Curriculum Mapping of the Master’s Program in Pharmacy in Slovenia with the PHAR-QA Competency Framework

This article presents the results of mapping the Slovenian pharmacy curriculum to evaluate the adequacy of the recently developed and validated European Pharmacy Competences Framework (EPCF). The mapping was carried out and evaluated progressively by seven members of the teaching staff at the University of Ljubljana’s Faculty of Pharmacy. Consensus was achieved by using a two-round modified Delphi technique to evaluate the coverage of competences in the current curriculum. The preliminary results of the curriculum mapping showed that all of the competences as defined by the EPCF are covered in Ljubljana’s academic program. However, because most EPCF competences cover healthcare-oriented pharmacy practice, a lack of competences was observed for the drug development and production perspectives. Both of these perspectives are important because a pharmacist is (or should be) responsible for the entire process, from the development and production of medicines to pharmaceutical care in contact with patients. Nevertheless, Ljubljana’s graduates are employed in both of these pharmaceutical professions in comparable proportions. The Delphi study revealed that the majority of differences in scoring arise from different perspectives on the pharmacy profession (e.g., community, hospital, industrial, etc.). Nevertheless, it can be concluded that curriculum mapping using the EPCF is very useful for evaluating and recognizing weak and strong points of the curriculum. However, the competences of the framework should address various fields of the pharmacist’s profession in a more balanced way.


Introduction
Traditional universities structured programs with a defined number of courses, exams, and contact hours. It was up to the teachers to know what students needed in order to graduate from the university. The system was rather clear and worked smoothly. The majority of older pharmacists received their degrees through education structured in this way, and the pharmacy profession developed well, even excellently. Three independent factors resulted in a need to change this mindset in order to introduce competence-oriented curricula: (a) a significantly greater amount of information (not necessarily knowledge), (b) a shorter half-life of research-based knowledge, and (c) an increasing number of universities due to drastic changes in the expectations of the general population. Namely, only 2% of the population was expected to participate in higher education in the 19th century, compared to the European trend of the 21st century, in which 40% of the population is expected to participate in vertical course linkages are very important. The primary objective of the Faculty of Pharmacy is to develop scientifically and professionally qualified, high-quality graduates familiar with ethical principles that autonomously carry out demanding tasks in community and hospital pharmacies, in all fields of the pharmaceutical industry, in clinical laboratories and laboratory medicine, laboratories for drug control and analysis, research institutions, educational organizations, state bodies, and wherever the work and presence of a pharmacist is required to increase health safety [9]. The faculty's commitment to quality teaching and research has been shown through many activities, including participation in projects initiated by EAFP [10], such as Pharmacy Education in Europe (Pharmine) and Quality Assurance in European Pharmacy Education and Training (PHAR-QA).
The European Commission has funded the international project PHAR-QA [11] to produce a consensual, harmonized framework of competences for pharmacy practice across Europe. This framework is intended to be used as a base for a QA system for evaluating university pharmacy education and training at the institutional, national, and/or European levels [12]. The second round of the PHAR-QA survey of competences for pharmacy practice in Europe was completed in 2016 [13].
The aim of this study was to evaluate the usefulness of the framework developed for pharmaceutical competences as a tool for mapping the master's pharmacy curricula by matching the existing curriculum of the master's program in pharmacy in Slovenia to the framework.

Materials and Methods
A team of seven members of the teaching staff in the integrated master's program in pharmacy [6] at the University of Ljubljana's Faculty of Pharmacy was involved in curriculum mapping. Two members of the team have previously been involved in the PHAR-QA project [11]; three members are responsible for coordinating the master's program, international student exchange, and traineeship as part of undergraduate study; and four members of the team are also members of the faculty management. The mapping was carried out and evaluated progressively, as indicated.
Step 1: A Microsoft Excel file was generated composing a matrix of 50 European Pharmacy Competences Framework (EPCF) competences [13] versus 60 courses in the master's curriculum. For greater transparency of the file, clusters are separated into individual worksheets and the competences within each cluster are listed in the y-axis. Courses were listed in a "drop-down" form for each year of the program in the x-axis ( Figure 1).
Step 2: Primary mapping was done by a single member of the team, who copy-pasted the competences as described in the master's curriculum from each course individually based on personal assessment of the matching. In cases where competences were defined more generically (covering multiple competences), they were mapped in two or more PHAR-QA competences. For example: the competence from the program "Students acquire basic knowledge about drug action within an organism and the organism's reaction upon exposure to drug(s)" was mapped in "(29) Ability to compile and interpret a comprehensive drug history for an individual patient," "(34) Ability to identify and prioritize drug-disease interactions (e.g., NSAIDs in heart failure) and advise on appropriate changes to medication," and "(35) Knowledge of the bio-pharmaceutical, pharmacodynamic, and pharmacokinetic activity of a substance in the body." If the description was too general, such as: "Development of competences and skills of using knowledge in a particular professional area," or not listed in the EPCF list, the faculty's competence was listed in a separate worksheet.
Step 3: The result of the primary mapping was individually evaluated and revised by the coordinator of the master's program, coordinator of the international student exchange, and coordinator of the traineeship. The revision was made based on their thorough knowledge of the course syllabuses.
Step 4: The final review of the mapping process and evaluation was made by all seven members of the team. Special attention was paid to: Competences absent from the curriculum; - The number of times each competence was addressed in the curriculum; -Building competences through teaching from lower to higher levels; -Dedicated time and ECTS credits planned in the curriculum for teaching to build individual competences.
Step 5: Gaps and inconsistences in the curriculum and EPCF list were identified.

Materials and Methods
A team of seven members of the teaching staff in the integrated master's program in pharmacy [6] at the University of Ljubljana's Faculty of Pharmacy was involved in curriculum mapping. Two members of the team have previously been involved in the PHAR-QA project [11]; three members are responsible for coordinating the master's program, international student exchange, and traineeship as part of undergraduate study; and four members of the team are also members of the faculty management. The mapping was carried out and evaluated progressively, as indicated.
Step 1: A Microsoft Excel file was generated composing a matrix of 50 European Pharmacy Competences Framework (EPCF) competences [13] versus 60 courses in the master's curriculum. For greater transparency of the file, clusters are separated into individual worksheets and the competences within each cluster are listed in the y-axis. Courses were listed in a "drop-down" form for each year of the program in the x-axis ( Figure 1).  The level of agreement of scores among individual evaluators participating in the study was assessed using the Delphi methodology [14,15]. A Delphi consensus panel was run with the aim of evaluating coverage of competences as defined by the PharQA framework in the current master's curriculum. The Delphi expert panel included four independent ratings performed by two individuals and two teams with two evaluators working together. The evaluators were six faculty professors that have insight into the pharmacy curriculum. The Delphi study consisted of two rounds. In the first round, panelists rated the coverage of the competences in the curriculum. Coverage was scored using the following five-point Likert-type scale: 0 = not covered at all, 1 = poor, 2 = fair, 3 = good, 4 = very good. Consensus on the coverage of competences was defined as the range of individual scores (Max-Min) being one or less. The panelists were also asked to provide comments on the clarity and their understanding of competences.
After the first round, the expert panel members met for a roundtable discussion. The results of the first round were presented and the panelists discussed the items for which consensus on coverage had not been attained and clarified the differences in ratings. In the second round, the panelists once again rated the coverage of competences, taking into account the roundtable discussion, the median of the panelists' answers, and the response distribution from the first round. Consensus was defined as the range being one or less.

Results
The starting point was the EPCF list of competences, and whether and where a particular competence is present in the curriculum was checked. The Slovenian pharmacy master's curriculum consists of 60 courses (subjects) in a 10-semester uniform program including a six-month traineeship in pharmacy, individual research work, and a master's thesis defense. The preliminary results of the competence mapping are presented in Table 1. The numbering of the competences in the table is consistent with the numbering in the PHAR-QA project [13], in which the first six questions address the profile of the respondents (age, duration of practice, country of residence, and current occupation) and were not included in the mapping process. The questions in clusters 7-16 are reflected in 60 competences for pharmacy practice across Europe: clusters 7-10 cover personal competences, and clusters 11-17 cover patient care competences.  Traineeship  3  4  7  2  1  3  3  4  3  3  3  30  36  Sum  68  39  58  57  9 18 15 25 7 13 17 410 Legend: 1st year of study 2nd year of study 3rd year of study 4th year of study 5th year of study Pharmacy 2017, 5, 24 7 of 12 All competences as defined by the EPCF are covered in our master's curriculum, although their distribution among subjects and across program years is not balanced. During the first two years of the master's program, in which the curriculum contains typically basic subjects in the natural sciences, personal competences from clusters 7 through 11 are predominantly covered, especially those dealing with abilities to learn independently and apply logic to solve problems. Later in the program, competences from all groups are distributed more evenly. It is also evident that each subject addresses at least one EPCF competence.
The preliminary results are a rough estimate of how competences are covered in our curriculum. It was obvious that the description of competences in the curriculum was not sufficient for adequate scoring. Namely, some competences are addressed several times in a particular subject and it is not clear to what extent the competence is actually covered (i.e., mentioned, discussed, or elaborated). On the other hand, it is not possible to recognize progression in the level and sequence of student learning and performance through the program. For this reason, the evaluation was enhanced by using the Delphi approach. Tables 2 and 3 present coverage of competence domains and individual competences in the first and second rounds of the Delphi study. Table 4 presents consensus building between the first and second rounds of the Delphi study.

Coverage of Individual Competencies
Competency

Discussion
Evaluation was performed based on the curriculum [6]. The performance of the program (i.e., educational outcomes of the competences achieved) was not part of our study. The authors of this study are aware of different approaches in curriculum mapping. The final goal is to compare intended, perceived, and achieved competences as evaluated by students, graduates, teachers, and employers. Such mapping would be very useful in improving the program and its performance [16,17]. However, for preliminary mapping with the available resources, only the first step was realistic: mapping the curriculum delivered as written in the accreditation documents, expanded by evaluation of the competences present in the curricula as explained in the section Materials and Methods.
The master's program in pharmacy in Slovenia educates students for both aspects of pharmacy practice-working in health services and the pharmaceutical industry in approximately the same proportion-and most EPCF competences cover healthcare-oriented pharmacy practice; this is also reflected in the results of our evaluation. Personal competences are addressed with relatively higher frequencies due to the fact that the EPCF predominantly covers healthcare-oriented pharmacy competences. Namely, the definition of the pharmacy profession or pharmacy practice at the international level is not always clear [18]. There is no doubt that a pharmacist is a healthcare professional, but not only that. The pharmacist is "the university professional whose primary mission is the management and the exclusive responsibility for the formulation, preparation and the responsible dispensing of drugs to the population in addition to its inevitable participation in the protection of health and improvement of the quality of life" [19]. Several inconsistencies are evident regarding the pharmacist's role more broadly; that is, in the pharmaceutical industry in developing and producing medicines and in laboratory medicine. The master's program in Slovenia is designed to provide pharmacy competences within the healthcare system as well as the pharmaceutical industry, medical laboratories, research laboratories, legislation, and education. From this perspective, the PHAR-QA framework of competences does not sufficiently cover competences outside the healthcare system. Competences in drug development and production should be developed and included in greater detail.
Some definitions were found to be rather loose and/or ambiguous. For example, the competence "Knowledge of the importance of research in pharmaceutical development and practice" seems to be too general and is addressed by the majority of subjects in our curriculum. The members of the study team had difficulty understanding what the competence covers; it seems self-evident. The curriculum sets competences about research in pharmaceutical development and practice at a higher level according to Bloom's classification [20].
It was further observed that some competences are too broad, covering multiple competences. Some examples include the following: "Ability to undertake a critical evaluation of a prescription ensuring that it is clinically appropriate and legally valid" should distinguish competences of a clinical and legislative nature/origin; "Ability to advise physicians on the appropriateness of prescribed medicines and-in some cases-to prescribe medication" should distinguish counselling (i.e., advising) from taking actions (i.e., prescribing); and "Ability to identify non-adherence to medicine therapy and make an appropriate intervention" should distinguish the ability to recognize from the ability to intervene. The problem of scoring arises when two partial competences are not from the same origin and cannot be covered in the curriculum equally. For example, prescription of medicines by a pharmacist is not allowed in many EU countries, including Slovenia. Therefore it is unreasonable to include such competences in the national curriculum.
During the education process, competences are built from lower to higher levels according to Bloom's taxonomy: remember, understand, apply, analyze, evaluate, and create [21]. Not considering this, only courses at the top of the pillars are recognized as important for a particular competence whereas basic courses are overlooked. For example, the team had difficulty differentiating the following competences: "(7) Ability to apply current knowledge of relevant legislation and codes of pharmacy practice," "(8) Knowledge of appropriate legislation and of ethics," and "(9) Ability to implement general legal requirements that impact upon the practice of pharmacy"; it seems that different levels of Bloom's classification are being addressed inconsistently. To develop competences at higher levels (i.e., to be able to perform), several lower-level competences (i.e., knowledge and skills) should be adopted and included in the curriculum. Lower-level competences are usually written very generally, such as "development of skills" or "capability of practical application of knowledge," and are not linked to a specific field or competences. On the other hand, competence at the highest level, such as "Ability to use pharmaceutical knowledge and provide evidence-based advice on public health issues involving medicines," means that students have already built sufficient pharmaceutical knowledge, which should be addressed inside the curriculum as separate lower-level competences (knowledge and understanding).
The roundtable discussion of the Delphi study and further analysis of the results revealed that the majority of differences in scoring arise from different perspectives on the pharmacy profession (e.g., community, hospital, industrial, academic, laboratory medicine, or regulative); for example, "7. Personal competences: learning and knowledge. 6. Ability to apply current knowledge of relevant legislation and codes of pharmacy practice." Scoring pharmacy practice from a healthcare perspective yields different results than scoring pharmacy practice from a more general perspective, also covering industrial and regulatory aspects of the profession. Similarly, the competence "11. Patient care competences: patient consultation and assessment. 2. Ability to perform appropriate diagnostic tests, e.g., measurement of blood pressure or blood sugar" can be understood as graduates' ability to perform some basic diagnostic tests in community pharmacy, or graduates' ability to work in laboratory medicine (synonyms: clinical biochemistry, clinical biology) [22]. This is a common situation in Slovenia [23]. Different perspectives and understandings of competences as defined by PharQA were discussed in the roundtable, leading to more a balanced approach to evaluation among the panelists. This resulted in greater consensus in the second round of the Delphi evaluation process: the panelists reached consensus for 49 out of 50 competences.
Competences have to be designed to fit the first-day-of-job pharmacist [2,8]. From this perspective, it was found that some of the competences in the EPMF were rather too ambitious and require additional graduate training and/or specialization, as also discussed by Atkinson [13].
It can be concluded that curriculum mapping using EPMF is very useful for evaluating and recognizing weak and strong points of the curriculum. However, it must also be recognized that some additional improvement of the existing framework is needed. Namely, the competences of the framework should address various fields of the pharmacy profession in a more balanced way.