Consensus was reached in the first Delphi round on core competency statements broadly related to providing NHP information and education, which became Professional NHP-related Competency Statements No. 2: Provide NHP Information and No. 3: Educate (Table ). It is likely that consensus of these statements was achieved early because similar competency statements already existed in Canadian standards of practice documents for pharmacists relating to drugs (eg, NAPRA's Model Standards of Practice for Canadian Pharmacists 2003).30
Thus, the idea of extending these competencies to include NHPs was easy for participants to embrace and endorse.9,11
Consensus on Professional NHP-related Competency Statement No. 1: Practice Pharmaceutical Care was achieved after the second Delphi round. Only 1 participant ranked this competency outside our definition of consensus (that all participants ranked a statement 4-very important or 5-essential) during the first Delphi round, so for those statements on which consensus was possible, it was achieved quite quickly.
The 3 professional NHP-related competency statements that emerged from this consensus exercise were consistent with the results of previous research conducted by our research team. Kwan reported that focus groups of consumers and practicing pharmacists thought that pharmacists should adopt a consultative role to help consumers integrate different sources of NHP-related information .9
This is represented most prominently in Professional NHP-related Competency No. 3: Educate. Additionally, previous research demonstrated that pharmacists placed emphasis on ensuring patient safety, especially regarding potential NHP-drug interactions,9
which is captured in Professional NHP-related Competency No. 1: Practice Pharmaceutical Care. Safety was also a key component identified in earlier research interviews of pharmacy leaders, consumer advocates, conventional and complementary health care practitioners, and NHP industry representatives.10
The lack of knowledge and reliable information on NHPs were identified as barriers to counseling patients on NHPs,10
which highlights the importance of creating NHP-related competencies. Shanthakumar found that Canadian pharmacists were more likely to endorse professional NHP-related responsibilities related to knowledge, including awareness of indications for use and expected outcomes, access to reliable references, and helping patients identify and access information, than any other types of NHP-related competencies.12
These knowledge responsibilities are incorporated into all 3 of the core competency statements.
Consensus was not reached on Additional Professional NHP-related Competency No. 4: Understand NHP Regulations, and Additional Professional NHP-related Competency No. 5: Report Suspected NHP Adverse Events (Table ). These statements received the greatest range of responses throughout all 4 Delphi rounds. These topics have received mixed reactions and levels of support from the pharmacy profession.10,12
For example, Olatunde found that many pharmacy leaders were unfamiliar with current pharmacy policies and guidelines concerning NHPs.10
Shanthakumar also found that Canadian pharmacists were least likely to endorse professional responsibilities related to documentation of NHP usage, which included reporting adverse events to Health Canada and recording use in patients' charts.12
Lack of consensus on this issue seems to be related to 2 distinct opinions: (1) that reporting adverse drug events related to NHPs is vital and should be a core competency, and (2) that reporting adverse drug events to Health Canada is not required in current standards of practice documents, so we should not create a precedent by first requiring this for NHPs. Similarly, understanding drug regulations is not identified as a core educational competency, although it is necessary for licensing. Thus, some participants argued that setting a precedent by first requiring this of NHPs was something they were not willing to do. As a result of our work, we were able to incorporate general documentation responsibilities into Professional NHP-related Competency No. 1: Practice Pharmaceutical Care, in an attempt to bridge the gap on the 2 perspectives on reporting NHP-related adverse events.
This study has limitations. The validity of the study was dependent on the active participation of all Canadian pharmacy schools and pharmacy organizations. While 7 out of 10 Canadian pharmacy schools were represented, there was no representation from either of the 2 French-language pharmacy schools in the province of Quebec. Reasons that representatives were not sent to the meeting included: prior commitments, lack of an appropriate individual to represent the institution, and no response to the investigators attempts to contact them. Lack of participation from the Quebec schools of pharmacy may have been due to all correspondence, as well as the Delphi rounds, being conducted in English. Representatives from Quebec may have had different perspectives on NHP-related core competencies for pharmacists as suggested by a Canadian survey that found the use of NHPs in Quebec to be seasonal and overall use of NHPs to be lower than in the rest of Canada.1
However, results of a recent national survey of practicing pharmacists' opinions about NHP-related professional responsibilities did not reflect that location influenced thoughts about NHP-related competencies,33
suggesting that our NHP-related core competency statements may be applicable nationally.
As NHPs represent a wide variety of products, we purposely did not limit the study to certain categories (eg, vitamins, minerals, herbal medicines, or homeopathy), but rather included the official definition of NHPs according to the NHP Regulations (2004)5
as a preface to our NHP-related core competency statements. However, whether our NHP core competency statements are applicable to all categories of NHPs is not clear, as we do not know what study participants thought when they read the term “NHPs.” Furthermore, previous research concluded that pharmacists were generally more likely to endorse professional responsibilities associated with vitamins, minerals, and herbal medicines, than with homeopathy,33
thus study participants may not agree that the developed core competency statements apply equally to all categories of NHPs.
This study also had several strengths. It was the culmination of a program of research that included key informant interviews,10
focus groups with pharmacists and consumers,9
and a survey of licensed Canadian pharmacists.33
Thus, the Delphi process benefitted from the input of a wide range of stakeholders including consumers, practicing pharmacists, pharmacy students, other health care providers, the NHP industry, policymakers, educators, and representatives from a variety of pharmacy organizations. The process of creating competency statements has been an inclusive one and the resulting competencies are likely, therefore, to be relevant to pharmacy practice in Canada. Additionally, this project stimulated much discussion among participants, which resulted not only in something concrete—the creation of competency statements—but also contribution to the advancement of pharmacy education in Canada. This project represented the first time that NHP educators from pharmacy schools across North America met to discuss NHP-specific curriculum.
Competency statements were never intended to stand alone, thus we plan to share results with the larger pharmacy community of North America, primarily through widespread dissemination of the competency statements. It is our hope that the NHP-related core competencies developed through this project will be incorporated into existing provincially and state-based standards of practice documents, and the educational outcomes documents that form the basis for pharmacy education at individual educational institutions. This would be accomplished in Canada through the Canadian Council for Accreditation of Pharmacy Programs (CCAPP) and the Association of Faculties of Pharmacy of Canada (AFPC) exploring how the developed competency statements may be incorporated into existing educational outcomes documents. Also essential is working with organizations that foster or accredit continuing professional education among practicing pharmacists, including the Ontario Pharmacists' Association (OPA), the offices of continuing education at Canadian Faculties of Pharmacy, and the Canadian Council on Continuing Education in Pharmacy (CCCEP). It is important to widely disseminate these competency statements to pharmacy organizations, policymakers, and pharmacy schools. Adoption by the pharmacy community at large will ensure that Canadian pharmacists can meet their professional responsibilities with respect to NHPs upon entry-to-practice, ultimately resulting in better patient outcomes.