Background

Non-medical prescribing is defined as the prescription of medicines by health care professionals who are not medical physicians or dentists [1]. Non-medical prescribing is a safe, clinically valuable, efficient, and cost-effective strategy for enabling health services to provide equitable and timely access to health care and medicines [2–7]. Furthermore, non-medical prescribing benefits health services, with improved staff satisfaction and increased retention of staff observed [1, 8].

First implemented in the United States of America in the 1960’s [9] non-medical prescribing has since expanded across the globe with 99 countries identified as having a non-medical prescribing policy with varying scope of professions, practice, and restrictions in place [1–8, 10]. In Australia, non-medical prescribing enables nurses, midwives, and some allied health professions to prescribe medications from a discipline and state jurisdiction specific formulary once endorsement is obtained from the relevant legislative body [10]. To obtain endorsement for scheduled medicines (ESM), Australian podiatrists are required to successfully complete postgraduate qualifications [11]. Whilst it is an essential component of registration for podiatric surgeons, uptake of the ESM option remains low for non-surgeon podiatrists (167 of 5,867) [12]. However, as the Council of Australian Governments Health Council and the Podiatry Board of Australia have recently provided approval for an ESM training pathway to be embedded into undergraduate podiatry education nationally [13], ESM numbers are expected to rise.

The Podiatry Board of Australia requires those who have been successful in achieving ESM credentialling to undertake an additional 10 hours per year of continuing professional development (CPD) specific to endorsement (separate to the 20 hours of CPD required for standard podiatry registration) [14]. Anecdotally, ESM podiatrists have raised concerns over the perceived lack of availability and appropriateness of ESM CPD resources. While this may be a symptom of low ESM numbers in podiatry, access to appropriate, equitable, affordable, and relevant CPD opportunities are required to ensure safe, efficacious, and responsible prescribing practices continue as the profession evolves [15]. The expected increase in participation by podiatrists will bring with it the requirement to meet ongoing training and competency needs of this work force.

Worldwide, CPD is accepted as the minimum requirement for health care practitioners to update their knowledge, skills, and performance to maintain their clinical competency [16]. However, the true impact of CPD in enabling improved clinical service delivery is still largely unknown due to inconsistencies in assessing CPD outcomes [17, 18]. Mandatory CPD programs most commonly focus on hours completed and do not assess the content, nor quality of the activity undertaken. Several gaps in the CPD system are documented in the literature and range from an emphasis on a time-based approach over quality and a lack of focus of translation to practice of learnings, to disincentives to engage in multidisciplinary learning and team building activities [19, 20].

For CPD to be effective in building complex skills and changes to clinical practice that aim to ultimately improve patient care, CPD should be constructed based on adult learning principles, rather than passive “tick a box” experiences [21]. Significant costs, both financial and time commitments, are associated with undertaking CPD, therefore it is imperative that the impact of CPD activities are adequately assessed [22, 23].

Kirkpatrick’s Model, developed in the 1950’s, is a widely accepted 4 stage model for evaluating training programs. Level 1 focuses on the learner’s reaction to the training; level 2 evaluates content, skills, and knowledge; level 3 measures translation of knowledge and skills to practice; and level 4 measures impact and sustainability of the training [24]. Based on this model, evaluations of CPD often focus on a narrow range (levels 1 and 2) of easily measured impacts such as knowledge, skills, and confidence. Works by Allen et.al [17, 25, 26] generated the CPDIS tool that consists of three scales capturing “‘learnings and self-efficacy’, ‘networking and building community’, and ‘achievement and validation’”. Whilst these scales do encompass Kirkpatrick’s four stages, they include impacts that are seldom measured and aim to capture a more wholistic evaluation of the effect of CPD [26].

With the continued implementation of non-medical prescribing models around the world and the expectation that many more podiatrists will obtain ESM status in the future, identifying factors associated with meeting CPD requirements, including whether podiatrists have adequate access to meaningful content are needed. Empirical evidence to support our understanding of these factors is essential to ensuring CPD experiences for podiatrists and non-medical prescribers alike, are both effective and appropriate to meet their needs.

The primary aim of this project was to investigate how ESM podiatrists meet the required CPD hours to maintain endorsement. The secondary aims were to determine if the learning opportunities currently available to ESM podiatrists are perceived by them to be accessible, relevant, and meaningful to achieve their desired learning goals.

Methods

Results

A total of 42 survey responses were received. Nine responses were excluded as participants were not ESM podiatrists or podiatric surgeons (n = 6) or failed to respond to questions outside of personal demographics (n = 3). The remaining 33 responses included in data analysis, represented 20% (n = 33/167) of the eligible population of ESM podiatrists and podiatric surgeons. Some survey participants skipped mandatory questions resulting in incomplete survey responses being received. Mandatory questions not involved in question logic that did not receive n = 33 responses were Q16 (n = 31); Q17 (n = 31); Q22–26 (n = 28).

Table 1 depicts the demographic data of participants. Respondents (n = 33) were largely ESM podiatrists (n = 26), the median years of practice was 11.5 years (IQR 6.8, 20.0), median years of endorsement was 2.5 (IQR 1.0, 9.0), and they were predominantly female (n = 18). Respondents were representative of all states and territories except the ACT and Tasmania.

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Table 1. Demographic details of respondents (n = 33).

https://doi.org/10.1371/journal.pone.0289217.t001

CPD habits and engagement of respondents

Participants had mixed views regarding the access to, and outcomes of ESM CPD. When asked how many hours of ESM CPD participants had completed in the previous 12-month registration period, 88% (n = 29) had undertaken the mandated 10 or more hours.

Participants perceptions regarding ease of access, affordability, meaningfulness, relevance to scope of practice of the CPD they had undertaken within the last 12 months, and its influence on knowledge and translation to a change in prescribing practice are summarised in Fig 1.

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Fig 1. Participant reflections of all endorsed for scheduled medicines continuing professional development activities completed in the past 12 months (n = 31).

https://doi.org/10.1371/journal.pone.0289217.g001

Overwhelmingly, 81% (n = 27) of respondents indicated there were improvements to be made to the content, accessibility, relevance, and meaningfulness of CPD available to ESM podiatrists.

Three further ideas arose from participants responses to the closed-ended questions regarding common behaviours and engagement strategies when undertaking CPD; a high level of mentoring exists within their cohort, most fail to set goals for CPD prospectively, and a wide variety of platforms are used to access CPD.

ESM podiatrists frequently seek and offer mentorship to peers. A majority 63% (n = 21) of respondents received mentoring from a more experienced prescriber. The main contributors to these mentoring relationships were ESM podiatrists (24%, n = 5), podiatric surgeons (29%, n = 6) and other medical specialists (33%, n = 7) such as infectious disease consultants or rheumatologists. Conversely, just over a third (36%, n = 12) of respondents had at some point mentored a podiatrist undertaking the ESM pathway to completion, with one participant reporting they had mentored 15 people through the education process. Ten respondents were mentoring a least one podiatrist undertaking the ESM pathway in the 2020 registration year, with one practitioner mentoring 10 pathway participants across the same period.

Nearly two-thirds (65%, n = 20) of respondents reported that they do not construct CPD learning goals at the start of a registration period, or they opt to write them reflectively after completing CPD activities.

Fig 2 outlines respondents’ preferences for receiving CPD. The top three selected modalities were case studies, peer support sessions, and journal articles. Participants reported most often that they believe the Australian Podiatry Association (APodA) and multidisciplinary platforms should be delivering CPD activities for ESM clinicians (Fig 3).

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Fig 2. Participant responses on how they prefer their continuing professional development to be delivered.

Participants (n = 33) were able to select their top 3 preferences.

https://doi.org/10.1371/journal.pone.0289217.g002

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Fig 3. Participant responses on which sectors they believe should be delivering continuing professional development for endorsed for scheduled medicines podiatrist.

Participants (n = 33) were able to select all that applied. (Note: APodA—Australia Podiatry Association. ACPS—Australasian College of Podiatric Surgery).

https://doi.org/10.1371/journal.pone.0289217.g003

Self-reflection on participants last ESM CPD activity completed

Participants outlined the type of CPD activity they participated in, reasons for choosing the activity, and provided an assessment of the activity against accessibility, affordability, change in practice, and other skills.

A range of CPD activities were reported by participants, including mentoring podiatrists undertaking the ESM pathway; reading COVID-19 updates, peer-reviewed journals, National Prescribing Service articles; accessing Therapeutic Guidelines; and taking part in or watching webinars.

The three most common reasons participants undertook their selected CPD activity was a clinical situation or interaction they had experienced (n = 13), it pertained to an area of interest (n = 13), or the ESM CPD activity was accessible (n = 13). No participants were prompted to undertake the activity due to a prescription audit or an error in prescribing.

Fig 4 outlines the respondent’s self-assessment of the most recently completed ESM CPD activity against criteria adapted from the CPDIS tool [26]. The vast majority of respondents (89%, n = 25/28) reported that the activity was easily accessible and affordable and 85% (n = 24/33) would recommend the activity to a colleague. However, when asked if the activity improved confidence in their prescribing; translated to a change in practice; improved their communication skills with clients and/or colleagues; or enabled networking, collaboration and relationship building, only 50% or less of participants agreed.

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Fig 4. Self-audit of the most recent endorsed for scheduled medicines continuing professional development activity undertaken (n = 28).

Participants were asked to rate on a 5-point Likert scale if the activity met the parameters outlined e.g. The activity enabled networking, collaboration and relationship building.

https://doi.org/10.1371/journal.pone.0289217.g004

Discussion

This survey presents the first known results describing how Australian ESM podiatrists are meeting the required CPD hours and if current learning opportunities are perceived to be accessible, relevant, and meaningful. While respondents appreciated and sought out the knowledge associated with ESM activities, participants repeatedly called for improvements across these three domains. The overarching message was improvements across several parameters could be made, including frequency, content, relevance, accessibility, and delivery, with respondents suggesting solutions for many of the concerns raised. The results of the current study support previous international findings that CPD is perceived to be beneficial by clinicians [20, 28, 40–45]. There were also similarities shared between our study and those reported elsewhere for frustrations with scarcity of specialised content, cost and available funding, time commitment required, and the lack of national infrastructure to support quality CPD [8, 20, 27, 28, 32, 40–43].

The majority of respondents in our study reported that they were able to meet their mandatory CPD requirements by accessing a variety of education opportunities, across multiple platforms, with many of these experiences being viewed positively. However, only one-third of respondents reported that they complete CPD learning goals at the start of a registration period. Goal setting for CPD is considered best practice, recommended by Australian and international health bodies [19–21, 40, 42, 46–54] to ensure CPD is individualised, relevant to practice, and aids future career development [45]. An example of CPD goal setting being utilised on a large scale is the NHS annual professional development plans. However, outcomes in this case are hard to identify as participation rates in this process are not transparent [55–57]. Studies explicitly investigating clinician engagement with goal setting were not found. However, reflective practice, and, by extension, goal setting, is reportedly low across many health disciplines [45, 55, 58]. One explanation described in the literature is that clinicians are not trained in reflective practice or goal setting, particularly those who have been in the workforce longer [44].

Although podiatrists reported not explicitly setting goals for their CPD, they did report choosing activities based on ‘clinical situations or interaction’ or ‘areas of interest’. This finding suggests an informal, implicit planning may be occurring when choosing CPD to engage with. While our survey did not capture the reasons for the lack of goal setting, several implications could be inferred; ESM podiatrists may not believe that planning results in a net benefit, there may be a lack of notification of appropriate CPD meaning they are unable to successfully plan their CPD for the coming year, or they fear that goal setting could impact their ability to achieve the mandatory CPD guideline requirements.

One reason reported by ESM podiatrists for completing CPD activities was ease of accessibility. Concerningly these accessible activities were often evaluated by participants as not providing relevant and meaningful content. International bodies governing or representing safe prescribing practice, advocate CPD should be undertaken with a focus on scope, and relevance to practice, aiming for the acquisition of knowledge and skills, and the ability to translate these into changes to the provision of clinical care [53, 54, 59]. Given CPD is mandatory, its effectiveness at achieving the required outcomes is worthy of examination, and to date the evidence in the broader literature of this effectiveness remains mixed [16]. In fact, while CPD has been shown to increase knowledge, translating this to practice change and safe delivery of quality care is yet to be clearly demonstrated [60].

Respondents to our survey provided numerous suggestions for improving ESM activities, including the creation of interprofessional networks. Interest in interprofessional learning has increased across the world with the concurrent shift to interprofessional and multidisciplinary patient centred health care models [61]. Interprofessional learning opportunities have demonstrated positive impacts that include improving interprofessional communication as well as an increase in earlier and appropriate referrals, and collaborative patient care delivery [61, 62]. Respondents suggested learning from and with pharmacists was a potentially valuable resource that to date has not been fully explored. Fostering such interprofessional collaborative learning opportunities not only are likely to meet the learning needs of ESM podiatrists but may produce a change in behaviour by increasing the understanding of each other’s professional roles, scopes, and improving communication [19].

A strong topic that emerged from this research was that some working environments provide broader opportunities for both structured and incidental CPD. For example, the isolated rural podiatrist may struggle to access adequate opportunities while those practicing in large multidisciplinary environments, surrounded by multiple prescribing practitioners may be at an advantage. It is well documented that rural health professionals experience barriers to engaging in professional development, including lengthy travel times to engage in events, a scarcity of backfill staffing to allow clinicians to attend events, and poor internet connections [63–65]. To ensure equity of access, CPD developers need to consider delivery modalities and the learning conditions of all potential participants regardless of their location.

With increasing demands on health services, the acceptance and support for non-medical prescribing is expected to rise [10]. Governments, professional advocacy, and regulatory bodies are encouraging clinicians internationally to become non-medical prescriber practitioners as a strategy to benefit consumers through improved access to medicines and to contribute to health care system efficiencies. In Australia, other allied health professions such as physiotherapy and pharmacy are currently exploring non-medical prescribing pathways for their professions. Preparing and planning for increasing numbers of endorsed non-medical prescribers is needed to ensure they can continue to practice in a safe, effective manner. This includes planning to support continuing professional development requirements associated with non-medical prescribing status.

Whilst these results provide some insight into ESM CPD experiences, there are limitations of this study that should be acknowledged. Firstly, only 20% of eligible ESM podiatrists responded to the survey. Only one response was received from a practitioner in Queensland, despite this jurisdiction having the second highest proportion (n = 42/167, 25%) of the overall ESM population [12]. Therefore, whilst these results provide some insight into ESM CPD experiences, they cannot be generalised to the entire ESM podiatry community. Secondly, on reflection, the survey design could have been strengthened by following high-quality survey development tools, such as those described by Artino et. al [66]. Thirdly, the authors also recognise that building questions around a priori topics may have limited the responses provided by participants. This was counteracted by the inclusion of a final open-ended question, “Do you have any other comments?” but may not have allowed participants to express all their views on CPD for ESM podiatrists. Further qualitative studies could add depth to the findings of this study.

From a medicine’s perspective, the goal of CPD is to ensure clinicians maintain prescribing competency with the aim that this translates to safe, effective, and judicious use of medicines against the National Prescribing Service Prescribing Competencies Framework [66, 67]. It would be valuable for future research to examine the effectiveness of CPD activities for ESM podiatrists, and non-medical prescribers generally in achieving this goal. Shifting the focus of CPD evaluation more towards levels 3 and 4 of Kirkpatrick’s Model and utilising tools such as CPDIS could assist in ascertaining if competency is achieved [17, 26]. Future work could also explore models for sustainable interprofessional learning and the effect of these programs on learning outcomes for each profession. With a projected increase in ESM practitioners in the future due to changes to undergraduate training programs and an increase in implementation of alternative models of health care, it will be important to explore changes in ESM practitioners learning requirements overtime. More broadly, utilisation of goal setting for CPD amongst the podiatry population could be evaluated to ascertain if the results of this survey are consistent across the profession.

Conclusions

The majority of ESM podiatrists do complete the 10 hours of mandatory training required by the Podiatry Board of Australia. However, some complete activities that are accessible and affordable, rather than being aligned to goals of learning, bringing into question the value of mandatory CPD. Respondents repeatedly called for improvements in CPD for ESM clinicians. They know what they want, how they want it delivered, and are prepared to invest in accessing relevant and quality resources to support their learning. ESM podiatrists would like podiatry led organisations and universities to deliver profession specific resources and develop interprofessional learning models that they can engage with. It is encouraging that these organisations have recognised the need to support ESM podiatrists in their CPD with new resources being recently released, however the challenge remains, as stated by clinicians in this survey “We want more!”.

Whilst this study has focused on the Australian ESM podiatry context, learnings should prompt international jurisdictions that have non-medical prescribing in place to review the quality of ongoing educational support for practitioners. This is especially important for emerging prescribing professional groups or for countries planning to implement non-medical prescribing for the first time. Considering the continuing education needs of the non-medical prescribing workforce prior to implementation will assist in ensuring prescribers are supported robustly to provide safe, effective, and appropriate medicines care.

Supporting information

Acknowledgments

The authors wish to especially thank all endorsed for scheduled medicines podiatrists and podiatric surgeons who volunteered to take part in this study.