Governments and health care practitioners share common goals to improve patients' clinical outcomes, quality of life and the rationale use of medicines [1]. To achieve such a goal, there has been an increasing international trend toward the delivery of professional services, in community pharmacy [2],[3]. A professional pharmacy service can be defined as:
“an action or set of actions undertaken in or organised by a pharmacy, delivered by a pharmacist or other health practitioner, who applies their specialised health knowledge personally or via an intermediary, with a patient/client, population or other health professional, to optimise the process of care, with the aim to improve health outcomes and the value of healthcare.” [4]
Professional services conducted in community pharmacy vary significantly in their objectives and complexity. These services can include, the provision of drug information, provision of ‘pharmacist only’ or ‘pharmacy medicine’, clinical interventions, screening services, medication management services, preventive care services for patients with chronic conditions, participating in therapeutic decisions amongst others [5]. At an international level, community pharmacies are slowly implementing these services into their routine practice, however, professional organisations, researchers and practitioners have recognised the need for external support during the implementation of such innovations in community pharmacy [6].
Pharmacy researchers have applied different implementation frameworks including the Promoting Action on Research Implementation in Health Services (PARiHS) framework. This framework presents successful implementation research as a function of the relationship between evidence, context and facilitation [7]. Of the three, ‘facilitation’ has been proposed as a key role which not only affects the context in which change is taking place, but also aids participants in making sense of the evidence being implemented [8]. Utilising a ‘change facilitator’ (CF) has become a key component in supporting teams during the implementation of change in practice [8]. A CF can provide support to stakeholders to “realise what they need to change and how to make changes to incorporate [professional service] evidence into practice” [9]. A stakeholder refers to “any group or individual who can affect or is affected by the achievement of the organization’s objectives” [10]
Roberts et al reported that pharmacists indicated implementation enablers such as ‘external support/ assistance’ as a critical requirement in the process of change [6]. Similarly, when adopting and implementing health literacy tools in pharmacy, researchers indicated that if pharmacists had the right external support, there could be important progress towards achieving their implementation goals [11].
For CFs to implement innovation such as professional pharmacy services, they will face a number of challenges when working with healthcare professionals ‘as they each work in specific social, organisational and structural settings involving factors at different levels that may support or impede change’ [12]. Factors pertaining to a specific context can enable or inhibit successful implementation of innovation. Implementation researchers have extensively explored such factors and have referred to them as; ‘constructs’ [13], ‘determinants of practice’ [14, 15], barriers [16], enablers [17], facilitators [16], problems and needs, or disincentives and incentives [18], and “implementation factors” [19]. Throughout this paper, these factors will be referred to as implementation factors as it has a neutral connotation, and the name reflects the objective to be achieved i.e. implementing an innovation [19].
Implementation factors can act as barriers or enablers to implementation. For example, a factor from the CFIR [20] is ‘knowledge and understanding of the innovation being implemented’. A lack of knowledge and experience would act as a barrier, while having knowledge and experience would act as a change enabler. Understanding when these implementation factors act as barriers, helps CF’s determine more effective strategies to tackle these obstacles [21].
In addition to identifying the barriers to implementation, the CF needs to determine the appropriate strategies to overcome these barriers. Linking barriers with strategies is a concept that has recently been explored [22]. Researchers have previously highlighted that ‘no single strategy appears to be sufficient to drive successful implementation’ [15, 23, 24]. As each pharmacy team will experience different barriers, the strategies to overcome such barriers may also differ. This can lead to a time-consuming and often disheartening ‘trial and error’ approach, until the correct strategy is identified, and the barrier is overcome.
This ‘trial and error’ approach also relies on the CF’s experience and knowledge, and whilst change facilitation research has delved into describing the roles and traits of CFs [25–27], there remains a high degree of variability in facilitation delivery ‘due to the facilitators’ professional backgrounds, role setup and activities’ [28].
The majority of randomised controlled trials involving facilitation interventions, focus on the evaluation of patient outcomes or implementation outcomes [29]. This type of evaluation does not take into account the effectiveness of the facilitation process or the effectiveness of specific facilitation strategies used by CFs during implementation. The need for such information is crucial as 5–30% of trials of behavioural change are described in adequate detail [30], making it difficult to discern which components are essential during implementation. The lack of appropriate evaluation has been highlighted in pharmacy research, where evaluations are required for all aspects of implementation including “assessment of strategies and/or implementation program and overall measures to generate a level of implementation (implementation outcomes)” [1]. Determining the effectiveness of facilitation strategies, in specific contexts such as community pharmacy, will shed light into the essential activities required during the facilitation intervention, reduce the ‘trial and error’ approach that many CFs take, and ensure the delivery of tailored, evidence-based strategies in practice.
In 2012–13, as part of its commitment to building capability in pharmacy and positioning the profession for the future, the Pharmaceutical Society of Australia (PSA) conducted a trial to test the feasibility of a changed model of community pharmacy, in which the pharmacist is repositioned as a primary healthcare provider and the pharmacy as a healthcare destination [31]. Following this trial, the PSA created a commercial program underpinned by the trial, called ‘Health Destination Pharmacy’ Program.