the health of individual patients and the wider population. Thus, it is crucial to identify the competencies required for pharmacists to enable them to work effectively in the ever-evolving healthcare system.
A competency is defined as a subset of knowledge, skills, attitudes and personal qualities essential to the practice of the healthcare profession at the desired level. 4 The importance and usefulness of competencies in the professional development of pharmacists has prompted the International Pharmaceutical Federation (FIP) to identify and clarify the competencies required for pharmacists globally to perform their tasks safely, effectively and efficiently. 5 Each competency comprises a set of behavioural statements that 'define how that competency would be observed or recognised'. 6 Therefore, a competency framework typically contains a set of competencies and associated behaviours required for effective performance in practice. 7 Developing a national competency framework across all sectors can be used as a mapping tool to inform and ensure a consistent quality pharmacy education as well as the professional development of pharmacists. 7 Evidence shows that using competency frameworks can facilitate professional Exploratory Research in Clinical and Social Pharmacy 5 (2022) 100095 performance development, identify knowledge gaps and tailor learning needs to maintain and attain fitness to practise. [8][9][10][11] In 2012, the FIP developed an evidence-based Global Competency Framework version 1 (GbCF v1) to support the foundation level (or early career) practitioners' development worldwide. 12 The aim of this was to facilitate a seamless transition from initial education through foundation level (day one of registration) to advanced and specialised practice. 2,13 The FIP GbCF v1 includes a set of competencies that can be used as a 'mapping tool' to develop country-specific frameworks according to the local needs of pharmacy practice. Since its development, it has been used successfully to develop country-specific frameworks for in-service pharmacists as well as pre-service education in a number of countries. [14][15][16][17][18] This provides evidence that the FIP GbCF can be adapted as necessary to relevant for the specific needs of a country. In response to the evolving roles of pharmacists and technology and therapeutic advances, in September 2020, the FIP published the GbCF v2, a revised and updated framework that adds new competencies to reflect these developments. 19 In Saudi Arabia, there are about 27,000 pharmacists distributed over private and governmental pharmacy sectors. 20 About 64.7% of pharmacists work in community pharmacies, 31.1% in hospitals, 2.9% in primary healthcare clinics and 0.7% in other settings, including factories, scientific offices and drug stores. 64.8% of the pharmacists are non-Saudi and 81% are males.
In community pharmacies and primary healthcare clinics, pharmacists take on the traditional role of medication dispensing and counselling. In hospitals, pharmacists are responsible for a range of activities, such as compounding and dispensing of medicines, management of medicines storage and supply, provision of drug information as well as pharmaceutical care services. [21][22][23] In order to practise, pharmacists must complete a Doctor of Pharmacy (PharmD) or a Bachelor's degree in Pharmaceutical Sciences (BPharm) from a higher education institution, sit a national licensure exam and acquire a specific number of hours of continuing pharmaceutical education annually for re-licensing. 24,25 No national competency framework or other standards for practice exist for pharmacists in any sector or stage of practice in Saudi Arabia. Although the National Commission for Academic Accreditation and Assessment (NCAAA), the national accrediting institute for higher education in Saudi Arabia, has published a detailed description of learning outcomes for both PharmD and BPharm, no competencies are identified. 26 However, given that learning outcomes are often used as a tool to measure how well students demonstrate a particular competency, it is essential to first identify competencies in order to define learning outcomes. 4,27 Importantly, identification of competencies will inform the development of competency-based education, a modern educational model that aims to instil in health graduates the competencies required to provide care services that meet societal healthcare needs. 28,29 The lack of a competency framework raises questions about the quality of pharmacy education, licensure and re-licensure processes to maintain pharmacists' competence and fitness to practise. In addition, there is a consensus of pharmacy experts in Saudi Arabia about the need to improve the current educational outcomes measure of pharmacy programmes at the national level, to ensure that the graduates meet the expected needs of the country. 30 Hence, there is a need for an evidencebased professional development tool to inform the pharmacy education development process and support current pharmacists to evaluate their capabilities and learning needs for a successful professional development journey.
Therefore, this study aimed to examine the relevance of the FIP GbCF v1 in a Saudi pharmacy practice setting by assessing pharmacists' perceptions of the relevance of the FIP GbCF v1 to their own practice. This will help to identify the competencies required for the effective performance of pharmacists within all sectors of practice, in order to develop a national competency framework for foundation level pharmacists. This will be used to inform and to ensure the quality of initial pharmacy education and, subsequently pharmacy practice in Saudi Arabia.

Study design
A cross-sectional anonymous online survey was conducted between August and November 2020. The survey aimed to assess the relevance of the FIP GbCF v1 to the practice of a broad population of pharmacists across different settings of practice in Saudi Arabia. This study was approved by the University of Nottingham's School of Pharmacy Research Ethics Committee (Ref. 011-2019).

Survey development
At the time of the survey development, the second updated version of the FIP GbCF v2 had not been published, 19 therefore, the survey was fully adopted from the FIP GbCF v1. The survey constituted 100 behavioural statements under 20 competency groups and divided over four broad clusters ( Table 1). The respondents were asked to rate the relevance of each statement to their current practice using a four-point Likert scale: highly relevant, relevant, low relevance and not relevant.
Open-ended questions were added at the end of each cluster where the participants were asked to add any comments or additional behaviours that they consider useful or relevant for each cluster. The online survey was developed using JISC (JISC Online Surveys, Bristol, United Kingdom). It included a cover page providing the background and the purpose of the study, an electronic informed consent form and nine demographic questions. All survey items were designed in English, which is the commonly used language in health professions in Saudi Arabia.

Data collection
All registered pharmacists were eligible for inclusion in this study as foundation level pharmacy practice has not yet been defined in Saudi Arabia. Therefore, a purposive sampling approach was used by approaching the Saudi Commission for Health Specialities (SCFHS), the licensing and registration body for all healthcare providers in Saudi Arabia; and the Saudi Pharmaceutical Society (SPS), the professional society that represents more than 4000 pharmacists in Saudi Arabia, to assist in the survey distribution.
They were asked to send the survey anonymous URL link to the emails of all pharmacists included in their registry lists. To increase participation, a snowballing sampling approach was also utilised. The survey URL link was further modified and distributed to the researcher's (SA) contact list via the social media platform, WhatsApp®. Contacts were asked to assist by forwarding the survey URL link to their contacts and colleagues. Following survey distribution, reminders were sent every two weeks for three months.

Data analysis
Quantitative data were downloaded directly into a Microsoft Excel spreadsheet. All data were cleaned and coded manually and systematically checked for errors. Of this, 10% data were cross-checked with the original downloaded Excel spreadsheet. Then, data were exported to the Statistical Package for Social Sciences (SPSS) version 27, for quantitative data analysis using descriptive and inferential statistics. Demographic data were analysed and reported using percentages and frequencies. To ensure a meaningful interpretation of the four-point Likert scale relevance rating, and for the purpose of analysis, it was planned empirically to integrate the response categories of 'highly relevant' and 'relevant' into one category: relevant; and the response categories of 'low relevance' and 'not relevant' into one category: not relevant. The agreement on relevance to practice was compared between these categories using percentages and frequencies. The percentages of relevance ratings within each cluster in relation to the respondents' characteristics were represented graphically using heat maps. The cut-off point on relevance to practice was attained when equal to or more than 80% of the responses were in the 'relevant' category. The published literature informed the decision to define at least 80% as the cut-off point on relevance rating. 17,18,31,32 Behavioural statements that had high responses in the 'not relevant' category were further analysed using Pearson's Chi-square (χ 2 ) test to evaluate the association between the responses and respondents characteristics such as the area of practice and length of time in practice as well as other demographics such as nationality and gender. To identify the significance in the analysis, a probability level of P < 0.05 was used. Qualitative data from open-ended questions were downloaded directly into a Microsoft Word document then analysed thematically using Qualitative Analysis Software NVivo version 12.

Demographics
A total of 522 pharmacists participated in the survey. Of them, 418 (80.1%) were male and 342 (65.5%) non-Saudi. Respondents working in direct patient care (DPC) settings, including community pharmacy, hospital pharmacy and primary healthcare centres, accounted for 79.3% of the sample. Respondents' median length of practice was ten years (IQR ±10). Respondents' characteristics are shown in Table 2.

Relevance rating-overall
From the 100 behavioural statements rated within the four competency clusters, 84 met the cut-off point of at least 80% agreement over relevance ( Table 3). The aggregated responses of each cluster showed that the PPH cluster scored the highest percentage of relevant responses (91.42%), followed by the PP cluster (87.08%), while a higher percentage of not relevant responses were evident in the OM cluster and PC cluster (18.40% and 14.66% respectively).

Relevance rating-per area of practice
Respondents from DPC settings, including community pharmacy, hospital and primary health care centres, showed a higher relevance across all clusters compared to Non-Direct Patient Care (NDPC) settings, including academia, industry and regulatory organisations (Fig. 1). Academia and industry showed little engagement in OM (academia = 69.56%; industry = 78.36%) and PC (academia = 76.59%; industry = 71.38%) compared to PPH (academia = 88.88%; industry = 86.53%) and PP (academia = 86.98%; industry = 84.31%) clusters.    Table 4 presents a comparison between respondents' nationality with each competency cluster. Data showed that non-Saudi respondents have showed a higher relevance to all clusters compared to Saudi respondents: PPH (94.59%, 85.41%, respectively), PC (87.15%, 81.88%, respectively), OM (85.20%, 74.75%, respectively) and PP (88.80, 83.81%, respectively). Table 5 presents a comparison between the gender of respondents and each competency cluster. Data showed an overall high relevance to all clusters in favour of male respondents than female respondents. Data of PPH and OM, in particular, showed high relevance of male respondents (92.34%, 83.62%, respectively) compared to female respondents (87.74%, 73.49%, respectively).

Relevance ratings-areas of disagreement overall
Findings shows that 16 behavioural statements have a percentage above the predefined cut-off point of relevance (20%) from the PC, OM and PP clusters. These behaviours represent two from 'compounding medicines' competency group, two from 'patient consultation and diagnosis', four from 'budget and reimbursement', two from 'human resources and management', four from 'procurement' and two from 'quality assurance and research in workplace' (Table 3).

Areas of disagreement-per area of practice
A Pearson's Chi-square (χ 2 ) test showed that eight out of the 16 behavioural statements of disagreement over relevancy were associated with the area of pharmacy practice (P < 0.05) ( Table 6). A higher percentage of respondents working in community pharmacy were more likely to perceive behaviours in the PC (4.1, 4.2, 8.1, 8.3) and the OM (10.2, 12.7) as being 'not relevant' to their practice compared to respondents working in other practice settings. Respondents working in hospitals were more likely (compared to other settings) to perceive behaviour in the OM (9.4, 12.6) as being 'not relevant'. Table 7 and Table 8 showed that non-Saudi and male respondents were more likely to perceive behaviours in the OM (9.2, 9.3, 9.4, 9.5, 10.2, 10.4, 12.6, 12.7) as 'not relevant' to their practice (P < 0.05). Table 7 showed also that Non-Saudi respondents were more likely to perceive behaviour 8.1 and 8.3 from the PC as 'not-relevant' to their practice (P < 0.05). Moreover, Table 8 showed that male respondents were more likely to perceive behaviour 19.1 in the PP as not relevant (P < 0.05).

Discussion
To our knowledge, this is the first study to explore the relevance of the FIP GbCF in Saudi pharmacy practice. This national survey investigated the relevance of the FIP GbCF v1 to the practice of pharmacists from different practice settings: community pharmacy, hospitals, primary health care clinics, pharmaceutical industry, academia and others.
The survey shows a broad agreement on relevance to practice for 84% of behaviours included in the GbCF v1. The PPH cluster scored the highest percentage of relevant responses (91.42%), followed by the PP cluster (87.08%) and the PC cluster (85.34%). On the other hand, the OM cluster scored the lowest percentage of relevant responses by the study population (81.60%). These findings are consistent with other global studies, which have shown similar findings on relevancy to the FIP GbCF. 10,18,32 In this study, the level of the relevance of OM competencies was low since pharmacists receive little or no training on these competencies in either undergraduate or post-graduate education. 33,34 This lack raises concerns about pharmacists' competencies to apply these skills in their practice especially when they undertake management roles. Alarifi (2013) reported that community pharmacists mostly acquire their managerial skills on the job and that few had post-graduate training in management or leadership. 35 The author suggests that the lack of formalised training programmes contributes to the difference in skills across the study population. Hence, incorporating these competencies at foundation level is highly warranted to enable pharmacists' transition to leadership roles and ensure a consistently high calibre of professional performance.
Respondents from DPC settings were more likely to perceive behaviours included in the FIP GbCF as relevant to their practice compared to respondents from the NDPC settings. This might be related to their scope of practice, which involves more responsibilities within health promotion, medicines compounding, dispensing and procurement activities. 22 The low relevance noted in 'budget and reimbursement, 'human resources management' and 'procurement' competency groups might be related to the fact that these responsibilities are conducted at the level of organisation or sector rather than on departmental level. Respondents rated low relevance for 'patient consultation and diagnosis' behaviours which might be explained in that patient diagnosis and assessment is not a common nor a regulated practice for pharmacists in Saudi Arabia. 21,22 Interestingly, recent local research reported that the provision of such services in community pharmacies is increasingly desired by consumers. [36][37][38] Respondents also scored low relevance for 'quality assurance and research in workplace' behaviours. This is consistent with AlRuthia et al. (2018) finding that pharmacists' participation in pharmacy practice research is limited, despite a high proportion working in DPC roles. 39 Most pharmacy practice research is lead mainly, not by practising pharmacists, but by researchers who are away from practice, including academics with claims that this is primarily to achieve academic promotion or by students to fulfil their graduation requirements. 22 This finding raises concerns about pharmacists' research skills and the presence of a research supporting environment, time and resources for practising pharmacists in Saudi Arabia. Interestingly, these findings are broadly similar to the situation Alhaqan et al.
(2020) reported in Kuwait, 18 a neighbouring country with similar pattern and scope of pharmacy practice.
While the area of practice was reported previously as a factor influencing pharmacists' perception of the FIP GbCF items relevancy, 10,18,31 this study adds to the increasing body of knowledge that the nationality and gender of pharmacists may influence their perceptions of the behaviours included in the FIP GbCF. Of the 16 'not relevant' behaviours, 12 and 10 of them were associated with nationality and gender, respectively. Table 4 shows that non-Saudi pharmacists perceived all clusters to be more relevant compared to Saudi pharmacists. This might reflect their practice experience in their home countries, especially as the majority, particularly those from Eastern Mediterranean countries, must practise locally for at least two years before they are allowed to travel and practise in Saudi Arabia. 21,40 However, the analysis of not relevant responses showed observed significant non-relevancy associated with non-Saudi pharmacists for behaviours within the following competency groups: 'patient consultation and diagnosis', 'budget and reimbursement', 'human resources and management', and 'procurement'. Non-relevance in the behaviours of the 'patient consultation and diagnosis' competency may have been perceived because the initial education of non-Saudis included little or no pharmacy practice or clinical-based learning to inform their practice equivalent to the local PharmD curricula, the dominant curricula currently, where pharmacy practice and clinical pharmacy courses and training are heavily weighted. 21 Moreover, the significant non-relevancy observed in 'budget and reimbursement', human resources and management, and 'procurement' competency groups was associated significantly with male non-   Saudi pharmacists. This may indicate that Saudi pharmacists primarily hold management and leadership roles. However, a comparison between male and female Saudi pharmacists showed higher relevance to OM competencies in favour of male pharmacists (78.87% male to 67.81% female). Therefore, further study on the impact of gender on leadership and management roles in pharmacy is suggested.
Considering the Saudi context, where almost 65% of pharmacists are non-Saudi and 81% of pharmacists are male, the findings of this study suggest a variation in competencies and of professional performance between Saudi and non-Saudi on the one hand and between male and female pharmacists on the other hand. Importantly, this finding indicates that sitting a licensure exam where merely minimum knowledge is measured to permit registration might not be enough. The development of a national competency framework with the core competencies required for performance excellence could provide a means to reduce the degree of variation shown in this study. It will additionally inform the development of competencybased education, not only to achieve the desired competencies for local pharmacists, but also of a national assessment and training programme for overseas pharmacists in order to establish a consistent performance before undertaking the licensure exam. Moreover, the availability of a competency framework would indeed inform the licensure exam and provide the foundations for new continuing education and continuing professional development activities. 17 It would also support practising pharmacists to identify learning needs to attain and maintain fitness to practise.
Currently, where the Saudi government is implementing major modernisation reforms, including in the pharmacy sector, developing a national competency framework that meets the government's plans for an expansion of pharmaceutical care roles in community pharmacies and the localisation of pharmacists would be of paramount importance in terms of fulfilling the government's 2030 Vision plans. 41,42 Addressing the country's needs for a qualified and competent pharmacy workforce to provide the new expanded roles in community settings requires education to be developed with respect to the needs-based competencies. By doing so, a huge reserve of local pharmacists will be equipped with the appropriate learning and competencies to meet the government plans. 43 The methods employed in this study provide a replicable example to other regional or global pharmacy practice researchers on how the FIP GbCF can be used as a first step to develop a country-specific competency framework. However, specific attention should be paid to local contexts, as local healthcare needs and other priorities will determine the competencies required for equipping pharmacists to meet local needs.
As an ideal first step to develop a country-level competency framework, the quantitative and qualitative findings from the study will serve as a basis to develop a national competency framework for foundation level pharmacists in Saudi Arabia. Future work involves conducting an expert panel to establish competency framework development based on local healthcare needs, followed by a validation of the draft framework.

Limitations
This study has some limitations. The utilisation of the snowballing sampling approach and the low sample size may limit the generalizability of the findings. This might have been caused by the large size of the survey (109 questions) or it may reflect a limited understanding of the concept and of the importance of competencies in professional development. Despite that, the number of responses in this study is comparable to other similar studies conducted elsewhere. 6,17,28,31,32 In addition, the low representation of academia, pharmaceutical industry and regulatory organisations may not provide a clear picture about their professional practice nor competencies required to fulfil their roles. Moreover, the lack of a specific definition of foundation-level pharmacy practice in Saudi Arabia may not provide a clear picture about the progress of pharmacists' performance over years and the relevance of the FIP GbCF to the practice of the foundation level pharmacists in the country. Additionally, the use of a self-completed survey may lead to self-reporting bias by the respondents. The use of multiple reminders may have led to duplicated responses, particularly given that the survey platform did not provide a feature to prevent this. Therefore, the results should be interpreted with caution.

Conclusion
This study investigated the relevance of the FIP GbCF in the Saudi pharmacy practice environment. The study found that competencies included in the GbCF v1 are relevant to pharmacy practice in the study population. However, some competencies and behaviours of the GbCF v1 require modification to be appropriate for the local needs of Saudi pharmacy practice and to develop a country-specific competency framework. The findings from this exercise will be used as a base to develop a foundation-level competency framework to inform the pharmacy education and professional development process in Saudi Arabia, equipping pharmacists to best meet local healthcare needs.

Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.