Exploring Knowledge, Skills, and Abilities Needed for Army Pharmacist Readiness Using the Nominal Group Technique

ABSTRACT

Introduction

The purpose of this study was to conduct a general educational needs assessment to identify deficiencies in current Army pharmacy education while projecting future educational requirements based on changes in pharmacy practice and evolving demands of military medicine.

Materials and Methods

Twelve pharmacists participated in a facilitated discussion using the nominal group technique. Data were analyzed using quantitative and qualitative methods to establish consensus. Member checking was used to verify and validate the findings.

Results

Participants generated 190 knowledge, skill, and ability (KSA) statements over 3 sessions. Twenty-one statements achieved consensus. Four consensus statements were skills, 7 were knowledge, and 10 were abilities. KSAs were categorized into pharmaceutical care, military, logistics, or legal domain based on a thematic analysis.

Conclusions

With modernized, relevant KSAs, the Army can measure and train a ready pharmacy force. Individual Critical Tasks augmented with KSAs are one potential approach we recommend as a strategy to improve Army pharmacist health profession education.

INTRODUCTION

Military pharmacists have played an essential role on the battlefield since Andrew Cragie was appointed Apothecary General during the Revolutionary War in 1775.¹ Much like Army pharmacists today, Cragie provided pharmaceutical health service support and force health protection by obtaining medical supplies and creating medication kits for Soldiers. While the fundamental role pharmacists fulfill in the Army has remained consistent, the education and training needs of Army pharmacists have evolved over the past 248 years along with the profession.²

A previous survey by Whiteside et al. found that the prior experiences of new Army pharmacists can vary.³ All Army pharmacists attend civilian pharmacy schools and must hold an active pharmacy license in at least one state. While postgraduate pharmacy training is increasingly prevalent among pharmacists working in civilian health system pharmacies, it is not currently a requirement for Army pharmacists. Whiteside et al. found that 42% of Army pharmacists report having completed a postgraduate year one (PGY-1) residency and 16% reported having completed a postgraduate year two (PGY-2) residency.³ Given the diverse past experiences of Army pharmacists (Supplement A), standardized education and training are needed to ensure a consistent level of competence and uniformity in practice to address any potential gaps across the corps.

One of the Army’s current educational approaches relies on establishing individual critical tasks (ICTs), which are then collated on an Individual Critical Task List (ICTL) that serves as the education and training requirements for Soldiers.⁴ The ICTs for Soldiers are often referenced by military commanders and educators to develop training plans, assess military readiness, and justify the allocation of resources (i.e., funding). However, the existing ICTL has a key limitation in that it constrains any health care professional, including pharmacists, to a finite number of ICTs (currently, there are only 21 ICTs for Army Pharmacists). Given the intricacies and complexities associated with contemporary pharmacy practice, distilling the profession down to no more than 30 discrete ICTs is a challenge. Therefore, the current ICT-centric approach may not support the multifaceted educational needs of Army pharmacists.

Several medical occupations in the military have addressed this shortcomings of ICTs by adopting a knowledge, skills, and abilities (KSAs)–based approach as a complementary or supplementary model to better support organizational goals of maintaining a “ready medical force”.⁵ The Army Pharmacy Readiness Program (RxRP) is the program office within the U.S. Army Medical Department responsible for pharmacy personnel, focusing on ensuring that Army pharmacists and pharmacy technicians are fully trained, equipped, and prepared to support the health care needs of Soldiers in various operational environments. By adopting a KSA-based approach similiar to other medical occupations in the military, the RxRP could more effectively communicate to U.S. Army Medical Department senior leaders and capture the complex educational needs of Army pharmacists.

The primary objective of this study was to perform a general needs assessment to identify gaps in the existing Army pharmacy education and training and forecast future educational needs based on advances in pharmacy practice and the rapidly changing needs of military medicine. Our hypothesis was that we would find several gaps between current ICTs and KSAs identified by key stakeholders. The findings from a general needs assessment can directly inform Army pharmacist educational requirements and ensure that educational offerings are aligned with the needs of learners and stakeholders.

METHODS

Kern’s 6-step curriculum development model was used as the basis for the study, which provides a structured framework for designing and implementing medical education curricula.⁶ The model was chosen to ensure that the curricula used to train Army pharmacists are systematically developed and meet the educational needs of learners. We began with the first step of this framework, which is centered around a general needs assessment, where an educator understands the gaps in current training and what learners need most. While a meticulous review of existing literature, including, but not limited to, published research studies and internal documents yielded some insights, consultations with subject matter experts were required in order to gain a better understanding of the KSAs needed by Army pharmacists. Thus, we used the nominal group technique (NGT) as the primary method for conducting the needs assessment.⁷ NGT, a structured process involving small-group discussions, was chosen because of its ability to foster direct participant engagement and produce immediate results for the RxRP to consider for implementation.⁷ The interactive nature of live discussions was also seen as a benefit since the participant responses could be used to generate a number of rich KSAs, forming the basis for future course development.

Three virtual NGT discussions were conducted to collect first-hand insights into the KSAs deemed critical for Army pharmacists to support large-scale combat operations. Each discussion was up to 120 min, with digital transcriptions for the principal investigators to extract and review. The NGT sessions consisted of 5 steps. First, participants were introduced to the research project and the guiding questions. Second, the participants were given time to silently generate ideas. Third, there was an opportunity for participants to share their statements which were collected. Fourth, the group was given time to discuss among themselves. Fifth, after each group reached consensus on a list of KSA statements, participants were asked to silently vote whether each KSA statement was critical, important, nice to have, or not necessary. This vote occurred at the end of each session, and while no statements were edited after the vote, participants were asked to contact the study investigators if they felt that any KSAs required changes. Participants in the second session were able to review and vote on KSA statements from the first session. Participants in the third session were allowed to contribute KSAs if they felt they were lacking from the first and second sessions but were primarily tasked with voting on KSAs generated during the first 2 sessions to generate sufficient consensus. Participants in the third session were asked an additional question related to whether they felt that the KSA was deployment related. This is an important question for setting future educational priorities given that not all educational needs have the same level of urgency or importance. KSAs that are deployment related could help the Army Office of the Surgeon General prioritize which needs must be addressed immediately and which can be addressed in the long run. “Critical” statements that received at least 75% of the participant vote were deemed to have met consensus based on the foundational work by Delbecq et al. that suggested NGT thresholds be set in a manner that reflects the collective judgment of the group while also taking into account the importance of the topic under consideration.⁸

Participant Selection

Purposive sampling was used to recruit Army pharmacists into the study.⁹ Participants were drawn from 2 groups. The first group included 6 Army pharmacists with a mix of qualifications, including service as past or current Commander, leadership position in a national pharmacy organization, completion of both PGY-1 and PGY-2 pharmacy residencies, experience as a past Army pharmacy consultant or deputy consultant, or possession of the “9A” proficiency designator, the highest recognition for professional excellence in the Army Medical Department.¹⁰ This group was intended to represent Army pharmacists who have achieved excellence in Army pharmacy practice and may have valuable insight into the future needs of Army pharmacists. The second group also included 6 pharmacists, each of whom had at least one operational deployment in the past 10 years. Army officers with recent operational experience possess a grounded understanding of current challenges, threats, and real-world scenarios faced in the field. This understanding is vital for the RxRP when developing education and training that is meant to address actual, rather than theoretical, operational pharmacy needs. These 2 groups aimed to capture a holistic representation of Army pharmacists, factoring in diverse experiences and roles. Pharmacists from both groups were invited to participate in the research study. Each NGT session was composed of a combination of participants from these 2 groups.

NGT Session Overview

This study was approved by the Institutional Review Board at the Uniformed Services University (RB#23-16,957). There were 3 virtual sessions conducted that followed the phases outlined in Supplement B. Before the start of NGT sessions, participants were acquainted with the research’s objectives and the concept of ICTs, along with definitions and examples of knowledge, skills, and abilities through an introductory e-mail. Participants could complete a questionnaire that would help generate initial discussion for the live NGT session (Supplement C). The guiding questions for the discussion included the following: (1) Based on your experience in the Army, what knowledge do you think Army pharmacists should have to best support the range of military operations?¹¹ (2) Based on your experience in the Army, what skills do you think Army pharmacists should have to best support the range of military operations? (3) Based on your experience in the Army, what abilities do you think Army pharmacists should have to best support the range of military operations? (4) Based on a statement provided (Supplement D), are there any additional knowledge, skills, and abilities you can think of that may be critical for Army pharmacists to support large-scale combat operations and prolonged field care?

Upon conclusion of the 3 NGT sessions, the four-person research team analyzed the results and compiled them in a document. The corresponding percentage of participants who assigned a KSA statement as critical, important, nice to have, or not necessary was then tallied and recorded. The statements were then ordered in descending order based on the percentage of participants who identified them as “critical.” Domains where consensus was achieved for a statement were identified, thereby prioritizing the level of importance within the evaluated knowledge, skill, or ability segment. A thematic analysis was conducted to further categorize each KSA into a domain. In some cases, during the analysis, statements were combined or edited for clarity. However, final results were sent to panelists via e-mail for member checking, allowing them to respond back with comments and verify the results.¹² The authors used the COnsolidated criteria for REporting Qualitative research Checklist to guide the reporting of results.¹³

RESULTS

A total of 12 Army pharmacists participated across the 3 sessions (4 in the first, 4 in the second, and 4 in the third). Participants had diverse pharmacy education/training (e.g., residency, fellowship, and other advanced degrees), command, and military backgrounds (Table I). The participants generated 189 KSA statements over the 3 sessions (Supplement E). There were 19 skill statements, 67 knowledge statements, and 103 abilities generated. After voting, a total of 21 statements (4%) achieved consensus. Seven of the consensus KSA statements were knowledge (Table II), 4 were skills (Table III), and 10 were abilities (Table IV).

A thematic analysis further classified these KSAs into 4 key domains: Pharmaceutical care, military operations, logistical supply chain, and rules and regulations. The pharmaceutical care domain encapsulates KSAs that revolve around the practice of pharmacy, incorporating everything from sterile compounding, drug interactions, pharmacokinetics, pharmacodynamics, patient counseling, medication management, and therapeutic outcomes (S1, S2, S4, K1, K4, K6, and A3–10). KSAs in this domain ensure that pharmacists safely prepare and effectively use medications, optimize therapeutic outcomes, and anticipate the pharmaceutical needs of patients.

The military operations domain focuses on KSAs (K2 and K3) that, while not inherently pharmacy-related, are crucial for ensuring the effective and efficient practice of pharmacy within the military. This includes an understanding of the chain of command, military protocols, the operational environment, and the integration of pharmacy services into the larger framework of the military health system. Recognizing the differences in the operational environment, from peacekeeping missions to combat zones, this domain ensures that military pharmacists are equipped not only as health care professionals but as Soldiers first and foremost.

Logistics, especially as it relates to pharmaceuticals, often transcends the mere movement of goods. The logistical supply chain domain focuses on KSAs (S3, K7, and A2) associated with temperature-sensitive medical products, an understanding of the pharmaceutical supply chain, and the nuances of medication procurement. This domain encompasses everything from inventory management, distribution dynamics, and strategic sourcing to ensure that the right medication reaches the right patient at the right time. Given the critical nature of medications, particularly in scenarios involving contested logistics, mastery of this domain is of the utmost importance.

The KSAs related to the rules and regulations of Army pharmacy (K5 and A1) concern the complex web of laws and policies that shape the landscape of pharmacy practice in the Department of Defense (DoD). It ensures that practitioners are well-versed in the legal implications of their actions, the rights and responsibilities they bear, and the legal boundaries within which they operate, particularly in the military context, where rules and regulations can differ significantly from civilian settings.

Fourteen (66%) consensus statements were in the pharmaceutical care domain, 3 consensus statements (14%) were in the logistical supply chain, 2 consensus statements (10%) were in military operations, and 2 consensus statements (10%) were in rules and regulations. KSAs were cross-mapped to the existing ICTs to identify potential training gaps (Supplement F). Eight (38%) of the 21 consensus statements had at least one ICTL that would meet the educational need.

DISCUSSION

This study found clear gaps between the existing 21 ICTs for Army pharmacists and the consensus statements generated by the participants identifying critical KSAs needed by Army pharmacists to be considered a “ready pharmacy force.”¹⁴ It was noted that the skills and abilities statements had more statements related to the pharmaceutical care domain compared to the knowledge statements that have a balance of the rules and regulations, military operations, and logistical supply chain domains.

These findings have important implications for the education of Army pharmacists moving forward. We propose the RxRP (who is responsible for ensuring that Army pharmacists are fully trained and prepared) adopt a KSA-based approach to augment the traditional ICT-based approach used by the U.S. Army Medical Center of Excellence. These data support the hypothesis that the existing approach is not optimized to meet the educational needs of pharmacy. It is inherently difficult for any health profession, let alone pharmacy, to try and capture their roles and responsibilities in a list of 21 ICTs. Given that the ICT-based approach is broadly applied to Soldier tasks and skills beyond medical professions, it is unlikely that the U.S. Army will amend the existing approach solely for military health care professionals. Therefore, advances in pharmacy practice, along with ongoing changes in the military health system, call for an adaptable educational approach to equip pharmacists with relevant KSAs for the duties they are most likely to perform.

The findings from this study suggest that the RxRP would likely need to create, modify, or acquire new curricula and training programs to maximize the readiness of Army pharmacists to perform their duties. The 6 abilities (A1, A5, A7–10) and 2 skills (S2 and S4) that did not have a cross-mapped ICT (Supplement F) could likely be taught through an existing “Pharmacy Operations Course” if the curriculum is revised to incorporate some of the missing skills and abilities. This would include, but is not limited to, activities such as demonstrating an ability to perform pharmaceutical calculations, resolving narcotic discrepancies, and demonstrating an ability to make ethical decisions. These could be nested within a scenario that involves a mass casualty event, thereby covering some of the skills activities. A live, simulation-based activity may be best suited to evaluate the learner’s mastery of these skills and abilities through direct observation although further research could validate this statement.

As for the 5 knowledge statements without a corresponding ICT (K2, K4–7), given the plethora of existing pharmacy content from national pharmacy organizations, the Army could acquire a learning management platform and assign academic modules to educate and evaluate Army pharmacists on their ability to recall key pieces of information. While knowledge statements related to the aseptic technique or commonly used medications can likely be met by the existing educational programs, custom content may need to be developed to address the Army-specific aspects of medical logistics, the pharmaceutical supply chain, or the specifics of pharmacy law in the context of Army pharmacy.

LIMITATIONS

The main limitations of this study are related to the sample, as the 12 participants represent approximately 10% of active duty Army pharmacists. However, while the sample size represents a smaller percentage of the total Army pharmacist inventory, it is a representative sample of pharmacists currently on active duty. While the active component (COMPO 1) pharmacists accomplish much of the day-to-day pharmacy activities for the Army, there are also hundreds of reserve component (COMPO 3) pharmacy officers who were not included in the study. Given that we relied on purposive sampling, assumptions were made that could lead to an over-representation or under-representation of certain concepts within the research.¹⁵ Future research might need to explore differences in training requirements between those in the reserves compared to those on active duty. For example, Army pharmacists who are reservists are generally practicing pharmacists when they are not activated for missions and may not need significant support in the pharmacy domain. However, given that they do not work in the military on a day-to-day basis like those on active duty, they may need additional support in the military, logistics, and legal domains where they may have less exposure or recall over time.

Additionally, a limitation of Kern’s Six-Step Curriculum Development Model as it relates to the military is its linear, sequential approach that may not always align with the dynamic requirements of the military and may not be well suited to the emerging educational needs.¹⁶ However, given the context of this study, many of the requirements are unlikely to dramatically change over time given the relative consistency of pharmacy practice over time. Lastly, NGT is fairly time consuming and may be a limitation when time is limited or in situations where there is a need for rapid decision-making, which can be the case in the military.¹⁷

With the bifurcation of readiness and health care delivery between the Army and the Defense Health Agency, future research could explore whether certain skills are health care delivery or deployment related.¹⁸ Moving forward, KSAs related to deployment would be the primary responsibility of the Army to define and provide training and educational programs. However, several KSAs related to the business of pharmacy or managing civilian pharmacists could be provided through a partnership with the Defense Health Agency. Future collaboration to streamline the various training pharmacy programs across the DoD has the potential to optimize the use of military pharmacists’ valuable time.

CONCLUSION

Without modernized, relevant, and standardized KSAs, the Army cannot effectively measure or train a “ready medical force.”¹⁹ Existing ICTs augmented with the identified KSAs are one potential approach we recommend as a strategy to inform and improve Army pharmacist health profession education. Given the Department of the Army’s core mission to organize, train, and equip its Soldiers to meet the defense needs of the United States, Army pharmacy must continually evolve its education and training to ensure that it is sound and useful and enables Soldiers to successfully accomplish their mission.

ACKNOWLEDGMENTS

The authors would like to acknowledge the contributions of the Army pharmacists who volunteered their time to participate in this research activity.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

This study was approved by the Defense Health Agency Institutional Review Board (23-16957), and determinations completed the submission with the outcome of exempt.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

R.C.C. collected and analyzed the data and drafted the original manuscript. A.A.G. and J.A.B. designed this research and reviewed and edited the manuscript. All authors read and approved the final manuscript.

INSTITUTIONAL CLEARANCE

Institutional clearance approved.

SUPPLEMENTARY MATERIAL

SUPPLEMENTARY MATERIAL is available at Military Medicine online.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The data that support the findings of this study are available on request from the corresponding author. All data are freely accessible.

REFERENCES

Author notes