Developing Core Competencies for Pharmacy Graduates: The Lebanese Experience

Background: In the absence of a national qualification framework for health professionals, the Lebanese Order of Pharmacists (OPL) took the initiative of developing a pharmacy competency framework to standardize pharmacy education in all universities. The objective of this manuscript is to describe the steps that led to the Lebanese Pharmacy Core Competencies Framework. Methods: Based on a primer developed by a group of academic instructors, following international reference documents from different parts of the world, the Academic board appointed by the OPL, reviewed, streamlined, and validated the suggested primer using the Delphi technique over three rounds, to come up with the final framework. Results: The framework encompassed competencies distributed over 7 domains: fundamental knowledge, professional practice, personal skills, supply of medications, safe and rational use of medications, pharmaceutical public health competencies, and organization and management competencies. Its structure was similar to that of the International Pharmaceutical Federation (FIP), with cultural and legal adaptations and the addition of some behaviors related to OPL specific practice and research projects. Conclusion: This work describes the elaboration of the Lebanese Pharmacy Core Competencies Framework, a project considered to be an essential step forward for the profession and a first step toward providing information on human resource planning and professional development of the pharmacy workforce. Instead of adapting existing international educational standards from resource-rich contexts, which may not meet the actual needs of Lebanon, universities can draw our findings to develop relevant programs targeting the skills needed for health workers in Lebanon.


Background
The pharmacy profession is constantly evolving with the emergence of innovative specialties and roles. Current trends show that pharmacy and other health care professions are becoming more focused on skills and competencies, [1][2][3][4][5] which is required by most educational certification bodies around the world. 6,7 Adopting competency-based educational designs de-emphasizes time-based curricula (based on the number of years of studies) and prepares pharmacists for their societal role, ultimately leading to improved health care and patient safety. 8,9 According to the International Pharmaceutical Federation (FIP) and the World Health Organization (WHO), the mission of the pharmacist is to contribute to health improvement by counseling patients and helping them make the best use of their medications. In 1997, the WHO introduced the "Seven-star pharmacist" concept covering the different roles each pharmacist must perform: care-giver, decision-maker, communicator, manager, life-long-learner, teacher, and leader. 10 Two additional roles-researcher and entrepreneur-were introduced later, leading to the "Nine-star pharmacist." 11 The FIP requires the pharmacist to have skills in 7 domains: fundamental knowledge, professional practice, personal skills, the supply of medications, safe and rational use of medications, pharmaceutical public health competencies as well as organizing and managing competencies. The Pharmacy Education Action Plan developed by the WHO, the UNESCO (United Nations Educational, Scientific and Cultural Organisation), and the FIP, encouraged identifying local needs and adapting educational programs to achieve competencies required to meet these needs. 12 Lebanon is a Middle-Eastern developing country with a specific context: a multi-cultural, socioeconomic, and religious society characterized by high disparities among its components, 13 a fragmented health system with no adapted health strategy, 14 transitional epidemiology with an expected increase in the percentage of the elderly population and related chronic diseases, [15][16][17][18][19][20] a substantial proportion of health illiteracy in the population correlated to medications misuse and abuse, 21 a considerable burden of infectious diseases and antibiotic resistance, 22 the absence of an operational pharmacovigilance system, 23,24 added to a large number of refugees living in precarious conditions and constituting an additional burden on the health system. 14 In the community setting, patients in Lebanon may use pharmacists' services without resorting to physicians to save time and money, particularly among lower education and socioeconomic status populations. Moreover, studies have shown that pharmacists in Lebanon are required to perform better by patients, 25 while Good Pharmacy Practice (GPP) standards are inadequately applied. 26 Additionally, Lebanon has no specific pharmacopeia, no list of safe and essential drugs, no generics classification system, and no national drug formulary, only a Drug Index published by the Ministry of Public Health as a reference during the practice of pharmacy.
From an educational point of view, five universities teach pharmacy in Lebanon, one is public (the Lebanese University), and the other 4 are private. The Lebanese University is bilingual and teaches in both French and English, and the Saint Joseph University of Beirut is exclusively French-speaking; both universities adopt the European Credit Transfer System (ECTS). The three other universities use the North American credit system: the Beirut Arab University applies the Canadian model, while the Lebanese American University and the Lebanese International University follow the American system. Whatever the system applied, pharmacy studies in Lebanon last 5 years and lead to a Bachelor of Science (BS) degree, while an additional year to earn a Doctor of Pharmacy (PharmD) degree is optional, except in Saint Joseph university where PharmD is mandatory ( Table 1).
The Ministry of Education and Higher Education in Lebanon (MEHE) regulates the number of credits of the pharmacy curriculum a student must achieve to graduate, but not the content. Furthermore, there is no national accreditation system for universities in Lebanon, and no national framework for professional qualifications, including pharmacy. From a curricular perspective, some universities in Lebanon did not structure their curriculum based on competencies and are still in traditional teaching based mainly on didactic courses and knowledge assessment (e.g., the Lebanese University). Other universities adapted their curricula to international sets of competencies to get accredited by foreign bodies if required (American, Canadian, or European) or certified by private firms (International Organization for Standardization-ISO certification). These competencies, adopted from developed countries, may not match Lebanon's needs. For example, the American model emphasizes clinical skills while clinical pharmacy is still poorly applied in Lebanon (for political reasons and lack of appropriate regulations). Also, the French model emphasizes fundamental sciences and research knowledge, while bench research is scarce in Lebanon (due to the lack of financial means). Moreover, several professional aspects and courses seem insufficiently addressed and evaluated in some curricula, particularly those related to public health and transferable skills such as communication skills, analytical skills, and critical thinking. This lack is mainly due to the classical reasoning of letting students retain more theoretical knowledge (through academic courses), without necessarily knowing how or being able to function in practice. 27 Given this context, Lebanese universities might probably be graduating pharmacists with discrepancies in skills, attitudes, and knowledge. A consequent mismatch between education and the market needs may occur, 28 as universities assess Lebanese graduates, without any consensus on the examination type or the skills to be tested. Moreover, the "colloquium," which is the national licensure examination necessary to apply for a license to practice pharmacy, organized by the MEHE, evaluates only the knowledge of graduates regardless of other skills. To date, no regulatory body in Lebanon has made any effort to standardize pharmacy education or adapt it to local needs, despite labor market drivers suggesting that a competency-based approach is sustainable for developing the workforce around the world. 1,29 The Lebanese Order of Pharmacists (OPL) is the official pharmacists' association in Lebanon. It is striving to become a leading organization through improving the profession and promoting excellence in patient care and scientific development in Lebanon and the Middle East. Given its stated mission, the OPL took the initiative to develop a pharmacy competency framework in collaboration with academia to deliver the required competency-based education and training. The ultimate goal was to standardize pharmacy education programs in Lebanon so that graduates (BS or PharmD) have the minimum required level to practice pharmacy. Thus, some areas need to be improved and/or standardized across pharmacy programs.
The OPL initiative aimed to standardize fundamental pharmacy skills, build competencies, and transform the pharmacy workforce in Lebanon through the use by educational institutions of the competencies framework, compatible with international requirements and adapted to the Lebanese context (cultural, legal, and local). Hence, the critical principle of competency-based education would lead to the effective use of curriculum-related learning objectives and the eventual mastery of the required competencies by pharmacy graduates who would thus achieve the minimal competence level required to practice efficiently and safely.
The objective of this manuscript is to describe the steps that led to the development of the Lebanese Pharmacy Core Competencies Framework.

Methods
This paper uses qualitative methods to outline the essential steps in designing a competency-based pharmacy curriculum, as suggested by the OPL. The developed framework would expectedly guide the successful organization, development, implementation, and assessment of these curricula in Lebanese universities. Suggestions were based on literature references where possible but were also imbued with the authors' experiences in implementing new curricula in the field of pharmacy and pharmaceutical sciences.

The Lebanese Order of Pharmacists Initiative: Procedures and Steps
The OPL is the official partner of 2 ministries: the MEHE that supervises pharmacy education, particularly in private universities, and of the Ministry of Public Health (MOPH), responsible for organizing the profession (delivering licenses to practice and authorizations to open community pharmacies, regulating hospital pharmacy practice, and enforcing the laws). Within the OPL, an appointed scientific committee has the role of executive authority: it takes decisions related to pharmacy education and research, such as continuing education management, congresses organization, professional research conduction, and helping in evidence-based decision making. Its mission is to promote research and development of excellence in pharmacy practice through building knowledge, expertise, and skills of the workforce to achieve optimal health outcomes. To tackle all issues common to the OPL and the academia, the scientific committee decided to create a subcommittee in association with academia representatives, in January 2016. This subcommittee termed the "Academic Board" had 13 members in total: 2 representatives from each faculty/school of pharmacy (including the deans of the schools of pharmacy) and three members appointed by the OPL scientific committee (1 hospital/clinical pharmacist, 1 community/administrative pharmacist, and 1 academic/administrative pharmacist). All members had more than 10 years of experience in their respective fields.

Designing the Core Competencies for Pharmacy
The work started with the use of a primer developed by a group of academic instructors, "the Lebanese Academic Pharmacists-Competencies Workgroup," who had taken the personal initiative to draft the competencies for Lebanese pharmacists; competencies were classified into domains and further derived into outcomes or behaviors. The suggested primer consisted of three stages: A). Mapping international competencies updated over the last 10 years. In the absence of an officially established European framework for pharmacists, and while the Conférence Internationale des Doyens des facultés de PHARMacie d'Expression Française (CIDPHARMEF) did not propose any competency framework, the international (FIP/WHO) and the North-American-related competencies were deemed to best represent the educational models in Lebanese universities and were thus selected. The used sets represent those already applied by some universities in Lebanon (see Table 1 35 These 2 documents were reviewed but not used since no official pharmacy competencies framework was found in the region. B). Drafting one document that included several domains, competencies, and outcomes/behaviors: domains were the overarching field of competence formed by several competencies, while outcomes/behaviors were items used to measure a competency. 30 The draft merged similar behaviors and competencies taken from the abovementioned documents. All the domains included measurable outcome verbs, except for the fundamental knowledge where "knows and understands" remained, the knowledge domain being the mostly assessed in the universities and the official examination (the colloquium). C). Improving the document by sending it to 10 experts in pharmacy education and practice outside the workgroup to give their input and suggest additional modifications. These experts were renowned university professors from Lebanon with PharmD or PhD credentials and more than 10 years of teaching and research experience, or experienced practitioners with at least 15 years of experience in the community, hospital, industry, and management sectors. The document agreed upon at this stage was the first draft termed the "suggested primer."

The Final Framework Review and Adoption
The OPL Academic board took this suggested primer, reviewed, streamlined, and finally agreed on the final framework of competencies, following the steps hereafter: It was agreed that the framework is to be used to prepare pharmacy graduates to enter the labor market throughout the 5 bachelor years: this is the minimum legal requirement in Lebanon for the MEHE to officially recognize the degree and the MOPH to issue a license to practice. For PharmD graduates, additional competencies would be adopted (beyond the scope of this document). All members critically read the suggested primer and mapped it with the competencies they were using in their respective curricula. Missing competencies deemed essential were added to the document (especially those related to knowledge and cultural plurality), while those considered similar were merged; advanced clinical competencies specific to PharmD programs were removed.
Using the Delphi technique over 3 rounds, the Academic Board members approved the final version by consensus; the same 10 experts who reviewed the primer further confirmed the final document. It is noteworthy that during every round, the Academic Board members sent the work to their respective faculty members (ad hoc committees or pre-existing curriculum committees), to have their feedback and suggestions. The OPL coordinator included suggested changes and worked on improved versions. The procedure was repeated until the Academic Board reached a complete consensus. The OPL finally adopted and published a Lebanese "Pharmacy Core Competencies Framework" in November 2018.

Added, Modified, and Removed Competencies
Outcomes/behaviors were culturally adapted, with a particular emphasis on cultural competency: due to the multi-cultural context of Lebanon, pharmacists are caring for individuals of diverse religions, sociodemographic characteristics (age, gender, nationalities, socioeconomic status, sexual orientation), and subsequent health beliefs. Examples of modifications introduced through the rounds of the Delphi technique were as follows: since the FIP global framework was considered as the most important international framework, all its components (competencies and behaviors) were included in the Lebanese framework; merging behaviors based on available international frameworks (FIP, ACPE, CAPE, and NAPRA); removing redundancies that resulted from merging several international frameworks, while adding some competencies and behaviors specific to Lebanon (to take into account the Lebanese laws related to pharmacy practice, and OPL specific projects to improve the profession); adding fundamental knowledge-related competencies and behaviors, including basic and clinical sciences, in addition to sciences related to the transferable skills; adding behaviors not mentioned in the preliminary draft document: frequent services in the community pharmacy (e.g., informing patients about chronic diseases devices), cultural competencies-related behaviors (e.g., respecting patients' opinions when dispensing nonprescription drugs, in particular, herbal products based on pharmacognosy knowledge), using OPL-specific electronic platforms (e.g., pharmacovigilance and patient profile online systems), and collecting data related to OPL practice and research projects; modifying some behaviors such as labeling medications to be compatible with the Lebanese laws (labeling is only allowed by adding handwritten advice on the medication box); removing behaviors that do not apply in the Lebanese context (such as involving pharmacists in administering vaccines, which is not allowed in Lebanon).

Final Framework
The final approved competencies are distributed over the 7 domains suggested by the FIP, i.e. fundamental knowledge, professional practice, personal skills, the supply of medications, safe and rational use of medications, pharmaceutical public health competencies, and organizational and management competencies. Cultural adaptation occurred at the level of the outcomes/behaviors. The fully detailed competencies are available in Online Appendix 1. Associated outcomes/behaviors are presented and grouped according to the stakeholders who will be responsible for applying it. For academia, it is the majority of knowledge-related outcomes, while the OPL will follow on continuing education-related outcomes mainly, and both will coordinate efforts in experiential-related education. Hence, OPL-related competencies would not be assessed until after graduation (at the end of a 1-year post-graduate training period, suggested and managed by the OPL). The post-graduate training includes activities related to core and advanced specialized competencies by specialty field (specific details of pharmacists post-graduate training are beyond the scope of this document).
Fundamental knowledge. The pharmacist knows and understands the basics of fundamental science, patient care, pharmaceutics and, social, behavioral, and administrative sciences. The pharmacist applies this knowledge in pharmacy practice according to the situation and field of specialty.
Professional practice. The pharmacist puts his professional skills into practice, respecting the patients' culture. The pharmacist demonstrates awareness of the code of ethics and the Lebanese pharmacy law and acts accordingly. The pharmacist acts as a team member and collaborates with other professionals in all aspects of practice. The pharmacist also applies the principles of continuing professional development, including assessing his own learning needs and developing plans to meet these needs.
Personal skills. The pharmacist shows leadership abilities within a team, recognizes the value of co-workers, whether pharmacists or other health care professionals, and acts accordingly. The pharmacist can take accurate, evidenced-based, and timely decisions. The pharmacist also communicates effectively with patients, support staff, and other relevant third parties. The pharmacist accepts self-assessment, learns from errors, and controls his behavior toward stress and work overload. The pharmacist also practices with innovation and entrepreneurship. The pharmacist develops new ideas to improve quality or overcome barriers to enhance the profession and uses information technology in his daily work.
Supply of medications. The pharmacist knows the principles of manufacturing and compounding of medications; the pharmacist performs various tasks efficiently in pharmaceutical plant and quality control units of products. The pharmacist also manages the supply chain; the pharmacist ensures the quality, safety, and integrity of products. The pharmacist finally dispenses medications safely and accurately to the patient.
Safe and rational use of medications. The pharmacist demonstrates consultation skills that allow to gather information and discuss medication and disease issues with the patient. The pharmacist also has counseling and advocacy skills: advises patients and acts to promote the best patient care, respecting patients' culture. The pharmacist monitors treatments and patient's progress and assesses therapeutic outcomes while prioritizing medication safety and acting accordingly. Special attention was given to antimicrobial resistance battle, rational use, and safe disposal of medications. The pharmacist also creates and maintains a working environment that promotes safety culture.
Pharmaceutical public health competencies. The pharmacist engages in health education and promotion activities with the patient and the general population. The pharmacist answers questions regarding medications' information and advises using appropriate strategies, respecting patients' various cultures. The pharmacist also applies knowledge, research skills, and professional judgment to make the right decisions.
Organization and management competencies. The pharmacist demonstrates personal and professional organization and management skills at work, in addition to skills relevant to human and financial resources (budget and reimbursement). The pharmacist also applies principles and skills relevant to quality assurance and understands the principles of pharmaceutical product development.

Discussion
In this manuscript, we presented the core competencies suggested by the OPL to allow pharmacists to graduate with skills adapted to the local needs. Competencies were distributed over the same 7 domains recommended by the FIP: fundamental knowledge, professional practice, personal skills, the supply of medications, safe and rational use of medications, pharmaceutical public health, organization, and management competencies. Pharmacists have to be skilled in all 7 domains to be considered able to practice.
Although fundamental knowledge is not explicitly present in international frameworks (except for the FIP recommendation), it was deemed necessary to include it in the Lebanese framework to homogenize the knowledge of graduate pharmacists at entry-level, given the discrepancies in pharmacy programs delivered in Lebanon. This knowledge is considered essential in making decisions that optimize medication-related patient outcomes. Competencies and outcomes related to this domain were developed and elaborated to help universities fill their respective gaps at this level. Nevertheless, although pharmacists must have a thorough knowledge of pharmaceutical sciences in addition to scientific/clinical evidence that forms the basis of rational drug therapy, much of what is learned by students in the classroom changes over time. 36 Cultural adaptation cannot be stressed upon enough, 37 this aspect explicitly mentioned, is essential to respect the Lebanese multi-cultural context and maintain impartiality and fairness during pharmacy practice.
As for the ethical aspect, the pharmacist is required to practice in accordance with Lebanese laws and the code of ethics published by the OPL; these mandatory legal documents currently regulate all sectors of the profession and were taken into account during the modifications and adaptations that were applied.
Moreover, academia must foster in students the skills necessary to become self-directed lifelong learners. Based on the Lebanese law that makes continuing education mandatory, striving for personal and professional development is encouraged to have a positive impact on health and health care. Schools and faculty members need to create engaged and active learning experiences (in the classroom and the practice setting) that emphasize initiative, innovation, critical thinking, and adaptability so that students are mindful of the importance of these skills and are assessed accordingly throughout their education and training. University teachers should clarify to students the outcome in terms of accountability to themselves, the team, patients/clients, or the broader health system. Additionally, the OPL and other scientific societies might shoulder the responsibility to promote competencies related to continuing education. The suggested contact with the OPL would increase the awareness of graduates about their roles, unique skillsets, and the job's expectations so that they can better position themselves to articulate what the profession can offer. Moreover, although continuing education is now mandatory in Lebanon, it still needs to be elaborated into a continuous professional development program based on advanced competencies, specific to different pharmacy specialties.
Pharmacists in the community setting play an important role in services to patients; they need to have all previously described competencies, in particular, personal, professional, and public health promotion competencies, detailed in the framework. They should be able to fill the current gaps of the health system, optimize medication use, decrease the burden of precarious conditions on the system, and promote patients' health and literacy, including that of special populations. 38 Special attention is needed to reduce frequent problems in Lebanon, such as antibiotic resistance, 39 tobacco smoking, 40 in addition to the misuse (23) and inappropriate disposal of medications. 41 In the hospital and industrial sectors, the lack of financial and human resources requires pharmacists to have optimal organizational and management skills, also detailed in the framework. Pharmacists should also deliver a high-quality team-based collaboration that is imperative for improving inpatient health outcomes. These skills are expected to increase the trust of other health care professionals and promote the implementation of clinical pharmacy in hospital settings. 42 Collaboration, communication, critical thinking, and problem-solving are inherent in interprofessional care and have been emphasized as important competencies for many years. Interprofessional education is expected to develop interprofessional collaboration, teamwork, and healthy relationships between different parties at work, as successfully highlighted in this project. 43 Competency-based education is essential for reforming educational systems and aligning curricula with the current health systems priorities, especially in resource-constrained settings. 44 Academic institutions that did not yet base their curriculum on competencies need to acknowledge this reality and exert efforts to change curriculum philosophy, rationale, structure, and content. Consequently, it is of utmost importance to permeate conversations about curricular changes, develop teaching, and assess activities based on this model, as quality accreditors promote curriculum design. 6,45,46 As outlined by Koster and collaborators, implementing the framework will be a long process requiring a system of effective quality management within universities and continuous professional development for teachers. 47 Furthermore, experiential education jointly managed by academia and the OPL is essential to prepare students for the experiences of real-world health care delivery. In addition, in the absence of a national assessment for pharmacists' skills (not even a preliminary one), these competencies can serve as a starting point to evaluate graduates and fill the gaps between academia and the labor market. They can also foster dialogue and potential partnerships between academic institutions, health care organizations, and other pharmacy practice institutions, addressing the training and educational needs of the healthcare workforce.
Based on the current suggested framework, future research can assess the needed competencies, which would help designing professional development programs accordingly. Innovative competencies assessment methods are also recommended: besides direct assessment of knowledge-related competencies (formative and summative traditional exams), transferable and clinical skills would be appraised through observation (rubrics), indirect assessment (surveys and developmental portfolios), and OSCEs (Objective Structured Clinical Examination). 48,49 Finally, mapping current curricula of universities to this framework, and comparing between previous and future outcomes is warranted, in addition to validating this framework structure (measuring validity and reliability, merging over-correlated items to shorten the list of behaviors). These future works would direct universities in their assessment and quality improvement endeavors. This framework is a first step toward bridging the gap between academia and the labor market, providing information on human resource planning and professional development of the pharmacy workforce. It also paves the way for future studies to gather new evidence in this area about graduates' competencies and practice quality in different pharmacy sectors.

Conclusion
This work describes the elaboration of the Lebanese Pharmacy Core Competencies Framework, a project considered to be an essential step forward for the profession and a first step toward providing information on human resource planning and professional development of the pharmacy workforce. Instead of adapting existing international educational standards from resource-rich contexts, which may not be compatible with the actual needs of Lebanon, universities can draw on the findings of this project to develop relevant programs targeting the skills needed for health workers in Lebanon.