Implementing cognitive services in community pharmacy: a review of facilitators used in practice change

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1 Review Article IJPP 2006, 14: The Authors Received May 19, 2005 Accepted May 26, 2006 DOI /ijpp ISSN Implementing cognitive services in community pharmacy: a review of facilitators used in practice change Alison S Roberts, SI (Charlie) Benrimoj, Timothy F Chen, Kylie A Williams and Parisa Aslani Abstract Faculty of Pharmacy A15, University of Sydney, NSW 2006, Australia AS Roberts, research fellow SI Benrimoj, pro-vice chancellor, University of Sydney TF Chen, senior lecturer in pharmacy practice KA Williams, lecturer in pharmacy practice P Aslani, senior lecturer in pharmacy practice Correspondence: Alison S Roberts, Faculty of Pharmacy A15, University of Sydney, NSW 2006, Australia. alison_roberts@usyd.edu.au Acknowledgements: This review was a component of a project funded by the Australian Government Department of Health and Ageing as part of the Third Community Pharmacy Agreement. Objective To investigate facilitators of change in community pharmacy and their use in the implementation of cognitive pharmaceutical services (CPS). Method Relevant literature published in English was identified through searches of online databases (no date limits), texts, conference proceedings, and bibliographies of identified literature. Literature that involved a discussion of facilitators of community pharmacy practice change in relation to the implementation and/or delivery of CPS was selected for review. Some of the identified studies were conceptual in nature, and although they were selected in the same way as the empirical research papers, were not able to be critically reviewed in an equivalent manner. A narrative, rather than systematic review, was considered more appropriate. Key findings The identified facilitators exist at two levels: the individual (e.g. knowledge) and the organisation (e.g. pharmacy layout). Few studies identified or measured facilitators drawn from experience, with many based on the views of researchers or participants in the studies, in reaction to identified barriers to CPS implementation. Purposive sampling was common in the reviewed studies, limiting the generalisability of the findings. Conclusion Although a number of facilitators have been identified in the literature, it appears that little consideration has been given to how they can best be used in practice to accelerate CPS implementation. Identifying facilitators at both individual and organisational levels is important, and future research should focus not only on their identification in representative populations, but on how they should be incorporated into programmes for CPS delivery. Introduction Community pharmacy has been moving towards more patient-oriented modes of practice, for more than two decades, particularly in the area of cognitive pharmaceutical services (CPS). 1 (Cognitive pharmaceutical services can be defined as professional services provided by pharmacists, who use their skills and knowledge to take an active role in patient health, through effective interaction with both patients and other health professionals.) Some frustration with the extent of change towards a greater service orientation has been expressed. 2 For example, There are positive signs of moving forward, but why is the profession not further along? For community pharmacy to successfully achieve both dispensing and patient management roles, it is necessary to focus on the challenges the profession faces in the delivery of quality services. 2 While individual resistance to change is a common phenomenon 3, in the area of CPS, there is evidence of pharmacists willingness to provide them, as well as consumer support for CPS and evidence of their clinical and economic benefits Despite this, for many, change is occurring at a slow rate. Attention has therefore turned to the identification of barriers to service implementation, and this is a well-developed topic in the literature. 12 What is not well developed is the concept of facilitating change, beyond matching individual solutions to problems (e.g. reimbursement). While it is important to know what challenges the profession faces in trying to implement CPS, overcoming barriers to achieve successful change clearly involves more than just 163

2 164 The International Journal of Pharmacy Practice, September 2006 motivating people to want to change, or paying them to provide a service. 13,14 The focus of this literature review is therefore on facilitators of change. In this case, facilitators are defined as those elements that make adopting a new behaviour or practice easier. Objective The objective of this research was to review the literature on facilitators of change in community pharmacy in order to investigate the facilitators, the methods used to identify them, and their use in the implementation of CPS. Methods The data sources, search terms, and criteria for selecting papers for review are shown in the Appendix. The literature search was undertaken in January A review of the literature concerning models and frameworks for change in community pharmacy has already been published. 1 The focus in this review, however, is on literature concerning facilitators of change, in relation to the implementation of CPS in community pharmacy. Despite a broad search, only a small number of papers met the required criteria, as assessed by the main researcher, in consultation with the research team. This body of literature included many papers which were conceptual, descriptive or non-empirical in nature, and thus often did not have methods sections. Therefore the papers were not subject to a quality assessment, and as a systematic review of this literature was neither possible nor appropriate, a narrative review was deemed more suitable. Results The conceptual framework for this review involved dividing the identified literature into two parts: 1 conceptual: papers that contained discussions of potential facilitators, which had not yet been experienced by pharmacists applying them in practice, or been subject to empirical testing 2 empirical: included facilitators that had either been proposed following the testing of a particular service, or which had themselves been evaluated in an experimental setting. The identified facilitators were categorised as existing on two levels: the individual and the organisation (Table 1), as the unit of analysis varied from pharmacist to pharmacy. They are presented in a condensed format in no specific order, as it is not possible to say which are more important than others, Table 1 Facilitators of change in community pharmacy Individual facilitators Organisational facilitators Pharmacist competence 28,34 Physical environment e.g. adequate space/privacy and workflow 16,22,28,30,34,35,37,58 60 Education and training for pharmacy assistants 40,56,57 Culture of the pharmacy 35,61 Education and training for pharmacists 16,19,22,23,30,37,40,57 59 Remuneration/incentives 14,16,19,34,35,57 59 Communication skills 22,32 Sufficient and qualified staff/manpower 28,30 Motivation 37,57 Use of pharmacy technicians 2,15,36,40,58 Leadership skills 30 Delegation of tasks 37,58 Professional satisfaction 24,39 Innovative practice orientation 26,28 Pharmacists knowledge of CPS 19 Patient demand/expectations 15,28,59 Pharmacists attitudes towards CPS 22,33,34,59 Relationship with doctors 22,28,30,34,35,58 Pharmacists confidence in ability to provide CPS 33 Equipment and technology, e.g. computers 2,15,22,28,30 Autonomy 23 Access to patient information/records 22,28,34 Attitude of pharmacy staff 16 Documentation system 32,35,58 Profile within the local community 40 Attention for special patient groups 37 Use of protocols 37,59 Interaction with other pharmacists 16,23,34,56 Support of management 40,61 Access to reference literature 35 Pharmacist patient relationship 56,58 Marketing 18,37,59 Support from professional organisations and/or government 16,30,34,58 Low script volume 32 Rural location 32 Legislation requiring or supporting provision of services 16,19,22,35,42 Attitude/perception of doctors 22 Attitude perception of patients 34,57 Examples from leading practitioners 16,59 External advisors or mentors 23,59 Evidence of benefits of services 22,35

3 September 2006, The International Journal of Pharmacy Practice 165 due to the variety of methods employed in the literature and the mix between empirical and conceptual facilitators. The relevant studies in both the conceptual and empirical fields of the literature are outlined below, with a discussion of both their contributions and their shortcomings. The key theoretical and methodological issues identified in the review are then discussed in the summary. Conceptual literature In a White Paper by Maddux et al, factors likely to promote change in the professional roles of community pharmacists were suggested: the opportunity to have a positive impact on patient health outcomes; use of technology and technicians; increased demand for drug information from consumers and health professionals; new opportunities for creating tailored drug therapies as pharmacogenomics develops; and the expansion of practice roles in community settings. 15 This paper was intended to be based on the visions of the authors, hence there was some review of relevant literature, but it was mostly expert opinion and projection. The drivers they identified, therefore, should be viewed as potential, but still add weight to the debate about what might promote change in pharmacy practice. Rovers et al posited that several key elements must be present in order for a pharmacy to successfully implement pharmaceutical care services. 16 These have been classed as internal factors, such as positive staff attitudes, incentives for motivation, pharmacy design and workflow, promotion of a professional health environment; and external factors, including supportive regulations, support from professional groups, training, formation of networks, and examples from leading practitioners. Missing from these lists appear to be businessrelated facilitators, such as marketing, which has been highlighted as important in the organisational change literature. 17 McDonough et al argued that there are distinct differences between the marketing of a product and that of a professional service, and that pharmacists involved in this process must be prepared to educate prescribers, patients and others about the value of the CPS they are providing. 18 Pharmacists have expressed concern that members of the general public and other health professionals have a poor understanding of the role of the community pharmacist, 19 and thus it has also been recommended that marketing of CPS should occur following collaborative efforts from all professional healthcare bodies. 6 Furthermore, various researchers have suggested that promotion of the community pharmacist s role needs to be targeted towards the general public in order to create a demand that will itself act as a facilitator of practice change. 6,20 Empirical literature Zelnio et al highlighted the need for a number of factors to be in place to facilitate practice change. 21 The research showed that pharmacists, although willing and able to provide an expanded level of services, were unlikely to do so. Nelson Jr et al subsequently undertook a series of 11 focus groups (n = 81) to try to understand why this might be. 22 Two expert panels were used: researchers in the first, to categorise and code data; and pharmacists in the second, to judge the reliability of the first analysis. One of the areas covered by the focus groups was the elements required to provide expanded services. Since the participants were not necessarily providing any extended services, the proposed facilitators included everything the pharmacists saw as requisites for service delivery, such as: training and education; knowledge and experience; advertising; demand; manpower; revenue generation; improved pharmacist and physician attitudes and relationships; favourable pharmacy atmosphere; communication skills; access to patient information; proven benefits; legislation; and computers. This early study provides good insight into the potential facilitators of CPS implementation, which according to other research identified in this review, are still pertinent today. Several studies were identified that specifically explored the factors affecting implementation of CPS that relate not only to the pharmacist, but also to the pharmacy. Ruston considered both the business-related and pharmacist-related characteristics that might influence pharmacists to adopt extended role activities. 23 A questionnaire was sent to a random sample of community pharmacies in Great Britain (n= 731). Respondents listed the extended role activities in which they were involved. Associations between the activities and the business and pharmacist characteristics were determined, and barriers to the provision of certain activities were identified. The authors suggested a number of facilitators to overcome barriers and assist in role expansion. These included autonomy; education; local networks; and external support. As these conclusions were made in light of correlations between reports of activities and the business and pharmacist characteristics of the respondent, it would be useful to have a clear explanation of how such correlations were made. Miller and Ortmeier also centred on the community pharmacy as the provider of services, rather than the individual pharmacist. 24 Their discussions were primarily focused on financial incentives. In a four-part questionnaire sent to a random sample of 590 community pharmacies, respondents (owners or managers) were asked to indicate the importance they placed on a number of different pharmaceutical care services; the importance of three motivational factors to their provision; and the potential barriers to implementation. Certain limitations of the study were acknowledged, such as the fact that the data were self-reported, and that the survey instrument had not been validated. Other limitations however, may include the fact that while the sections in the questionnaire on pharmacy services and barriers were derived from the literature, there was no explanation for the derivations of the motivational factors. Three factors were proposed as influencing pharmacy service delivery: professional reward; compliance with legal or contractual requirements of payers; and financial reward, but the evidence for their proposal was unclear. While financial incentives did rank statistically significantly higher in terms of importance compared with the other two motivational factors, the recommendations of the authors do not seem to involve the former two factors and other possible influences on the provision of pharmacy services. For example, training, knowledge and professional reward are given only a cursory mention in the paper s conclusions, with the focus being on documentation and payment for pharmacy service provision. The issue of financial reward was also highlighted by Kröger et al, who made the point that

4 166 The International Journal of Pharmacy Practice, September 2006 employees and owners are not necessarily influenced by reimbursement in the same way as each other, and therefore future strategies towards pharmacists behaviour change should take employment status into account. 25 A study by Doucette and Jambulingam was similarly focused at the community pharmacy level. 26 The authors proposed that the entrepreneurial orientation (EO) of a community pharmacy could be a facilitator of service provision. EO was defined as an intangible resource that describes a pharmacy s capability to, in this case, offer a new service. A random sample of 324 community pharmacies was surveyed to determine their EO (based on five dimensions: proactiveness, innovativeness, risk taking, autonomy, and competitive aggressiveness), and to investigate the relationship between EO and provision of innovative services. Using confirmatory factor analyses, they found that pharmacies with a high entrepreneurial orientation were more likely to provide new pharmacy services than those with a low EO, with recognition of the limitations of self-reported data. Other outcomes of the study included the development of a valid and reliable tool for measuring a community pharmacy s EO. This tool was recommended for use by pharmacy managers to evaluate their pharmacy s level of EO, before they implement CPS, and to track performance over time. This could indeed prove useful, if, as the authors predict, EO can improve a pharmacy s performance through creating a competitive advantage. A later study suggested that EO would be more likely to create such an advantage in an environment which is full of opportunities. 27 Comparing pharmacies with different levels of innovation is not without precedent. Odedina et al compared 10 providers of pharmaceutical care with 10 non-providers, in telephone interviews. 28 (Providers were defined as the pharmacists scoring in the top 10% of the Behavioral Pharmaceutical Care Scale, a multi-item scale to measure pharmacists efforts towards providing pharmaceutical care, and non-providers as those in the bottom 10%.) Using open-ended questions, the researchers asked providers to describe factors they believed had acted as facilitators to pharmaceutical care provision, and the non-providers to outline barriers. The researchers found that the factors identified as barriers and facilitators were similar and could be categorised under eight themes: physical layout of the pharmacy, qualified support personnel, practice orientation (service orientated versus profit-driven), patient expectation, co-operation of doctors, computer support, patient medical information, and pharmacists competence. Although the sample size was small, this study highlights the value of gaining information about facilitators from pharmacists who are already providing pharmaceutical care, and, as suggested by the authors, this information can be used to develop strategies to assist those who have not yet implemented it in their practices. The findings also suggest that barriers perceived or experienced by non-providers may not be so different from those of the providers, in contrast to other researchers findings. 29 Future studies using a similar approach with larger and more representative samples to confirm these findings would be valuable. Similarly, Doucette and Koch compared the resources and practice activities of four pharmacies that had made changes with two that had not. 30 The authors used an organisational change and innovation perspective, finding distinguishing features between the two groups included: links with pharmacy associations and colleges; adequacy of staff skills; leadership skills of the owner; addressing constraints; and complexity of the change involved. It is difficult to generalise from this exploratory study, due to the small sample size and sampling technique. The authors concluded that future research should address this limitation, and should involve a development of a model of the process of pharmacy practice change, advocating the use of models from the fields of innovation and organisational change. They also recommended that pharmacies be observed throughout the process of practice change, rather than relying on self-reporting. A randomised trial was carried out to determine the influence of both the pharmacy and the pharmacist s characteristics on delivery of CPS. 31 To allow the researchers to ascertain these characteristics and also to measure the amount of services being performed and how much it was documented, two questionnaires were sent to pharmacies randomised into either the control or the study group. Participants in the study group received payment for their interventions, while those in the control group did not. 32 Using multivariate analyses, correlations were made between pharmacist and pharmacy characteristics, and the delivery and documentation of services. The authors found that there were associations between higher rates of service delivery and documentation and less busy pharmacies; pharmacies located in medical centres or rural settings; and remuneration for the service. As well as these potential facilitating factors, the authors suggested that communication and assistance with documentation might be helpful to start the implementation of CPS. For existing services with low participation, changing the work environment or pharmacists performance expectations were suggested as potential facilitators. One of the limitations of this study is that data in relation to the volume of service delivery were self-reported. Another issue is that while the study objectives referred to the amount of services being performed, in the discussion, the authors only refer to documented services activities. It might well be that services are being delivered but not documented, and the factors influencing delivery of services may be different from those influencing their documentation. The factors influencing pharmaceutical care service delivery were also investigated by Venkataraman et al, in 162 rural pharmacies. 33 Although the survey was intended to measure perceived barriers and facilitators experienced by pharmacists providing pharmaceutical care, it was interesting to note that one of the objectives of the study was to determine the influence of the barriers and facilitators on the extent of provision of pharmaceutical care services. While this may be possible for barriers to provision, i.e. the services are not being provided due to certain perceived barriers, it would be seemingly difficult to link perceived facilitators to actual provision of services. The main findings were that confidence and a positive attitude should act as facilitators of implementation. Like many of the studies in this area, the authors note that the self-reported nature of the data means further validation is required. The attitudes and opinions of community pharmacists towards pharmaceutical care were also recognised as facilitators by Bell et al. 34 During in-depth interviews with 20 community

5 September 2006, The International Journal of Pharmacy Practice 167 pharmacists, participants were asked to comment on factors they believed had influenced their provision of pharmaceutical care. Facilitators included a private counselling area, access to medication records, interacting with other pharmacists, and a good relationship with the local doctor. A number of other facilitators were proposed in response to the identified barriers, and these included support from government and professional bodies, increased staff, and training. Although the results may not be generalisable due to the purposive sampling used, the sample was selected to include pharmacists with a range of experience, working in different roles (e.g. owner versus locum) and in different practice settings (e.g. independent pharmacy versus chain), and this gives strength to the data obtained. Another qualitative study was undertaken by Krska and Veitch. 35 The researchers interviewed potential policy makers (defined as members of pharmaceutical organisations in Scotland who were likely to be involved in policy making and who had a major interest in either pharmaceutical care or community pharmacy 35 ) and leading-edge practitioners (defined as pharmacists practising in primary care, either in community pharmacy or a medical practice and who had either demonstrated innovative practices or were influential in such development 35 ) to identify the factors they perceived as influencing the development of pharmaceutical care. Eleven potential policy makers (two of whom were also practitioners), and five innovative pharmacists were interviewed. A semi-structured interview guide incorporated barriers and facilitators identified in the literature, but exactly which items were included is not specified in the paper. Although participants were initially asked open questions about the factors they felt would enable the development of pharmaceutical care, they were then asked to give their views on any remaining factors they had not mentioned, from the interview guide. A range of potential facilitators was reported, including remuneration, documentation, use of dispensary technicians, and space. No distinction is made, however, between the factors identified by participants without prompting, and those that were suggested only upon prompting from the interviewer. Gathering data from the two groups of participants is a valuable approach, as they may have different perspectives on the development of pharmaceutical care. In the results, however, differences in responses from the two groups have not been reported, which may be due to the small sample size in the study. It would be valuable to know whether any important differences were identified, as these would need to be addressed in the future development and implementation of CPS. Indeed, some differences were identified in a study which employed a similar approach. 36 For example, the strategists felt that additional training was required, while the practitioners did not. The value of obtaining insights from different people involved in change was also recognised by Pronk et al. 37 They conducted a qualitative study using focus group interviews with 18 pharmacists and 20 technicians. The focus groups aimed to determine the barriers and facilitators at each stage of the process of implementing a patient education model. Once identified, barriers and facilitators were categorised into five stages: 38 agenda setting; matching; redefining/restructuring; clarifying; and routinising. Facilitators identified included: task division among technicians; attention for special patient groups; availability and use of a leaflet system; a patient-friendly layout in the pharmacy; continuing education and motivation in specialist areas; and use of protocols. These facilitators were classified as relating to either the restructuring or clarifying stages of the model, but not the routinising stage. A conclusion was therefore drawn that the activities had not been made part of everyday practice. The identified facilitators should be considered in light of the study s stated limitations that due to a low response rate, the sample was likely to be biased towards highly motivated individuals. However, these respondents were considered to be at least in the implementation stage for patient education, and therefore could reflect on what had facilitated the process based on their experiences rather than supposition. Taking a different approach both in terms of study objectives and methods was a study by Tully et al. 39 The Delphi method was employed to gain consensus on motivators and barriers to the implementation of prescription monitoring and review services, performed by pharmacists either in the pharmacy or the general practitioner s (GP s) surgery. The 84 community pharmacists were purposively selected in an attempt to ensure that the views of pharmacists with different levels of involvement were captured. This was done to allow comparison of the attitudes of the two groups, referred to as involved and non-involved. Although not generalisable due to the purposive sample used, the motivators on which consensus was achieved included being able to improve the public and GPs perception of pharmacists, experiencing professional fulfilment and personal challenge. Conversely, being motivated by saving money for the health system was a strong motivational factor for the involved pharmacists, but an issue on which the non-involved pharmacists could not reach consensus. The authors recognised that asking participants to respond only to pre-written statements on the questionnaire meant that other barriers and motivators might not have been identified. Notwithstanding this limitation, the methods used could provide a useful way to identify facilitators of practice change, from pharmacists at a range of involvement and activity levels. In contrast to the previous studies reported, Rossing et al. employed a quantitative methodology, but the focus was still on pharmaceutical care. 40 A questionnaire was sent to all pharmacies in Denmark, with a 76% response rate (n = 218). Pharmacists were surveyed on barriers and facilitators they perceived or had experienced while trying to implement pharmaceutical care. No differentiation was made between perceived and actual, however, when the results were presented. A strength of this study is its detailed discussion of barriers; however, the facilitators are not described in the same depth. In light of the study s objective to examine both barriers and facilitators, it would be interesting to know why, for example, the participants were asked to rate the importance of barriers (with subsequent confirmatory factor analyses being performed), whereas for facilitators, they simply answered yes or no to each initiative. Of the 23 initiatives listed in the questionnaire, those that ranked the highest included: in-service training for pharmacists and technicians; increased profile of the pharmacy within the local community; management support; and better utilisation of existing personnel.

6 168 The International Journal of Pharmacy Practice, September 2006 The value of the data on facilitators from this study is that they were obtained by asking pharmacists about initiatives they had actually experienced in the pharmacy. One of the limitations, however, is that participants appeared to have to choose only from the items listed in the questionnaire and were not able to add extra facilitators from their experience. This means that concepts not included in the questionnaire, and that perhaps are specific to pharmacy practice in Denmark, may not have been identified. Finally, it appears that some researchers and policy makers have assumed that legislation could be used to force changes in community pharmacy practice, 41,42 thereby acting as a facilitator. A study examining pharmacists role expansion in South Africa compared pharmacists allowed limited prescribing rights for certain medications, to a random sample of community pharmacists. 41 The findings showed that those pharmacists with the permit offered a full range of healthcare services to their patients and reported more frequent and meaningful contacts with other health professionals. When new activities such as screening and monitoring services were included, however, those with permits did not show a higher level of engagement than the ordinary pharmacists. To overcome these implementation barriers, changes in legislation were proposed, along with appropriate education and training. Others have argued that legislation alone is not a successful strategy for achieving behaviour change. 43,44 While it may be one part of an overall approach towards increasing CPS delivery, there are still other barriers to be overcome, as some experiences with USA legislation would attest Furthermore, Almarsdóttir et al argue that the fundamental changes in focus that are required for pharmacists to provide CPS are not something that can be imposed upon them. 43 The authors suggest that changes must come from within the profession of community pharmacy itself. Discussion It is interesting to note that 16 years ago, Hepler cautioned that reimbursement for pharmaceutical care should not be seen as the saviour of practice change. 48 Despite this, many researchers and policy makers have since placed a significant focus on remuneration as the single most important factor in achieving practice change. This remained the overriding philosophy at least until the late 1990s when there was some realisation that remuneration alone was not producing the changes required, and that it was important to consider other factors. 11,24 An exception to this early focus is one of the more comprehensive studies in this review, which identified barriers, motivators and potential facilitators of expanded services, and was published more than two decades ago. 21 Unfortunately it appears that little new information has been gleaned in this area since. Furthermore, although a number of facilitators have been identified, it appears that little consideration has been given to how they can best be used in practice. There also seemed to exist in the literature a notion that for every barrier, there is an equal and opposite facilitator, as in many cases the proposed facilitators appeared to be based on this assumption. Few of the studies attempted to identify facilitators that were based on experience, with the rest being based on the opinions of researchers or participants in the studies. This may be due to the fact that adoption of CPS has been slow, and therefore it is difficult to find practitioners who have actually been through the implementation process. Innovative pharmacists who are providing certain services, however, did participate in some of the studies. This highlights an interesting methodological issue in relation to how information about facilitators should be obtained, as a range of sources has been used. Some studies involved pharmacists with differing levels of involvement in specific services, including those with no involvement at all, who can only provide information on potential facilitators. From a methodological perspective, few of the studies in this review used randomly selected subjects. Where specialist information is required, a random sample may be neither possible nor desirable. 49 There is certainly value in the knowledge about facilitators from those who have actually been or are going through the process of change, and in this case, a purposive sample is more appropriate. The drawback is that the generalisability of findings to the population is limited. The views of innovative practitioners and policy makers, for example, are not expected to be representative of the greater body of community pharmacists. 29 Using leading-edge practitioners to model new services has been suggested to help others shift their practice, giving rise to the concept that these innovative pharmacists may themselves be facilitators of change. This highlights a need for further research to determine whether the facilitators of change are the same for all pharmacists, other pharmacy employees, and pharmacies. The difficulty in doing this, which has been reported by other researchers, is that those who agree to participate in research tend to be the more motivated and innovative practitioners. Other limitations of the studies reviewed included frequent use of self-reported data; and inadequate justification of questions or items included in questionnaires and interview guides. Not all of the studies included a discussion of limitations. This becomes a limitation in itself because interpretation of conclusions should be made with awareness of the study s limitations. Conclusion There is a need to clarify how facilitators, once identified, can be used in practice to accelerate implementation. Understanding the relative importance of the range of facilitators identified would also be most useful in understanding how they may contribute to a total solution. Farris and Schopflocher caution that Pharmaceutical care implementation programs which address individual factors singly... will not be successful. 50 This advice echoes that of change management experts such as Dunphy, who stated the effective management of change depends increasingly on understanding the larger social trends and forces that affect organizations. These forces are greater than individuals. 51 It is therefore important to identify facilitators at a range of organisational levels Further research which uses organisational solutions is also recommended as these approaches have successfully found their way into other healthcare settings but are yet to be fully utilised in community pharmacy. 55

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