CPD Activity dental oral
22
In a review of systematic reviews, that looked at the effects of continuing medical education on physician clinical care and patient health, Bloom (2005) concluded “ Burgeoning knowledge from RCTs and meta-analysis of CME is clear on the most-effective techniques that alter medical-care processes and patient health outcomes – interactive education, audit and feedback, reminders, academic detailing and other outreach programmes, and somewhat less so, clinical practice guidelines and opinion leaders. In addition, combining techniques, for example, interactive education plus academic detailing, leads to greater effect than either of the techniques alone. The literature is also clear on the least-effective education methods- didactic lectures and distributed print materials alone. But even a technique of low-efficacy (such as didactic lectures and distributed print materials alone) can become useful when combined with interactive tools.”
The findings of a Cochrane Review of the effects of continuing education meetings on professional practice and health care outcomes (Forsetlund et al. 2009) echoed Bloom’s conclusions that the effects of such meetings on these aspects were small and that educational meetings alone were not likely to be effective for changing complex behaviour.
In their systematic review of the effectiveness of continuing medical education Marinopoulos et al. (2007) also found multimedia was more effective than print and (unsurprisingly) multiple exposures (to CME) more effective than a single exposure. The need for learning methods for the continuing education of nurses that involve active participation, as opposed to didactic lectures was stressed by Griscti and Jacono (2006). In a review commissioned by the General Medical Council (GMC) and Academy of Royal Medical Colleges (AMRC) (Schostak et al. 2010), this theme was developed further and it was suggested that the literature supports the view that active learning should link CPD with needs analysis and multiple learning activities if it were to be likely to change doctors’ practice. In a review for the Professional Associations Network (PARN), Friedman and Woodhead (2008) stressed the need for individuals to plan their CPD and to reflect after all CPD activities. The need for follow up was also highlighted by Schostak et al. (2010) who reported that “Effective knowledge should be integrated with everyday working practices and combined with follow-up activities in order to ensure reinforcement and critical development, such as real-time or virtual discussion with peers.”
Notwithstanding the above findings, a degree of caution should be exercised when selecting effective modes of CPD. Grant (2011) has pointed out that the findings of studies into CPD underline the influence of contextual and intervening variables and the problems associated with trying to isolate their effects on the results. Marinopoulos et al. (2007) concluded that more research is necessary to determine with any certainty which types of media, techniques and exposure volumes (to CME), as well as what internal and external characteristics, are associated with improvements in outcomes.
In conclusion, no studies of high quality existed to demonstrate the effectiveness of CPD, in terms of quality of care delivered, performance, professional standards, competence, public satisfaction or safety, or their longer-term effects on knowledge retention and application. However, particular elements of individual CPD programmes were deemed to be effective. These include the benefits of sustained, repeated, or longer term CPD activities, involving an interactive method of delivery utilising multimedia, or combining techniques, for example, interactive education. The importance of planning, self directed learning and reflective practice were highlighted as were the perceived benefits of personal learning plans and reflection to help clinicians to identify and take part in appropriate CPD.
23
What are the least and most effective qualitative and quantitative measures of CPD activity for the healthcare professions, and in particular dentistry?
From the dental literature, the review only revealed one Grade 4 paper (Table 8) which reported on the development of an Index of Dental Educational Activities (IDEA) as part of an exploration of continuing professional development activities among a sample of general dental practitioners in Yorkshire (MacGregor et al. 1991). The authors described IDEA as a measure to demonstrate CPD activities. The index was based upon a variety of CPD activities, where points were awarded for degrees of involvement in each area, to give a simple summation. However, whilst the utility of the index as a summary of CPD practices, and its potential as a comparative measure across health professions was highlighted, the authors also stated how mere attendance at continuing education events will not necessarily result in better patient care.
Table 8: An index of dental educational activities
Professional group Key topic area
Dentists
Utilising an index of dental educational activities (IDEA) to explore continuing professional development activities among a sample of general dental practitioners (GDPs) in the Yorkshire Region in Britain. (MacGregor et al. 1991) Grade 4
The literature from other healthcare professional groups highlighted the challenges in defining the concept of “effectiveness”, and measuring outcomes of CPD. The pharmacy literature revealed a portfolio-based model involving external competency assessment to develop “patient facing scenarios” (CPI 2010). This is described at the end of this section (5.1. of the report).
As mentioned previously, Grant (2011) listed 38 methods of following up CPD and showing its effectiveness, such as appraisal, audit, educational records and log books, self-assessment. Schostak et al. (2010) considered that “any meaning we attribute to “effectiveness” is to be left open because it is complex and multi-dimensional and accordingly, incompatible with measurement.” The same authors also reported that effectiveness is facilitated when professionals are able to determine their own learning needs through reflection within the totality of their practice and that this means being able to go beyond what is quantifiable.
Self-accounting with appraisal by an “independent” professional peer is one technique for measuring CPD activity and is capable of addressing the diversity of practice (Schostak et al. 2010). The same authors (Schostak at al. 2010) and Grant (2011) also recognised the value of self-directed and informal learning and they have been incorporated in the AMRC’s ten principles of CPD (Appendix E) used by Medical Royal Colleges and Faculties.
The difficulties in defining exactly what CME outcomes should be measured and how they should be measured was highlighted over 30 years ago (Bertram and Brooks-Bertram 1977). As Grant (2011) concluded, education and learning do not take place in a laboratory and it is a very great challenge to identify and measure factors relevant to performance and patient care. She went on to state that with many studies which ostensibly concern themselves with the outcomes of CPD, the outcomes are not connected or are loosely connected to CPD, in that they fail to address the issues of changes in practice and in practice outcomes (Grant 2011). Hours undertaking CPD is one such measure.
24
Grant goes on to suggest that for medical practitioners, far better qualitative measures of successful outcomes after CPD could include changes in:
Prescribing practices
Use of screening techniques
Preventive care practice
Diagnostic accuracy
Referral patterns
Each of the 38 methods for demonstrating the effectiveness of CPD, that Grant has identified, have advantages and disadvantages. For example some, such as referral patterns, are simple to record, whereas others such as confidence levels and corporate image are difficult to assess objectively. However, very few studies have attempted to compare their relative value as effective quantitative or qualitative measures of CPD for healthcare practitioners, making evidence-based recommendations impossible.
Some regulatory bodies continue to use input variables such as completed hours as a measure of CPD activity. It has been suggested that hours accumulated from activities involving active and targeted participation, which have been shown to be more effective than passive learning, should attract more credits (Bloom 2005). However, both Schostak (2010) and Grant (2011) have described the weakness of using input to measure CPD. For example, Grant (2011) stated that: The measurement of participation in CPD by accumulation of credits, or hours, is perhaps the most commonly applied framework. Evidence would suggest that it is probably not effective in ensuring that CPD has an effect in practice. In the Professional Associations Research Network (PARN) report – Approach to CPD Measurement , Friedman and Woodhead (2008) reviewed the advantages and disdvantages of using input versus output to measure CPD. They concluded that although the input approach had the advantages of simplicity and was easy to monitor, it was difficult to assess whether or not the hours of CPD translated into improved performance and could be meaningless if for example participants fell asleep during lectures. They stated that the output approach attempts “to measure what CPD is intended to achieve directly” and enabled individual professionals to monitor their own progress (Freidman and Woodhead 2008). They concluded that “along with improvements in the supply of output measurement techniques, we believe the demand for such systems will grow significantly as pressures on professional bodies towards providing evidence for continuing competence and maintaining professionalism grow both from the professionals themselves and from other stakeholders.”
The outcomes framework for Pharmacists, evaluated by Donyai et al. (2010) may offer one example of targeted, “active” participation in CPD. The framework is based on the concept that each pharmacist will plan and record their CPD and have to demonstrate that it is relevant to their field of practice and has contributed to the quality of development of their practice (Donayi et al. 2010). However, the evaluation of this outcomes framework involved a small sample of volunteers and further, far larger trials, using representative samples, are necessary before it could be generally accepted as a reliable measure of CPD.
With regard to qualitative and quantitative measures of CDP the Pharmaceutical Society of Ireland (PSI) propose that all Irish Pharmacists should be required to record a balance of different CPD activities in a portfolio accompanied by a robust external competency assessment which should be developed by peers and recreate “patient facing scenarios” (PSI 2010). The proposals are based on 13 principles with an “overriding focus on patient safety, patient care and public welfare” (PSI 2010). The same report also highlighted the benefits of blended learning using a mixture of online and face-to-face activities and an online portfolio to allow a flexible approach that focuses on outcomes relevant to an individual practitioner’s practice (PSI 2010).
25
Feedback from workshops indicated that Irish Pharmacists wanted to move away from measuring CPD by hours (PSI 2010). The need for an international benchmark was recognised and the Irish Pharmacists Association has been reported, as encouraging, a move from a purely points gathering exercise by requiring that any CPD undertaken is relevant to the individual pharmacists role (PSI 2010), a view shared by the Institute of Continuing Professional Development (ICPD 2006). There is a view that because of the variety of roles that registrants undertake, other than training and retraining in communication skills, there is no need for compulsory CPD in some topics (Grant 2011). In conclusion, overall, both the dental and non-dental literature demonstrated the difficulties in developing effective and evidence-based recommendations for quantitative or qualitative measures of CPD. PARN has suggested that output measures may be more effective than input at measures as a means to assess the effectiveness of CPD. A number of regulatory bodies and professional associations are adopting this approach. However, as yet there have been no studies on this topic specifically related to dentistry.
5.2 Regulatory purposes of CPD What are the regulatory benefits of CPD participation in dentistry?
The dental literature did not reveal any studies that demonstrated benefits relating to regulatory purposes of CPD participation in terms of improved quality of care delivered, performance, professional standards, competence, public satisfaction or safety. Only low quality studies (Grades 4 or 5) were found. In one Australian study, its authors suggested that lower attendance rates at CPD courses may occur as a result a lack of mandatory requirements in the country concerned (Abbott et al. 2010). Another study commented on reasons behind attendance at mandatory CPD (Hopcraft et al. 2010).
In 2006, in Western Australia (WA) there was no requirement for dentists to participate in CPD. A Grade 5 study into the participation pattern of dentists in WA in CPD activities between 2001 and 2006 revealed that attendance was low (Abbott et al. 2010). Between 10.1-24.4% of dentists registered in WA attended at least one course each year. The authors drew comparisons with a study in the United Kingdom that showed that 96% of the participants had attended 2.5 hours or more of courses and lectures in a one year period (Bullock et al. 2003). It should be noted that the data for this study (Bullock et al. 2003) were collected before CPD was made a mandatory requirement for UK dentists. Furthermore, Abbott et al. (2010) only included participants who attended courses organised by the University Continuing Dental Education Committee and therefore the results did not necessarily reflect the total CPD activity of all Western Australian dentists.
In a Grade 4 study investigating participation in continuing professional development by dental practitioners in Victoria, Australia in 2007, Hopcraft et al. (2010) found that approximately one in five respondents undertook CPD activities for the sole purpose of meeting the mandatory requirements, rather than for professional and educational reasons.
Care must be exercised when considering the findings from these studies, due to the limitations of self-reported data and convenience sampling. Making direct comparisons between different schemes and countries may not always be appropriate due to the different requirements regarding clinical and non-clinical hours, and verifiable and non-verifiable CPD activities.
The non-dental CPD literature identified a range of regulatory benefits of participation in CPD. These encompass assuring activity levels and competency, satisfying public expectations, keeping abreast of advances in patient care and as a registration instrument.
26
The PSI (2010) highlighted that the primary benefit of CPD is the assurance of a minimum level of development activity for all members of the profession, which in turn is intended to ensure a certain level of competency thus safeguarding patients.
The ICPD stated that “professions continually need to be seen to be responding to the public perception that they oversee the competencies of their members, particularly as a result of greater business transparency and an increasingly litigious environment” (ICPD 2006).
Similarly, although aimed at physicians, Bloom (2005) suggested that “the objective of physician continuing medical education is to help them keep abreast of advance in patient care, to accept new more-beneficial care and to discontinue use of existing lower-benefit diagnostic and therapeutic interventions.” Bloom’s suggestion is echoed by Friedman and Phillips (2001).
In conclusion, the literature identifies a range of regulatory benefits of participation in CPD, but fails to demonstrate any clear associations with quality of care delivered, performance, professional standards, competence, public satisfaction or safety.
What are the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation?
The review of dental literature did not reveal any information to answer this question. However, it was apparent from the grey literature (GDC 2011, GMC 2011) that regulatory processes involve both the public, and individual professionals, in assuring and demonstrating professional standards and competency and supporting clinicians to achieve and maintain acceptable standards. Four of the non-dental publications did provide answers to this question, as follows:
To demonstrate that patient care has benefited in some way in the context of safety, quality and efficacy in terms of tangible outcomes (Donyai et al. 2010).
To enable individual professionals achieve a measure of control and security in the often precarious workplace (Friedman and Phillips 2001) and thus be less likely to act in an unprofessional manner.
As a means of assuring a wary public that professionals are indeed up-to-date, given the rapid pace of technological advancement. (Friedman and Phillips 2001).
As a means whereby it can be verified that professional standards are being upheld (Friedman and Phillips 2001).
To support the public service duty by ensuring that anyone claiming to be a member can be relied upon to have kept their knowledge and skills up to date (ICDP 2006).
To assure competency across the profession, to meet patient needs and demonstrate this competency to others (PSI 2010).
In addition, the GDC website (GDC 2011) reminds registrants that: “Patients are right to expect that all members of the dental team are keeping their skills and knowledge up to date throughout their
27
careers. We ensure that this is happening by making CPD a requirement for all dental professionals registered with us.”
The General Medical Council’s website (GMC 2011) states that the GMC has a statutory role to promote high standards and co-ordinate all aspects of medical education. This includes doctors’ continuing medical education. It also states that “Good medical practice requires doctors to keep their knowledge and skills up to date throughout their working life and to maintain and improve their performance. Continuing professional development (CPD) is a key way for doctors to meet these professional standards and is one of the sources of information required for appraisal and revalidation”.
In conclusion, the dental literature did not reveal any studies that demonstrated the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation. Information from other healthcare sectors focussed on maintaining and demonstrating professional standards and competency to the public.
5.3 CPD participation How do healthcare professionals, and in particular dental professionals, currently engage with, perceive and benefit from CPD; and does CPD have particular consequences for different groups and forms of practice in dentistry?
The dental literature revealed only Grade 2 and Grade 3 studies for this research theme regarding dentists and dental hygienists. Table 9 describes key topic areas arising from papers of Grade 2 and Grade 3 quality for dentists. No studies were found which demonstrated particular consequences for CPD for different groups and forms of practice in dentistry.
Only one Grade 3 paper was identified which examined dental hygienist participants' satisfaction with a continuing education course in periodontics (Young et al. 1989).
Table 9: How dentists currently engage with, perceive and benefit from CPD
Professional group
Dentists GDP participation rates (Firmstone et al. 2004) Grade 3 Reasons why GDPs undertake CPD programmes in endodontics and implant dentistry, and participation rates of CPD (John and Parashos 2007) Grade 3 GDP perceptions of the effectiveness of personal learning plans (Carrotte et al. 2007) Grade 3 Perceptions of PDP and participation in CPD (Bullock et al. 2007) Grade 2 Attitudes towards online CPD (Francis et al. 2000) Grade 3 Perceptions of e-learning cross-infection control CD-ROM provided to all general dental practitioners in England. (Gray et al. 2007) Grade 3 Orthodontists’ perception of the utility of computer-based continuing education about super-elastic arch wires for the initial stage of orthodontic treatment (Marsh et al. 2001) Grade 3 The use of targeted email reminders (designed as cues to action) to influence participation by dental providers in an Internet delivered intervention for tobacco control (Houston et al. 2010) Grade 2
28
These Grade 2 and 3 studies describe GDP participation rates in specific topic areas, and in particular localities; reasons behind choice of CPD topic; perceptions of personal development plans; attitudes towards individual CPD applications and the use of targeted e-mail reminders to influence participation.
In a study utilising a convenience sample of GDPs in three postgraduate dental deaneries in England, Bullock et al. (2004) reported that the most frequently undertaken forms of CPD were found to be journal reading and courses. Specifically, 97% of the dentists who responded reported attending at least one two and a half hour session in the study period and 43% for more than 15 hours.
In an Australian study, John and Parashos (2007) reported that for CPD programmes in endodontics and implant dentistry, overall, most participants (72 %) agreed that they relied on formal CPD programmes to keep up-to-date in practice, with 92% having undertaken their particular course to improve their clinical skills. Interestingly, 35% of participants that reported that they had undertaken the programme to fulfil their Board requirements.
Carrotte et al. (2007) reported very positive feedback from GDPs on the use of a PDP. Practitioners felt that new skills were being employed, or that an improved understanding had led to a reduction of previous inaccurate or wrong practices. The authors suggested that greater ownership of an educational programme, coupled with a sense of belonging to a study group, may stimulate and motivate practitioners to a greater extent.
Bullock et al. (2007) reported similar findings in a RCT investigating GDP perceptions of PDPs and participation in CPD in general. Participants undertook a median number of 17 educational activities in the six month period of the study (mean of 50 hours). Most frequent activities were reading and attendance at courses. These two accounted for over half the total number of educational activities. The main ‘other’ activities included staff meetings or discussions with colleagues, training activity with new dentists and peer review but a range of other CPD was also listed (including journal clubs, conferences, clinical audit). The results showed that developing a PDP with the aid of a tutor was viewed positively, and almost all would recommend developing a PDP to other dentists. Compared with the control group, those with a PDP in the experimental group engaged in proportionally less reading and more courses and ‘other’ CPD activity.
In a study investigating the impact of two online modules on dental radiology and occupational safety and health administration standards, Francis et al. (2000) reported positive findings. The majority of participants agreed that accessing online continuing dental education at their convenience was a definite advantage (88%), they would recommend it to their professional colleagues (88%), and the material in the course(s) was useful and applicable to professional activities (76%). Participants were enthusiastic about online learning but desired much more interactivity than existed in the current design. The least-liked aspects related to technical and formatting issues.
Similar findings were reported by a study investigating perceptions of a CD ROM in cross-infection (Gray et al. 2007) and super-elastic arch wires (Marsh et al. 2001). Gray et al. (2007) showed how the majority of participants felt that the CD ROM was well-designed and fit for purpose, and supported and extended their subject knowledge in the area of cross-infection control whilst simultaneously serving as a useful reference tool. Negative comments were limited and principally referred to typestyle and layout, and distribution failures. Marsh et al. (2001) showed how over 90% of the viewers thought the CD ROM program was well-designed and provided useful information.
29
A more specific finding in the use of online CPD resources was demonstrated by (Houston et al. 2010) who examined the use of targeted e-mail reminders (designed as cues to action) to influence participation by dental providers in an Internet delivered intervention for tobacco control. The e-mail reminders resulted in the largest number of visits on the day the e-mail was sent (e-mail release day). The day after the e-mail also showed an increase in website visits, then returning to baseline. On days when no recent reminders had been sent, very little participation occurred.
Other than the four Grade 3 studies relating to CPD for dental hygienists that have been reviewed earlier in this report, only poor quality evidence (Grade 4 or Grade 5) was found with regard to CPD for DCPs. The relevant studies are listed in Table 10.
Table 10: How DCPs currently engage with, perceive and benefit from CPD
Professional group Titles (NB all only Grade 4/5)
In a review of systematic reviews, that looked at the effects of continuing medical education on physician clinical care and patient health, Bloom (2005) concluded “ Burgeoning knowledge from RCTs and meta-analysis of CME is clear on the most-effective techniques that alter medical-care processes and patient health outcomes – interactive education, audit and feedback, reminders, academic detailing and other outreach programmes, and somewhat less so, clinical practice guidelines and opinion leaders. In addition, combining techniques, for example, interactive education plus academic detailing, leads to greater effect than either of the techniques alone. The literature is also clear on the least-effective education methods- didactic lectures and distributed print materials alone. But even a technique of low-efficacy (such as didactic lectures and distributed print materials alone) can become useful when combined with interactive tools.”
The findings of a Cochrane Review of the effects of continuing education meetings on professional practice and health care outcomes (Forsetlund et al. 2009) echoed Bloom’s conclusions that the effects of such meetings on these aspects were small and that educational meetings alone were not likely to be effective for changing complex behaviour.
In their systematic review of the effectiveness of continuing medical education Marinopoulos et al. (2007) also found multimedia was more effective than print and (unsurprisingly) multiple exposures (to CME) more effective than a single exposure. The need for learning methods for the continuing education of nurses that involve active participation, as opposed to didactic lectures was stressed by Griscti and Jacono (2006). In a review commissioned by the General Medical Council (GMC) and Academy of Royal Medical Colleges (AMRC) (Schostak et al. 2010), this theme was developed further and it was suggested that the literature supports the view that active learning should link CPD with needs analysis and multiple learning activities if it were to be likely to change doctors’ practice. In a review for the Professional Associations Network (PARN), Friedman and Woodhead (2008) stressed the need for individuals to plan their CPD and to reflect after all CPD activities. The need for follow up was also highlighted by Schostak et al. (2010) who reported that “Effective knowledge should be integrated with everyday working practices and combined with follow-up activities in order to ensure reinforcement and critical development, such as real-time or virtual discussion with peers.”
Notwithstanding the above findings, a degree of caution should be exercised when selecting effective modes of CPD. Grant (2011) has pointed out that the findings of studies into CPD underline the influence of contextual and intervening variables and the problems associated with trying to isolate their effects on the results. Marinopoulos et al. (2007) concluded that more research is necessary to determine with any certainty which types of media, techniques and exposure volumes (to CME), as well as what internal and external characteristics, are associated with improvements in outcomes.
In conclusion, no studies of high quality existed to demonstrate the effectiveness of CPD, in terms of quality of care delivered, performance, professional standards, competence, public satisfaction or safety, or their longer-term effects on knowledge retention and application. However, particular elements of individual CPD programmes were deemed to be effective. These include the benefits of sustained, repeated, or longer term CPD activities, involving an interactive method of delivery utilising multimedia, or combining techniques, for example, interactive education. The importance of planning, self directed learning and reflective practice were highlighted as were the perceived benefits of personal learning plans and reflection to help clinicians to identify and take part in appropriate CPD.
23
What are the least and most effective qualitative and quantitative measures of CPD activity for the healthcare professions, and in particular dentistry?
From the dental literature, the review only revealed one Grade 4 paper (Table 8) which reported on the development of an Index of Dental Educational Activities (IDEA) as part of an exploration of continuing professional development activities among a sample of general dental practitioners in Yorkshire (MacGregor et al. 1991). The authors described IDEA as a measure to demonstrate CPD activities. The index was based upon a variety of CPD activities, where points were awarded for degrees of involvement in each area, to give a simple summation. However, whilst the utility of the index as a summary of CPD practices, and its potential as a comparative measure across health professions was highlighted, the authors also stated how mere attendance at continuing education events will not necessarily result in better patient care.
Table 8: An index of dental educational activities
Professional group Key topic area
Dentists
Utilising an index of dental educational activities (IDEA) to explore continuing professional development activities among a sample of general dental practitioners (GDPs) in the Yorkshire Region in Britain. (MacGregor et al. 1991) Grade 4
The literature from other healthcare professional groups highlighted the challenges in defining the concept of “effectiveness”, and measuring outcomes of CPD. The pharmacy literature revealed a portfolio-based model involving external competency assessment to develop “patient facing scenarios” (CPI 2010). This is described at the end of this section (5.1. of the report).
As mentioned previously, Grant (2011) listed 38 methods of following up CPD and showing its effectiveness, such as appraisal, audit, educational records and log books, self-assessment. Schostak et al. (2010) considered that “any meaning we attribute to “effectiveness” is to be left open because it is complex and multi-dimensional and accordingly, incompatible with measurement.” The same authors also reported that effectiveness is facilitated when professionals are able to determine their own learning needs through reflection within the totality of their practice and that this means being able to go beyond what is quantifiable.
Self-accounting with appraisal by an “independent” professional peer is one technique for measuring CPD activity and is capable of addressing the diversity of practice (Schostak et al. 2010). The same authors (Schostak at al. 2010) and Grant (2011) also recognised the value of self-directed and informal learning and they have been incorporated in the AMRC’s ten principles of CPD (Appendix E) used by Medical Royal Colleges and Faculties.
The difficulties in defining exactly what CME outcomes should be measured and how they should be measured was highlighted over 30 years ago (Bertram and Brooks-Bertram 1977). As Grant (2011) concluded, education and learning do not take place in a laboratory and it is a very great challenge to identify and measure factors relevant to performance and patient care. She went on to state that with many studies which ostensibly concern themselves with the outcomes of CPD, the outcomes are not connected or are loosely connected to CPD, in that they fail to address the issues of changes in practice and in practice outcomes (Grant 2011). Hours undertaking CPD is one such measure.
24
Grant goes on to suggest that for medical practitioners, far better qualitative measures of successful outcomes after CPD could include changes in:
Prescribing practices
Use of screening techniques
Preventive care practice
Diagnostic accuracy
Referral patterns
Each of the 38 methods for demonstrating the effectiveness of CPD, that Grant has identified, have advantages and disadvantages. For example some, such as referral patterns, are simple to record, whereas others such as confidence levels and corporate image are difficult to assess objectively. However, very few studies have attempted to compare their relative value as effective quantitative or qualitative measures of CPD for healthcare practitioners, making evidence-based recommendations impossible.
Some regulatory bodies continue to use input variables such as completed hours as a measure of CPD activity. It has been suggested that hours accumulated from activities involving active and targeted participation, which have been shown to be more effective than passive learning, should attract more credits (Bloom 2005). However, both Schostak (2010) and Grant (2011) have described the weakness of using input to measure CPD. For example, Grant (2011) stated that: The measurement of participation in CPD by accumulation of credits, or hours, is perhaps the most commonly applied framework. Evidence would suggest that it is probably not effective in ensuring that CPD has an effect in practice. In the Professional Associations Research Network (PARN) report – Approach to CPD Measurement , Friedman and Woodhead (2008) reviewed the advantages and disdvantages of using input versus output to measure CPD. They concluded that although the input approach had the advantages of simplicity and was easy to monitor, it was difficult to assess whether or not the hours of CPD translated into improved performance and could be meaningless if for example participants fell asleep during lectures. They stated that the output approach attempts “to measure what CPD is intended to achieve directly” and enabled individual professionals to monitor their own progress (Freidman and Woodhead 2008). They concluded that “along with improvements in the supply of output measurement techniques, we believe the demand for such systems will grow significantly as pressures on professional bodies towards providing evidence for continuing competence and maintaining professionalism grow both from the professionals themselves and from other stakeholders.”
The outcomes framework for Pharmacists, evaluated by Donyai et al. (2010) may offer one example of targeted, “active” participation in CPD. The framework is based on the concept that each pharmacist will plan and record their CPD and have to demonstrate that it is relevant to their field of practice and has contributed to the quality of development of their practice (Donayi et al. 2010). However, the evaluation of this outcomes framework involved a small sample of volunteers and further, far larger trials, using representative samples, are necessary before it could be generally accepted as a reliable measure of CPD.
With regard to qualitative and quantitative measures of CDP the Pharmaceutical Society of Ireland (PSI) propose that all Irish Pharmacists should be required to record a balance of different CPD activities in a portfolio accompanied by a robust external competency assessment which should be developed by peers and recreate “patient facing scenarios” (PSI 2010). The proposals are based on 13 principles with an “overriding focus on patient safety, patient care and public welfare” (PSI 2010). The same report also highlighted the benefits of blended learning using a mixture of online and face-to-face activities and an online portfolio to allow a flexible approach that focuses on outcomes relevant to an individual practitioner’s practice (PSI 2010).
25
Feedback from workshops indicated that Irish Pharmacists wanted to move away from measuring CPD by hours (PSI 2010). The need for an international benchmark was recognised and the Irish Pharmacists Association has been reported, as encouraging, a move from a purely points gathering exercise by requiring that any CPD undertaken is relevant to the individual pharmacists role (PSI 2010), a view shared by the Institute of Continuing Professional Development (ICPD 2006). There is a view that because of the variety of roles that registrants undertake, other than training and retraining in communication skills, there is no need for compulsory CPD in some topics (Grant 2011). In conclusion, overall, both the dental and non-dental literature demonstrated the difficulties in developing effective and evidence-based recommendations for quantitative or qualitative measures of CPD. PARN has suggested that output measures may be more effective than input at measures as a means to assess the effectiveness of CPD. A number of regulatory bodies and professional associations are adopting this approach. However, as yet there have been no studies on this topic specifically related to dentistry.
5.2 Regulatory purposes of CPD What are the regulatory benefits of CPD participation in dentistry?
The dental literature did not reveal any studies that demonstrated benefits relating to regulatory purposes of CPD participation in terms of improved quality of care delivered, performance, professional standards, competence, public satisfaction or safety. Only low quality studies (Grades 4 or 5) were found. In one Australian study, its authors suggested that lower attendance rates at CPD courses may occur as a result a lack of mandatory requirements in the country concerned (Abbott et al. 2010). Another study commented on reasons behind attendance at mandatory CPD (Hopcraft et al. 2010).
In 2006, in Western Australia (WA) there was no requirement for dentists to participate in CPD. A Grade 5 study into the participation pattern of dentists in WA in CPD activities between 2001 and 2006 revealed that attendance was low (Abbott et al. 2010). Between 10.1-24.4% of dentists registered in WA attended at least one course each year. The authors drew comparisons with a study in the United Kingdom that showed that 96% of the participants had attended 2.5 hours or more of courses and lectures in a one year period (Bullock et al. 2003). It should be noted that the data for this study (Bullock et al. 2003) were collected before CPD was made a mandatory requirement for UK dentists. Furthermore, Abbott et al. (2010) only included participants who attended courses organised by the University Continuing Dental Education Committee and therefore the results did not necessarily reflect the total CPD activity of all Western Australian dentists.
In a Grade 4 study investigating participation in continuing professional development by dental practitioners in Victoria, Australia in 2007, Hopcraft et al. (2010) found that approximately one in five respondents undertook CPD activities for the sole purpose of meeting the mandatory requirements, rather than for professional and educational reasons.
Care must be exercised when considering the findings from these studies, due to the limitations of self-reported data and convenience sampling. Making direct comparisons between different schemes and countries may not always be appropriate due to the different requirements regarding clinical and non-clinical hours, and verifiable and non-verifiable CPD activities.
The non-dental CPD literature identified a range of regulatory benefits of participation in CPD. These encompass assuring activity levels and competency, satisfying public expectations, keeping abreast of advances in patient care and as a registration instrument.
26
The PSI (2010) highlighted that the primary benefit of CPD is the assurance of a minimum level of development activity for all members of the profession, which in turn is intended to ensure a certain level of competency thus safeguarding patients.
The ICPD stated that “professions continually need to be seen to be responding to the public perception that they oversee the competencies of their members, particularly as a result of greater business transparency and an increasingly litigious environment” (ICPD 2006).
Similarly, although aimed at physicians, Bloom (2005) suggested that “the objective of physician continuing medical education is to help them keep abreast of advance in patient care, to accept new more-beneficial care and to discontinue use of existing lower-benefit diagnostic and therapeutic interventions.” Bloom’s suggestion is echoed by Friedman and Phillips (2001).
In conclusion, the literature identifies a range of regulatory benefits of participation in CPD, but fails to demonstrate any clear associations with quality of care delivered, performance, professional standards, competence, public satisfaction or safety.
What are the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation?
The review of dental literature did not reveal any information to answer this question. However, it was apparent from the grey literature (GDC 2011, GMC 2011) that regulatory processes involve both the public, and individual professionals, in assuring and demonstrating professional standards and competency and supporting clinicians to achieve and maintain acceptable standards. Four of the non-dental publications did provide answers to this question, as follows:
To demonstrate that patient care has benefited in some way in the context of safety, quality and efficacy in terms of tangible outcomes (Donyai et al. 2010).
To enable individual professionals achieve a measure of control and security in the often precarious workplace (Friedman and Phillips 2001) and thus be less likely to act in an unprofessional manner.
As a means of assuring a wary public that professionals are indeed up-to-date, given the rapid pace of technological advancement. (Friedman and Phillips 2001).
As a means whereby it can be verified that professional standards are being upheld (Friedman and Phillips 2001).
To support the public service duty by ensuring that anyone claiming to be a member can be relied upon to have kept their knowledge and skills up to date (ICDP 2006).
To assure competency across the profession, to meet patient needs and demonstrate this competency to others (PSI 2010).
In addition, the GDC website (GDC 2011) reminds registrants that: “Patients are right to expect that all members of the dental team are keeping their skills and knowledge up to date throughout their
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careers. We ensure that this is happening by making CPD a requirement for all dental professionals registered with us.”
The General Medical Council’s website (GMC 2011) states that the GMC has a statutory role to promote high standards and co-ordinate all aspects of medical education. This includes doctors’ continuing medical education. It also states that “Good medical practice requires doctors to keep their knowledge and skills up to date throughout their working life and to maintain and improve their performance. Continuing professional development (CPD) is a key way for doctors to meet these professional standards and is one of the sources of information required for appraisal and revalidation”.
In conclusion, the dental literature did not reveal any studies that demonstrated the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation. Information from other healthcare sectors focussed on maintaining and demonstrating professional standards and competency to the public.
5.3 CPD participation How do healthcare professionals, and in particular dental professionals, currently engage with, perceive and benefit from CPD; and does CPD have particular consequences for different groups and forms of practice in dentistry?
The dental literature revealed only Grade 2 and Grade 3 studies for this research theme regarding dentists and dental hygienists. Table 9 describes key topic areas arising from papers of Grade 2 and Grade 3 quality for dentists. No studies were found which demonstrated particular consequences for CPD for different groups and forms of practice in dentistry.
Only one Grade 3 paper was identified which examined dental hygienist participants' satisfaction with a continuing education course in periodontics (Young et al. 1989).
Table 9: How dentists currently engage with, perceive and benefit from CPD
Professional group
Dentists GDP participation rates (Firmstone et al. 2004) Grade 3 Reasons why GDPs undertake CPD programmes in endodontics and implant dentistry, and participation rates of CPD (John and Parashos 2007) Grade 3 GDP perceptions of the effectiveness of personal learning plans (Carrotte et al. 2007) Grade 3 Perceptions of PDP and participation in CPD (Bullock et al. 2007) Grade 2 Attitudes towards online CPD (Francis et al. 2000) Grade 3 Perceptions of e-learning cross-infection control CD-ROM provided to all general dental practitioners in England. (Gray et al. 2007) Grade 3 Orthodontists’ perception of the utility of computer-based continuing education about super-elastic arch wires for the initial stage of orthodontic treatment (Marsh et al. 2001) Grade 3 The use of targeted email reminders (designed as cues to action) to influence participation by dental providers in an Internet delivered intervention for tobacco control (Houston et al. 2010) Grade 2
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These Grade 2 and 3 studies describe GDP participation rates in specific topic areas, and in particular localities; reasons behind choice of CPD topic; perceptions of personal development plans; attitudes towards individual CPD applications and the use of targeted e-mail reminders to influence participation.
In a study utilising a convenience sample of GDPs in three postgraduate dental deaneries in England, Bullock et al. (2004) reported that the most frequently undertaken forms of CPD were found to be journal reading and courses. Specifically, 97% of the dentists who responded reported attending at least one two and a half hour session in the study period and 43% for more than 15 hours.
In an Australian study, John and Parashos (2007) reported that for CPD programmes in endodontics and implant dentistry, overall, most participants (72 %) agreed that they relied on formal CPD programmes to keep up-to-date in practice, with 92% having undertaken their particular course to improve their clinical skills. Interestingly, 35% of participants that reported that they had undertaken the programme to fulfil their Board requirements.
Carrotte et al. (2007) reported very positive feedback from GDPs on the use of a PDP. Practitioners felt that new skills were being employed, or that an improved understanding had led to a reduction of previous inaccurate or wrong practices. The authors suggested that greater ownership of an educational programme, coupled with a sense of belonging to a study group, may stimulate and motivate practitioners to a greater extent.
Bullock et al. (2007) reported similar findings in a RCT investigating GDP perceptions of PDPs and participation in CPD in general. Participants undertook a median number of 17 educational activities in the six month period of the study (mean of 50 hours). Most frequent activities were reading and attendance at courses. These two accounted for over half the total number of educational activities. The main ‘other’ activities included staff meetings or discussions with colleagues, training activity with new dentists and peer review but a range of other CPD was also listed (including journal clubs, conferences, clinical audit). The results showed that developing a PDP with the aid of a tutor was viewed positively, and almost all would recommend developing a PDP to other dentists. Compared with the control group, those with a PDP in the experimental group engaged in proportionally less reading and more courses and ‘other’ CPD activity.
In a study investigating the impact of two online modules on dental radiology and occupational safety and health administration standards, Francis et al. (2000) reported positive findings. The majority of participants agreed that accessing online continuing dental education at their convenience was a definite advantage (88%), they would recommend it to their professional colleagues (88%), and the material in the course(s) was useful and applicable to professional activities (76%). Participants were enthusiastic about online learning but desired much more interactivity than existed in the current design. The least-liked aspects related to technical and formatting issues.
Similar findings were reported by a study investigating perceptions of a CD ROM in cross-infection (Gray et al. 2007) and super-elastic arch wires (Marsh et al. 2001). Gray et al. (2007) showed how the majority of participants felt that the CD ROM was well-designed and fit for purpose, and supported and extended their subject knowledge in the area of cross-infection control whilst simultaneously serving as a useful reference tool. Negative comments were limited and principally referred to typestyle and layout, and distribution failures. Marsh et al. (2001) showed how over 90% of the viewers thought the CD ROM program was well-designed and provided useful information.
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A more specific finding in the use of online CPD resources was demonstrated by (Houston et al. 2010) who examined the use of targeted e-mail reminders (designed as cues to action) to influence participation by dental providers in an Internet delivered intervention for tobacco control. The e-mail reminders resulted in the largest number of visits on the day the e-mail was sent (e-mail release day). The day after the e-mail also showed an increase in website visits, then returning to baseline. On days when no recent reminders had been sent, very little participation occurred.
Other than the four Grade 3 studies relating to CPD for dental hygienists that have been reviewed earlier in this report, only poor quality evidence (Grade 4 or Grade 5) was found with regard to CPD for DCPs. The relevant studies are listed in Table 10.
Table 10: How DCPs currently engage with, perceive and benefit from CPD
Professional group Titles (NB all only Grade 4/5)
CPD Activity dental oral
![CPD Activity dental oral]()
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