Continuing Profesional

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COMMENTARY Professional development

2069Am J Health-Syst Pharm—Vol 61 Oct 1, 2004

COMMEN TARY

MICHAEL J. ROUSE, B.PHARM. (Hons.), M.P.S.,is Assistant Executive Director, Internationaland Professional Affairs, Accreditation Coun-cil for Pharmacy Education, 20 North ClarkStreet, Suite 2500, Chicago, IL 60602

Continuing professional developmentin pharmacy

MICHAEL J. ROUSE

Am J Health-Syst Pharm. 2004; 61:2069-76

Continuing professional devel-opment (CPD) is a frameworkfor, or approach to, lifelong

learning and is being discussed as apotential model for pharmacists inthe United States. CPD is not a re-placement for continuing education(CE), as quality-assured CE is an es-sential component of CPD. This arti -cle explains the concept and compo-nents of CPD, describes some of the

driving forces behind the reevalua-tion of current systems of CE forpharmacists, defines relevant terms,and outlines some experiences withCPD in selected foreign and U.S.health systems that have alreadyadopted the model. This article is in-tended to provide a basis for furtherdiscussions regarding CPD and ex-plain what it could mean for the pro-fession of pharmacy and pharmacistsif implemented nationwide.

The fol lowing sentences introducethe American Society of Health-System Pharmacists (ASHP) state-ment on continuing education:

Next to integrity, competence isthe first and most fundamentalmoral responsibi li ty of all healthprofessions . . . Each of our pro-fessions must insist that compe-tence will be reinforced throughthe years of practice. After thedegree is conferred, continuing

([email protected]).

Copyright © 2004, American Society of Health-System Pharmacists, Inc. All rights re-served. 1079-2082/04/1001-2069$06.00.

education is society’s only realguarantee of the optimal qualityof health care.1

Perhaps ahead of their time, theobjectives of the ASHP statement,approved in 1989, read remarkablylike a framework for CPD.

What is CPD?CPD is an ongoing,self-directed, structured, outcomes-focused cycle of learning and person-

al improvement. The Chartered Insti-tute of Personnel and Development(CIPD) put forth an early definitionof CPD in October 19972: “CPD issystematic, ongoing, self-directedlearning. It is an approach or processwhich should be a normal part of how you plan and manage yourwhole working life.”

In 2002, the concept of CPD wasdefined by the International Phar-maceutical Federation (FIP) as

the responsibility of individualpharmacists for systematic main-tenance, development andbroadening of knowledge, skillsand attitudes, to ensure continu-ing competence as a professional,throughout their careers.3

Variations of the basic CPD mod-el, using different terms to describethe stages, have been adopted or dis-cussed in pharmacy, but the differ-ences are not significant. Implemen-tation strategies and the professionaland regulatory framework within

which the CPD model is adopted do,however, differ considerably, andsome examples are described later.Essentially, the concept of CPD isbased on a cycle in which individualpracti tioners reflect on their practiceand assess their knowledge andskills, identify learning needs, createa personal learning plan, implementthe learning plan, and evaluate theeffectiveness of the educational in-terventions and the plan in relationto their practice. Documentation isan integral aspect of CPD, and a per-sonal portfolio is typically used forthis purpose. A five-step cycle wasused to describe CPD in a statementadopted by FIP in 2002,3 and an ad-aptation—in which the cycle in-cludes self-appraisal, developmentof a personal plan, action, documen-tation, and evaluation—has beenused as the basis for some of the earlydiscussions of CPD in the UnitedStates.

Another representation of the CPDcycle, offered by the author (Figure1), in which documentation—theportfolio—is shown as an integralcomponent but not a separate stage,may help to explain the elements of CPD and their sequence.


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2070 Am J Health-Syst Pharm—Vol 61 Oct 1, 2004

The purpose of CPD is to ensure

that pharmacists maintain theirknowledge, skills, and competenciesto practice throughout their careersin their specific area of practice;improve personal performance; andenhance their career progression.CPD is designed to be self-directed,practitioner-centered, and outcomes-based to meet the specific goals andobjectives of individual pharmacists,ultimately improving patient andpublic health outcomes. It emphasiz-es the importance of practice-basedlearning and, in the United King-dom’s model, of identifying andachieving organizational goals andobjectives. As CPD is a relatively newconcept, evidence has not yet beenprovided that widespread adoptionof a CPD model is more effectivethan traditional CE systems inachieving these goals.

Definitions. An understanding of

and a distinction between the termsused in this paper are important, andmost of the following are currentlyused within pharmacy or otherhealth care professions.

Competence is defined as follows:

The ability to perform one’s du-ties accurately, make correct

judgments, and interact appro-priately with patients and withcolleagues. Professional compe-tence is characterized by goodproblem-solving and decision-

making abilities, a strong knowl-

edge base, and the ability to ap-ply knowledge and experience todiverse patient-care situations.4

Li felong learni ng is defined asfollows:

All learning activity undertakenthroughout life, with the aim of improving knowledge, skills andcompetences within a personal,civic, social and/or employment-related perspective.5

Continuing education was definedin 2000 as follows:

Organized learning experiencesand activities in which pharma-cists engage after they have com-pleted their entry-level academiceducation and training. Theseexperiences are designed to pro-mote the continuous develop-ment of the skills, attitudes, and

knowledge needed to maintainproficiency, provide quality ser-vice or products, respond to pa-tient needs, and keep abreast of change.4

A more recent (2003) definitionfollows:

Continuing education for theprofession of pharmacy is astructured process of education

designed or intended to supportthe continuous development of pharmacists to maintain andenhance their professional com-petence. Continuing education

should promote problem-solving and critical thinking andbe applicable to the practice of pharmacy.6

Perhaps the terms lifelong learn-ing and CE should be synonymous.CE has been associated more with or-ganized or structured educational ac-tivities, as defined above by the Ac-creditation Council for PharmacyEducation (ACPE).

Why change? In a changing, in-creasingly complex profession, andwith rapid medical and technologicaladvances, the need for lifelong learn-ing for pharmacists is irrefutable.Health care professionals are re-quired to engage in CE. While appro-priate, competency-based educationcan prepare a pharmacist to enterpractice, no professional programcan provide or develop the knowl-edge, skills, attitudes, and abilitiesthat a pharmacist will ever need.Such development requires a combi-nation of an appropriate preserviceeducational foundation, inservicetraining, hands-on work experience,and l ifelong learning. For profession-als, education is a continuum. Unlikemedical practitioners, a minority of pharmacists obtain postgraduatequalifications or specialty certifica-tions, although a variety of such pro-grams are offered. Approximately3% of licensed pharmacists are certi-

fied, and of the 2001–02 pharmacyschool graduates, approximately14% successfully completed anASHP-accredited pharmacy practiceresidency in 2003.7-12Council on Cre-dentialing in Pharmacy resourcedocuments on CPD and credential-ing in pharmacy provide details of these programs.13,14 Certificate pro-grams, for which national standardswere introduced in 1999, are longerthan the average CE program and de-

Figure 1. Continuing professional development cycle centered around a portfolio.

Evaluate

Reflect

PlanRecord

(Portfolio)

Act


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signed to develop knowledge or skillsin a specific area (e.g., immunization,diabetes management). However,participation in certificate programsby pharmacists has been limited. In

2002–03, 4824 participants—some2% of licensed pharmacists—completed the 81 certificate pro-grams offered by 37 ACPE-accreditedproviders.7,15 CE is, therefore, thesimplest and most common form of postgraduate training for pharma-cists.16 Emphasizing the professionaldevelopment of practitioners, theCPD model expands in breadth anddepth the traditional model of life-long learning, thereby offering, some

believe, a quality improvement forcurrent CE systems.Many factors are driving a critical

reevaluation of CE systems. Virtuallyall state boards of pharmacy rely onpharmacists’ participation in a de-fined number of hours of ACPE-accredited or otherwise approved CEto provide assurance of pharmacists’competence.7,17 Since the mid-1970s,when the number of states requiringmandatory CE started to grow, thenumber of accredited providers of-fering a broad range of quality CEprograms has significantly increased.In 1978, ACPE accredited 72 CE pro-viders; currently there are over 400.18

CE programs are delivered in avariety of formats to accommodatedifferent learning needs and prefer-ences. However, state boards of pharmacy have few specific require-ments regarding the content of CEand its relevance to the practice of the pharmacist. ACPE standards re-

quire CE providers to have systemsin place to identify the learning needsof participants and offer programs tomeet those needs.19In the current CEmodel, the programs offered are in-tended to meet the learning needs of a number of pharmacists. Clearly, itis unrealistic to expect CE providersto attempt to identify and respond tothe individual needs of practitioners.Furthermore, meaningful assessmentof learning is difficult and many

times not even attempted. In theCPD model, more responsibility isplaced on individual practitioners toidentify and participate in programsthat meet their own specific learning

needs and assess the impact and ben-efit of such programs.A growing body of evidence (pri-

marily from the medical literature)shows that, while CE can be effectivein improving knowledge, skills, atti-tudes, behavior, and patient healthoutcomes, traditional approaches toCE are not usually curricular innature, do not optimally address allrequired competencies, and are notalways successful in changing prac-

tice behaviors.

20-25

Not only is the rel-ative effectiveness of different educa-tional strategies difficult to measureand compare, many extrinsic factorscan influence the effectiveness of CEand its impact on performance, prac-tice, and patient outcomes. More re-search is needed to improve our un-derstanding of these factors and howthey influence CE outcomes.

What is evident from the litera-ture, however, is that achieving prac-tice change requires some very un-common practices, which do notconsistently happen. Davis et al.26

concluded that there is

some evidence that interactiveCME [continuing medical edu-cation] sessions that enhanceparticipant activity and providethe opportunity to practice skillscan effect change in professionalpractice and, on occasion, healthcare outcomes [and] variables

over which the CME providerhas control and appear to have apositive effect are the degree of active learning opportunities,learning delivered in a longitudi-nal or sequenced manner, andthe provision of enabling meth-ods to facilitate implementationin the practice sett ing.

Ample studies indicate that utili-zation of multiple educational meth-

ods and participation in self-directedlearning activities that are based onidentified learning needs or personalgoals, are relevant to practice, are in-teractive, are ongoing, have defined

outcomes for the practitioner andthe organization, and can be rein-forced through practice are morelikely to achieve sustainable learningand practice change.23-25,27-31 The CPDmodel incorporates a number of these strategies.

Pressure to change approaches tocontinuing education is comingfrom outside and within the pharma-cy profession. Providers of healthcare services are required to increase

attention to quality and quality im-provement. In a series of reports, theInstitute of Medicine (IOM) high-lighted deficiencies in health systems,identified key factors contributing tothe state of affairs, and made a num-ber of recommendations.32-34 IOMnotes that the knowledge and skills of health care professionals are oftennot optimally utilized and that prob-lems arise because they work in a sys-tem that does not adequately preparethem, or support them once they arein practice, to deliver the best care totheir patients. IOM has concludedthat the education and training of health care professionals need a ma-

jor overhaul and advocates that edu-cation and training (both preserviceand lifelong) must be competencybased. Pharmacy has been com-mended for its competency-basedstandards for degree-program ac-creditation and cited as an examplefor other health care professions to

follow.34 ACPE’s new definition of CE highlights the professional com-petencies applicable to the practice of pharmacy.6 IOM has identified fivecore competencies that all health careprofessionals should possess: (1)provide patient-centered care, (2)work on interdisciplinary teams,(3) employ evidence-based practice,(4) apply quality improvement mea-sures, and (5) use informatics. It hasrecommended that all health profes-


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sions should move toward requiringlicensed health care professionals toperiodically demonstrate their abilityto deliver patient care through directmeasures of technical competence,

patient assessment, evaluation of pa-tient outcomes, and other evidence-based assessment methods.34 Thislatter recommendation has profoundimplications, but it is unlikely that asystem of direct assessment (alreadyin use in some countries) would beconsidered feasible or desirable bythe pharmacy profession in the Unit-ed States at this time. While manypractitioners may already use a CPDmodel for their lifelong learning and

professional development, couldprofessionwide adoption of themodel provide the required level of assurance (and public accountabili-ty) that licensed pharmacists aremaintaining and updating their pro-fessional competencies?

Preparing pharmacists to deliverpharmaceutical care. In 2000, awhite paper on pharmacy’s futureroles, responsibilities, and manpow-er needs noted that, while the philos-ophy of pharmaceutical care hadbeen broadly endorsed in the early1990s as the new vision for pharma-cy, progress toward widespread im-plementation of the practice modelhad been frustratingly slow.35 Manyhave probably underestimated theimportance and enormity of thechange involved. While many factorshave affected the rate of implementa-tion of pharmaceutical care, the factthat many practicing pharmacistswere not originally trained for such a

practice model and may lack some of the required knowledge and skillsmust be considered. For many phar-macists, a retooling of knowledgeand skills is probably required, and i twould appear that current CE sys-tems, which primarily focus on im-proving and updating practitionerknowledge36 (Travlos DV, ACPE,personal communication, 2003 Jul),are unlikely to adequately addressthis need.

Neither CPD nor CE alone canensure professional competence. Al-though CPD is a largely unprovenmodel in pharmacy, might it buildon the traditional methods of CE and

offer more effective lifelong learningfor pharmacists? Early adopters of the concept believe it can, and someexamples of CPD implementationare emerging in pharmacy and otherprofessions. Great Britain and On-tario, Canada, provide good casestudies from programs initiated forpharmacy in the mid-to-late1990s.13,37-41

A better learning model? TheCPD model for lifelong learning and

professional development of practi-tioners is sound theoretically and wasdeveloped using well-tested princi-ples of learning and continuousquality improvement.42,43 In the1970s and 1980s, Kolb and Smith44-46

described how people learn and han-dle day-to-day situations in theirlives.

Based on the work of Kolb, a four-stage cycle of experiential learninghas been described: (1) have a newexperience, (2) reflect on that experi-ence, (3) draw some conclusions,and (4) act differently as a result of the experience.47

Research has demonstrated thatlearning that is sought to meet iden-tified and existing needs and rein-forced through practice is more likelyto be sustained.23 Some of the four-stage cycles that have been adoptedwithin the context of CPD incorpo-rate these principles of learning.48,49

In this context, the terms reflection,

assessment, and self-appraisal aresomewhat interchangeable.

The CPD cycle.CPD has been de-scribed using four- and five-stage cy-cles. In essence, these cycles are verysimilar. In the five-stage cycle, docu-mentation is included as a separatestage to emphasize its importance.Documentation is, however, an im-portant component of each of theother four sequential stages. Theelements of the four-stage cycle—

reflect, plan, act, evaluate—are nowdiscussed. As shown in Figure 1, therecord (documentation) step of thefive-stage cycle is in the center of thefour-stage cycle.

Reflect. Also referred to as self-appraisal or assessment, this stage re-quires pharmacists to reflect on per-sonal and organizational needs andgoals for professional developmentand to assess their knowledge, skills,and competence. Reflection is im-portant to learning; it has been de-scribed as a complex and deliberateprocess of thinking about and inter-preting an experience in order tolearn from it.50 Ideally, reflection is

performed in two ways: (1) on an adhoc or unscheduled basis, usually areaction to specific day-to-day prac-tice experiences (a “ reflection inpractice” ) and (2) on a scheduled orproactive basis (e.g., annually, bian-nually) or when a major careerchange occurs or is anticipated (a“ reflection on practice” ).

Accurate self-assessment is diffi-cult, and pharmacists are likely toneed assistance in this task. Ideally,self-assessment should be balancedwith the considered judgment andopinion of others, such as peers andsupervisors. Tools to assist pharma-cists in appropriately and accuratelyassessing their learning needs havebeen developed in a number of coun-tries, including the United States.51,52

The National Association of Boardsof Pharmacy, which administers na-tional licensure examinations on be-half of state boards of pharmacy, isdeveloping an Internet-based self-

assessment tool to offer pharmaciststhe opportunity to assess, in a non-threatening and support ive environ-ment, their needs and interests.53

Daily practice experiences shouldalso contribute to the self-appraisal,leading to identification of individu-al learning needs based on actual is-sues confronting the pharmacist.

Documentation in the pharma-cist’s personal portfolio begins at thisstage in the cycle.


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Plan. The second stage involvesthe design of a personal developmentplan. Pharmacists who have no priorexperience with such planning willprobably need assistance with this,

which will likely create service op-portunities for professional member-ship organizations and CE providers.The plan should include all of theactivities that will address identifiedlearning and development needs andgoals. The learning goals should beclear, specific, measurable, achiev-able, relevant, and time based. Theoutcomes should be linked to one ormore specific professional compe-tencies.6 When possible, pharmacists

should also address patient healthcare needs.Personal development plans could

include structured programs (such asaccredited CE programs), as well as adiverse range of informal learningactivities, many of which will bework based or work related (e.g., dis-cussions with colleagues, job shad-owing, interest group meetings, sec-ondments, deputizing, peer review).The activities should fit with thepharmacist’s preferred learning style.When specific subject matter is re-quired, ACPE’s P.L.A.N. (pharma-cists’ learning assistance network)database is available (www.acpe-accredit.org) to assist pharmacists toidentify appropriate CE offeringsand certificate programs in variousformats (e.g., seminars, journals, In-ternet courses). Other resources orsources of support should be identi-fied. The activit ies wil l help the phar-macist to use and augment his or her

knowledge and skills base.54Details of the personal develop-

ment plan are recorded in the per-sonal portfolio. While remaining fo-cused on the pharmacist’s identifiedneeds and goals, the plan should bedynamic, being changed and updat-ed as required. Because each phar-macist’s situation is unique, no twosets of learning needs and personalplans will be the same. As with anyplanning process, priorities should

be established. Short-, medium-, andlong-term objectives may be identi-fied. Different objectives will requiredifferent strategies, and the plan’ssuccess will likely depend on the

effective use of multiple learningmethods.Act. Putting the plan into action is

the third stage. The activities chosenmust be outcomes driven to meetidentified needs and goals, not mere-ly to meet a mandatory “hour require-ment.” CPD does not replace accredit-ed CE programs. CPD builds on thisessential, quality-assured component.It also encourages different methods of delivery for learning.

Evaluate. As with reflection, eval-uation should occur on an ad hoc

basis (reacting to day-to-day experi-ences) and through a more formal,structured or proactive process. Eval-uation will consider (1) if and howwell the learning and developmentobjectives have been achieved, (2)how appropriate and effective theplan was, (3) how well the activitiesundertaken correlated with the plan,(4) if the methods of learning wereappropriate, (5) what impact therehas been on knowledge, skills, com-petence, and confidence, (6) if andhow practice has changed, and (7) if there were improved patient out-comes as a result of the activities.

Evaluation can be conducted bythe individual practitioner, by thepractitioner’s peers, or by the practi -tioner’s supervisor or manager. Itmay form an integral part of a formalperformance review, where individu-al and organizational goals are con-

sidered. In some CPD models (e.g.,those in the United Kingdom), theportfolio is subject to review by theregulatory body. In Ontario, there isthe opportunity for small-group peerreview of the learning portfolio anddirect assessment of knowledge andskills. Some form of third-party re-view or evaluation of the portfoliowould appear to be valuable, notonly to provide feedback to the phar-macist but also as a means to identify

those who may be having difficulty inone or more aspects of CPD and arein need of assistance or remediation.The evaluation also protects societyfrom the few practitioners who oth-

erwise would not self-assess and cor-rect deficiencies. A further advantageof third-party evaluation is that areasfor improvement, which are transfer-able elsewhere in practice, may beidentified. Feedback from third par-ties should be given in a constructiveand nonthreatening way, with theprimary objective being to help theindividual move forward in his orher professional development. InOntario, data gathered during a re-

view may not be shared with the in-vestigative or disciplinary branchesof the pharmacy registering and reg-ulating body.40

Most importantly, the evaluationleads to the next stage of the continu-um, reflection, followed by the designof a new plan based on updated learn-ing and development needs and goals.

Record. Central to the CPD cycle isthe practitioner’s personal portfolio,which becomes a comprehensiverecord—much l ike a professional di-ary or transcript—covering all thestages. The portfolio, which can beelectronic or paper based, should bereadily accessible and simple to use.Ideally, a standardized format shouldbe adopted to facilitate training, dataentry, and, where applicable, portfo-lio evaluation.

Traditionally, there has been littleor no need or incentive for the ma-

jority of pharmacists to documenttheir learning activities, apart from

their record of participation in ac-credited CE courses as a requirementof relicensure. In CPD portfolios,pharmacists record all relevant learn-ing experiences, accredited CE cours-es and informal work-based or work-related activities. When such activityhas had a tangible outcome (e.g., animproved patient outcome, a changein practice method or behavior, newknowledge or skills, a new creden-tial), it is noted in the portfolio. In


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time, the pharmacist’s portfolio willdevelop into a comprehensive recordof education and practice with multi -ple possible applications.

Principles of CPD. The princi-

ples of CPD can be summarized asfollows54:

· CPD is a systematic, ongoing, cyclical

process of self-directed learning.

· CPD includes everything that practi-

tioners learn that enables them to be

more effective as professionals.

· CPD includes the enti re scope of the

practitioner’s practice and may in-

clude activities both within and out-

side the usual work setting.

· CPD can strengthen the partnership

between the practitioner and his or

her organization, so as to meet the

development needs of both.

· Practi tioners are responsible for their

own professional development. The

organization can have a role in helping

practitioners meet the developmental

needs related to job performance.

Three important features of CPDare clear: CPD is (1) practitioner cen-tered and self-directed, (2) practicerelated, and (3) outcomes oriented.

Although defined as a continuouscycle involving multiple stages, CPDshould be considered an approach tolifelong learning rather than a num-ber of stages that a practitioner has tomethodically and laboriously workthrough. Progression through thestages of CPD should, to a large extent,become seamless and second nature,although more conscious effort willbe required until CPD becomes sec-

ond nature to a practitioner.CPD in health-system pharmacy.

Although its adoption may not yet bewidespread, the CPD model for life-long learning is already in use in theUnited States. Apart from individualpractitioners who use this approach,examples can be found in somehealth systems, including the VeteransAffairs health care system.55 To complywith accreditation requirements (e.g.,those of the Joint Commission on Ac-

is support for the concept, evidencedby recent statements and resolutionsby several national pharmacy organi-zations.53,56-60 Not all stakeholders,however, will feel the need for

change. While CPD appears logicaland straightforward, implementa-tion certainly poses a number of challenges. It would require a differ-ent approach by CE providers, prac-titioners, and health systems. Newskills and competencies will need tobe developed. For example, identify-ing individual learning needs and de-veloping and evaluating a personaldevelopment plan are areas in whichfew currently have expertise. Based

on the experiences of practitioners inother countries, a system that in-cludes some flexibility is likely toachieve better “buy in” by pharma-cists. Evidence from Great Britainand Canada also indicates that a ma-

jority of pharmacists have been ableto demonstrate that they can self-direct their learning at the requiredlevel, that personal adoption of CPDwas not as burdensome as expected,and that CPD, overall, was well ac-cepted by pharmacists.37,38,40

The full implications of wide-spread adoption of a CPD modelneed further discussion. A perfectsolution—simple, effective, inexpen-sive, and acceptable to all—does notexist and is unlikely to be realized.However, improving the quality of the existing CE system for pharma-cists needs to be purposefully ex-plored by the profession in a timelymanner.

Conclusion. CPD appears to offer

pharmacists a viable model for indi-vidualized ongoing learning and per-sonal improvement.

References

1. American Society of Hospital Pharmacists.ASHP statement on continuing education.Am J Hosp Pharm . 1990; 47:1855.

2. Continuing professional development—the IPD policy. London: Chartered Insti-tute of Personnel and Development;1997:4.

3. International Pharmaceutical Federation.Statement of professional standards oncontinuing professional development.

creditation of Healthcare Organiza-tions [JCAHO]), institutions mustensure that their health care practi-tioners are scientifically and profes-sionally competent to practice. As

stated earlier, as professionals, healthcare practitioners are responsible formaintaining their competence topractice, but institutions can assistwith this responsibility. A number of JCAHO standards (e.g., HR.3.1,HR.4, HR.4.2, HR.5) address issuesrelating to competence, lifelonglearning, and staff development. Ac-creditation standards require institu-tions to demonstrate that systems arein place to support staff learning and

development and assess staff mem-bers’ abilities to meet performanceexpectations, both initially (at em-ployment) and on an ongoing basis.Assessment should include self-ap-praisal, peer review, and perfor-mance appraisal by a supervisor ormanager.

An institution that is focused onquali ty and quality improvement canprovide an excellent practice-basedlearning environment for groups of practitioners who are mutually sup-portive in addressing identifiedlearning needs and meeting personaland organizational goals. Throughinservice education programs, jour-nal clubs, newsletters, case studies,and other means, practitioners canidentify and address their own learn-ing needs. While not all of these ac-tivities would meet the criteria foraccredited CE, the value of suchlearning activities is obvious. Becauseof i ts relevance to daily work and the

potential for regular reinforcementthrough practice, such learning ismore likely to be sustained, result inpractice change, and ultimately leadto improved patient outcomes. Insuch a learning environment, self-directed CPD becomes second na-ture rather than the mechanical,burdensome process that it mightappear to be on initial consideration.

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