understanding practice change in community pharmacy: a qualitative study in australia

Research in Social and Administrative Pharmacy

1 (2005) 546–564

Understanding practice changein community pharmacy:

A qualitative study in Australia

Alison S. Roberts, B.Pharm. (Hons.)a,*, S.I. (Charlie)Benrimoj, Ph.D.a, Timothy F. Chen, Ph.D.a,

Kylie A. Williams, Ph.D.a, Trine R. Hopp, M.Sc.(Pharm.)b, Parisa Aslani, Ph.D.a

aPharmacy Practice Research, Faculty of Pharmacy, University of Sydney,

NSW 2006, AustraliabDepartment of Social Pharmacy and FKLdResearch Centre for Quality in Medicine Use,

The Danish University of Pharmaceutical Sciences, Universitetsparken 2,

2100 Copenhagen :, Denmark

Abstract

Background: Much of the research on cognitive pharmaceutical services has focusedon understanding or changing community pharmacist behaviour, with few studiesfocusing on the pharmacy as the unit of analysis or considering the whole professionas an organisation.

Objectives: To investigate practice change and identify facilitators of this process incommunity pharmacy, with specific focus on the implementation of cognitive phar-maceutical services (CPS) and related programs.

Methods: Thirty-six in-depth, semistructured interviews were conducted with partic-ipants from 2 groups, community pharmacies and pharmacy ‘‘strategists,’’ inAustralia. The interview guide was based on a framework of organizational theory,

with 5 subject areas: roles and goals of participants in relation to practice change;experiences with CPS; change strategies used; networks important to the change

* Corresponding author. Tel.: C61 2 93514445; fax: C61 2 93514391.

E-mail address: [email protected] (A.S. Roberts).

1551-7411/$ - see front matter � 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.sapharm.2005.09.003

mailto:[email protected]

547A.S. Roberts et al. / Research in

Social and Administrative Pharmacy 1 (2005) 546–564

process; and business impacts of CPS. Interviews were transcribed verbatim and the-

matically content analyzed, using NVivo software for data management.Results: Five key themes relating to the change process were derived from the inter-views: change strategies (process- and behaviorally oriented); social networks (withinand beyond the pharmacy); drivers of change (eg, government policy); motivators (eg,

professional satisfaction); and facilitators of practice change (remuneration for imple-mentation or service delivery, communication and teamwork, leadership, task delega-tion, external support or assistance, and reorganization of structure and function).

Conclusion: The use of an organizational perspective yielded rich data from whichan understanding of the practice change process in relation to CPS implementationwas gained. Current programs for the implementation and delivery of CPS have

not taken into account all of the factors that have the ability to facilitate changein community pharmacy. Not only do future programs need to be underpinned bythese elements, but policy makers must include them when planning remuneration

and dissemination strategies.� 2005 Elsevier Inc. All rights reserved.

Keywords: Australia; Community pharmacy; Cognitive pharmaceutical services; Change;

Facilitator; Implementation

1. Introduction

The changes occurring in community pharmacy practice as the professionattempts the transition from a product to a service orientation are well docu-mented in the literature.1-4 There is agreement among all writers aboutchange: it is hard, and generally more complex than anyone first anticipates.5

To achieve successful change, it has been suggested that 3 essential dimen-sions need to be addressed.6,7 These are the content (what is to be changed);the context (considers the impact of internal and external factors); and theprocess (actions undertaken to effect change, and steps toward successful im-plementation). In community pharmacy, there is agreement regarding thecontentda shift to a service- and patient-oriented practice.1-4 However,the literature is less abundant in the areas of context and process. The impactof factors affecting change has largely been limited to discussion of barriers,with little focus on the factors that facilitate change. There also seems to bea trend toward ‘‘matching’’ facilitators to barriers, for example, if lack ofmoney is a barrier, then it is often assumed that reimbursement is the totalsolution, an assumption that others have cautioned against.8,9

There is an increasing body of pharmacy practice research in the area ofcognitive pharmaceutical services (CPS), defined by Cipolle et al as ‘‘the useof specialized knowledge by pharmacists for the patient or health care profes-sionals for the purpose of promoting effective and safe drug therapy.’’10Muchof this research has focused on community pharmacists and on understandingor changing their behavior, with few studies focusing on the community phar-macy as the unit of analysis or considering the whole profession as an

548 A.S. Roberts et al. / Research in


organization.11,12 Furthermore, the identified facilitators seem to be focusedon internal factors, often ignoring wider organizational factors.

Organizational strategies used to assist the process of change, which can bebroadly categorized as process-based or behaviorally based, can assist in theunderstanding of the change process.13 These change strategies are docu-mented in other literature such as nursing14 but appear limited in communitypharmacy research. Indeed, few studies have investigated the implementationprocess for pharmaceutical care or CPS,15,16 especially in the Australiansetting.

Being informed about an organization’s structure and culture and identi-fying key stakeholders and their role in the change are key components inunderstanding the process of change.17 Kanter et al suggested that changeis so complex and challenging because there is no agreement about whyor how the change should take place, and note that ‘‘the point of view ofthose who think they are creating change as an intentional process will bedifferent from those who are on the receiving end.’’5 It has also beensuggested that programs are more likely to be successful if the goals ofthe various stakeholders are taken into account,17,18 allowing explorationof the context dimension of change. Furthermore, it is important to considerhow far advanced in the change process the people who will be accepting orrejecting the change to be implemented are, because ‘‘this analysis can helpyou ‘customise’ your implementation strategy to better fit with the needs ofvarious identifiable groups of people.’’19

In this study, the aims were therefore to

1. investigate the process of practice change in community pharmacy, withspecific focus on the implementation of CPS and related programs; and

2. identify facilitatorsc of the practice change process as they relate to theimplementation of CPS and related programs in community pharmacy.

1.1. Setting

This study was conducted in Australia. A brief summary of the system ofcommunity pharmacy in Australia is shown in Figure 1.

2. Methods

2.1. Theoretical framework for research

The theoretical framework adopted in this study was based on organiza-tional theory. A full description of the framework appears in another

c Facilitators refers to elements that make adopting and maintaining a new behavior or

practice easier.



publication.20 Such an approach provides a useful perspective for recogniz-ing and describing the important components of an organization, and howthey may affect each other and the whole organization. Organizational the-ory does not exclude individual change, however. In fact, as Woodman andDewett21 stated, ‘‘It is not really possible to change organizations in any tru-ly meaningful sense unless organizational participants perform their jobsdifferently, [and] change their thinking or attitudes in ways that supportthe needed changes.’’ The organizational theory framework therefore allowedthe identification of factors affecting practice change from an organizational,not just individual, perspective and thus assists in better understanding theprocess of change in community pharmacy.

2.2. Study population

Based on the theoretical framework, subjects were drawn from 2 organi-zational levels: the individual community pharmacy level and the commu-nity pharmacy strategy level. Interviewing a variety of participants froman organization is a technique that has been used in organizational casestudy research,22 and gathering data at these 2 levels allowed the perspec-tives of different participants within the community pharmacy professionto be incorporated in the study’s findings.

2.2.1. Individual community pharmacy levelThe population comprised community pharmacists, including pharmacy

owners, managers, and other employed pharmacists and nonpharmacist

Australia has approximately 12,000 community pharmacists and 5,000community pharmacies, for a population of 20 million people.

Ownership of community pharmacies is restricted to pharmacists.

An average community pharmacy’s ratio of prescription sales to non-prescription sales is 70:30.

The major payer is the Australian Government, with community pharmacydispensing $169 million of subsidised prescriptions annually (excluding patientcontributions).

There are a number of Government-funded CPS delivered from Australiancommunity pharmacies, designed to assist the achievement of theGovernment’s National Health Policy, particularly in relation to Quality Use ofMedicines. They include:

Medication review to patients in aged care facilities (Residential MedicationManagement Review) – in collaboration with the patient’s physicianMedication review to patients in the domiciliary setting (Home MedicinesReview) – in collaboration with the patient’s physician

Consumer Medicine Information (CMI), brand-specific written informationabout medicinal products, targeted to consumers.

Figure 1. Community pharmacy in Australia.54



staff such as dispensary technicians, pharmacy assistants, or ‘‘retail manag-ers’’ who were currently or had been involved in attempting to implementCPS or related programs in community pharmacy. As the position of a per-son within an organization and his/her access to information can affect his/her perceptions of change,12 involving participants with different roles andresponsibilities within the pharmacy was important to capture theseperceptions.

2.2.2. Community pharmacy strategy levelAt the broader level of the profession, the population comprised commu-

nity pharmacy ‘‘strategists,’’23 defined in this study as key people involved inthe development and/or dissemination of projects or programs involving theprovision of CPS by community pharmacies, such as pharmacy practiceresearchers and people employed by professional pharmacy organizations.

Participants were drawn from 4 Australian states: New South Wales,Queensland, South Australia, and Victoria, and from both metropolitanand nonmetropolitan areas.

2.3. Sample selection

Following approval from the University of Sydney’s Human ResearchEthics Committee, participants who had some experience with the 2 keycommunity pharmacy programs from the Third Community PharmacyAgreement were sought:d

- The Home Medicines Review (HMR) program, a medication reviewservice provided to patients who are living at home.24 It involves colla-boration between the patient, an accredited pharmacist (who conductsthe medication review), and the patient’s medical practitioner and aimsto reduce medication-related problems. The program was introduced in2001, with approximately 55% of community pharmacies registered todeliver HMRs at the time of the study.

- The Quality Care Pharmacy Program (QCPP), a quality assurance pro-gram introduced in 1998 with the aim to raise the standard of customerservice and professional practice in Australian community pharmacies.25

QCPP is intended as the framework underpinning the delivery of HMRand future CPS. Pharmacies that wish to register to provide HMRs arerequired to be either QCPP accredited or undergoing the accreditationprocess.26 At the time of the study, approximately 58% of communitypharmacies were accredited with QCPP.

d This is a 5-year agreement (2000-2005) negotiated with the Australian Government, by the

Pharmacy Guild of Australia, on behalf of community pharmacy owners, addressing issues such

as remuneration for medication supply and service delivery.



2.3.1. Community pharmaciesTo identify community pharmacies at different stages in the change pro-

cess, state-based coordinators (employed by The Pharmacy Guild of Aus-traliae) for HMR and QCPP were contacted. The coordinators were eachasked to nominate approximately 10 pharmacies that had some experiencewith, but were at different stages of the implementation process with, eitherHMR or QCPP. A similar method has been described by Tann et al.27 Fif-teen pharmacies were contacted by telephone. Of these, 14 pharmacy own-ers, 6 employed pharmacists, and 3 pharmacy assistants from 13 communitypharmaciesf agreed to participate in the interviews.

2.3.2. StrategistsKey stakeholders involved in the development and/or dissemination of

HMR and QCPP were identified through discussions with leading research-ers in this field, and contacted by telephone. The strategists were also askedto suggest other stakeholders who may be useful to talk to about these issues,using the technique known as snowballing.28 While there are disadvantagesto this approach, such as only including members of a specific network,28

it was still believed to be the most useful way of identifying key stakeholders.Fifteen strategists were contacted and of these, 13 agreed to participate in theinterviews. Two universities (nZ 2 strategists), 2 professional organizations(nZ 8), and 3 ‘‘banner’’ groupsg (nZ 3) were represented.

This method of sample selection is known as purposive sampling.28 Apartfrom the lack of generalizability, one of the disadvantages of using this tech-nique to target participants with some experience of particular programswas that the views of those who had not begun the change process were ex-cluded. This is important because the factors that would assist them inchanging their practice may be quite different to those of the majority,and will almost certainly differ from those of participants who take on aninnovation in its early stages.27,29 However, there are advantages to obtain-ing information on actual, rather than perceived, facilitators of change, andtherefore it was important that the participants interviewed had experiencewith the practice changes required to implement CPS. Phillips describesa similar purposive sample selection technique as allowing access to ‘‘thosewho possessed the kind of knowledge that I was looking for or who could berelied upon to contribute valuable and valid information.’’30

e The Guild is a national employers’ organization, whose members are owners of pharmacies

throughout Australia.f Community pharmacies in Australia can be owned in partnerships; therefore, a pharmacy

can have more than one owner.g Banner groups generally refers to the groups established by the pharmacy wholesalers and

others, to give groups of pharmacies a common brand name. Although pharmacies are individ-

ually owned, they pay a subscription to belong to such a group, and in some cases receive

benefits such as group advertising, marketing, training, and support.



2.4. In-depth interviews

In-depth interviews were chosen for this study as they would allow de-tailed descriptions of individual experiences and behavior to be elicited, withthe opportunity for immediate clarification of ambiguities and probing ofparticipant responses.28 The interviews were semistructured, based on an in-terview guide without fixed wording or ordering of questions.20 One of thepotential disadvantages of the in-depth interview is how to know whetherthe participant is giving an ‘‘accurate’’ representation of the situation.31

For the objectives of this research and many other qualitative inquiries,however, the rich data obtained relate to the participant’s experiences, feel-ings, views, or described ‘‘truth,’’ and therefore the accuracy of the informa-tion becomes less of an issue.28 Another disadvantage is the potential forinterviewer bias; however, this can be reduced by good interviewer tech-nique: putting the participant at ease, maintaining a conversational tone, al-lowing the issues to be explored from the participant’s perspective, andlistening well.28 In approximately half of the interviews, the participantsknew the interviewer, and in all cases were aware that the interviewer wasa pharmacist. Arguments have been made both for and against the use of‘‘insider’’ interviewers.h Although the advantage of insiders is that theymay ‘‘pose different questions due to their insight.which an outsidermay interpret as merely typical of the entire sample.’’ The opposing viewis that an insider may take participants’ meanings and concepts forgranted.31 Attempts were made to guard against this last potential problemthrough the use of probing questions to clarify issues that would notordinarily be clear to an outsider.

2.5. Instrument design

The research instrument for this study was an interview guide20 consistingof 5 subject areas: roles, experiences, change strategies, networks, and busi-ness impact. The face and content validity of the interview guide were testedwith a group of pharmacists and strategists (nZ 5) resulting in some minormodifications being made.32 The difficulty in measuring the reliability ofa semistructured interview guide used in in-depth interviews has been ac-knowledged, because using such a technique makes it impossible to replicateexactly the interview process.31 However, clearly setting out the researchprocess, including an explanation of the theoretical perspectives adopted,having a second researcher code the data, and cross-checking the data, wereall undertaken to improve the reliability of the instrument used.31,33

h Insider researchers or interviewers have been defined as those who belong to the same social

group or profession that is being studied,31 eg, pharmacists researching pharmacists.



2.6. Sample size

A total of 36 in-depth interviews were conducted from August to Novem-ber 2002. While in-depth interviews by their nature and definition are under-taken in person,31 5 of the interviews had to be conducted by telephone,because of resource constraints and difficulty in finding a mutually suitabletime for a face-to-face meeting with certain participants. After approximate-ly 20 interviews, no new information appeared forthcoming. Data satura-tion was therefore deemed to have been reached,28 and a decision wasmade to stop once all the agreed interviews had been undertaken.

2.7. Data analysis

Complete transcripts of the interviews were prepared and these files wereanalyzed, together with the digital recordings of the interviews, using the-matic content analysis.33 This involved broadly categorizing the interviewdata, initially using the subject areas of the interview protocol as a guide.Within these categories, subcategories were inductively derived while codingthe data.28 Coding was assisted by the use of NVivo, a computer softwarefor the management of qualitative data.34 Two researchers undertook thisprocess with the first 4 interviews to allow as broad a range of categoriesas possible to be derived and any discrepancies to be resolved. Individual in-terviews were analyzed and then compared with others from a particularcase (eg, all pharmacy owners, 3 interviews from a single pharmacy), as wellas with other cases (eg, pharmacists and strategists), using the cross-case35

and constant comparative36 methods. This latter technique involved goingback and forth through the interview transcripts to compare the data fromdifferent transcripts and find repeated examples of the themes and sub-themes. Quotes from individuals were used to illustrate the themes arisingcollectively from the different organizational levels.

3. Results

Although data were gathered under the subject areas of the interviewguide, it became apparent in the process of data analysis that there were 5central themes emerging from the complete data set (Table 1).

3.1. The process of practice change

3.1.1. Change strategiesThe interview data provided an insight into the change process from the

perspective of the change strategies used. A rational, pragmatic approachto change, in which systems and documentation were key features,13 wasdescribed by many participants from both organizational levels. In this


approach, participants indicated that procedures and checklists played animportant part, and staff were expected, rather than encouraged, to becomeinvolved. When one pharmacy assistant was asked how everyone on thestaff were encouraged to participate in QCPP, she replied, ‘‘well, they didn’thave a choice.we just told them they had to.’’

‘‘I think it’s excellent, with all the checklists and all that sort ofstuff.if the checklist is done, everything in the shop should be run-ning smoothly.’’ (Pharmacy Cdpharmacy assistant)

A less mechanical, more behavioral, approach to change was describedby other participants. In this approach, participants indicated that educa-tion, training, and support, as well as practicing new behaviors, formedan integral part of the change process for both QCPP and HMR:

‘‘The staff had to be trained [and] we spent a fair bit of time upgradingtheir knowledge, then to upgrade our knowledge, which we did.[then] you can offer the full servicednot only the products but thebackup.’’ (Pharmacy Cdowner)

3.1.2. Social networksParticipants from both organizational levels gave an insight into the

change process through the depiction of the social networks37 operatingin community pharmacy at several organizational levels: within and beyondthe community pharmacy. Strategists tended to describe a much broadernetwork that included universities, banner groups, and professional organ-izations as being vital to the change process, as reflected by the followingquote:

‘‘I think that we can’t just have an academic view point, there needs tobe a policy and a political aspect to it as well.there needs to be a num-ber of groups or association or providers that are closer to the phar-macists to facilitate the implementation of these particularprograms.’’ (Strategist K)

Table 1

Themes identified in qualitative interview data

Theme Explanation

Change strategies Types of change strategies being used in the change process

Social networks The key people or organizations involved in the change process

Drivers of change Who and what are creating the impetus for change to occur?

Motivators of change What are the important issues or values that make someone

want to change their practice?

Facilitators of change The factors that assist with successful implementation and

maintenance of practice change




Pharmacists, conversely, were more likely to list local factors or peoplesuch as medical practitioners and other pharmacists with whom they haveregular interaction, within their network:

‘‘You have got to know your place but also you don’t have to be sub-servient [to the doctors]. Consequently over a period of time you buildup a rapport.the relationship actually prospers.’’ (PharmacyLdowner)

‘‘I know another friend of mine who I did the [HMR] course with.itwas great to get the network re-established with him because.it wasquite daunting, quite different from what you are used to doing. So forthe first couple of [HMRs] it’s nice to have someone you can bounceoff.’’ (Pharmacy Edemployed pharmacist)

3.1.3. Drivers of changeParticipants from both organizational levels described feeling external

pressures for current community pharmacy practice to change and shiftfrom a product-focused role to a more patient-centered, service deliverymode. They described this pressure as coming from government, supermar-kets, and the professional pharmacy organizations:

‘‘I don’t think the [pharmacist’s] role has changed that much, but theemphasis by our government.is really more for the ‘hands-on’ serv-ices.’’ (Pharmacy Hdowner)

‘‘We are losing a lot of products to supermarkets and that is alwaysa bit of pressure on us.’’ (Pharmacy Edowner 2)

‘‘I don’t think the profession [of community pharmacists] really knowswhere we heading. Where it is being driven is in PSA (the Pharmaceuti-cal Society of Australia) and theGuild, and the academics. The pharma-cy profession doesn’t come to you and say, ‘we want a cognitive servicefor medication systems.’ You just don’t hear that.’’ (Strategist C)

3.1.4. Motivators of changePharmacists described a number of sources of motivation, or their own

philosophical values, which gave them the impetus to start the change pro-cess. These included a desire to successfully compete against other pharma-cies, achieving professional and career satisfaction, and a sense of obligationto the pharmacy profession, as illustrated in the following quotes:



‘‘There are actually people getting started in this now and if you’re notprepared to do the HMRs and the other people around you are, youmay well lose some of your high script patients to other pharmacies.’’(Pharmacy Gdowner)

‘‘I feel as though that is the way we should be going. Basically it getsyou a lot more job satisfaction really using all of the skills.’’ (PharmacyJdowner 2)

‘‘If pharmacists are passionate about things they will invest in a futurefor the benefit of the profession.’’ (Pharmacy Gdowner)

3.2. Identifying facilitators of the practice change process

Participants from both organizational levels outlined a separate range offactors that had assisted or were assisting with overcoming barriers andachieving implementation of QCPP and HMR.

3.2.1. Remuneration of implementation and/or serviceParticipants indicated that to sustain programs such as HMR and QCPP,

appropriate incentive and remuneration structures needed to be in place:

‘‘If there hadn’t been that financial incentive there potentially wemight not have done [QCPP], just because it was such a time-consum-ing process, frankly. It was good that [the money] was there and Ithink maybe we would have still done it but it would have been muchharder and it wouldn’t have been as focused.’’ (Pharmacy Bdowner 1)

‘‘There needs to be a [financial] incentive tobecomeapproved as a serviceprovider and become accredited [to doHMRs].’’ (Strategist C)

‘‘We have to make a profit for us to keep on doing it.’’ (PharmacyCdowner)

3.2.2. External support or assistanceParticipants expressed having an external person to assist with implemen-

tation or act as a mentor, as a facilitator of the change to and maintenanceof a new practice:

‘‘You want someone to emulate in that kind of way and people whohave got skills that you don’t.because you often get stuck thinkingthat your pharmacy is the most important thing in the world and



you owe the bank millions of dollars and you can understand why youneed to focus on it, but you need to continue to think outside of thesquare.’’ (Pharmacy Adowner)

3.2.3. Reorganization of the pharmacy’s structure and functionTrying to incorporate the activities of QCPP and HMR into the everyday

working life of a community pharmacy required some reorganization of reg-ular activities, according to the participants. Although not easy, creatinga structure and having the staff to support delivery of CPS was felt to be im-portant in ensuring the sustainability of the practice. This had involved insome cases, employing new staff, reallocating tasks, and changing the phys-ical layout of the pharmacy:

‘‘I don’t know how you actually do it if you don’t have that structurein place. I think people have just got to understand that maybe theyneed to carry more pharmacists to be able to do it and invest in it.’’(Pharmacy Gdowner)

Another suggestion was that without some reorganization, the longer-term sustainability of CPS would be compromised, as illustrated by the fol-lowing quote:

‘‘These pharmacists are doing these extra things on top of their every-day current load. And yes they are receiving some remuneration forthat, [but] there’s a big question of [tiring] out and [lack of] sustainabil-ity.’’ (Strategist H)

3.2.4. Communication and teamworkCommunicating the reasons for the pharmacy’s involvement in programs

such as QCPP and HMR to all staff members at the pharmacy was high-lighted by participants as an important factor in achieving staff commitmentto the change, successful teamwork, and a unified vision. Several tools to aidin communication and teamwork were proposed by participants, includingstaff meetings and interviews and communication books. These techniqueswere used to assist communication between staff members and to allowinput from each member of the team:

‘‘I guess you have to communicate to staff what you’re doing and whyyou are doing it. The staff see the benefit in it and they are linked inbecause they see people they visit at home, somebody struggling withtheir medication and who would be good for an HMR, so they acceptthat part of practice and they can support it.’’ (Pharmacy Gdowner)

3.2.5. LeadershipNot only did the reasons for change and the processes involved have to

be clearly communicated to all involved, participants also indicated that



having someone leading the change and acting as a role model to others wasanother important factor in its success. This leadership could be either pro-fession-wide or internal to the pharmacy. For HMRs, the issue of leadershipdid seem to have a broader connotation to involve leaders of the professionmore generally. These were people who had similar qualities as those de-scribed but may not be directly connected with the individual pharmacy.Conversely, in some cases for QCPP, it was a pharmacy assistant who actedas the leader within the pharmacy:

‘‘Staff saw how hard I was working on it and so they picked their gameup a bit. I would say that was [because] they saw me as an example.’’(Pharmacy Adowner)

‘‘If you have got strong leadership and if you get out there and you arepublic about it, they follow.[the pharmacists] do want good leader-ship and they want innovation and they want you to open up new mar-kets for them and new opportunities.’’ (Strategist J)

3.2.6. Delegation of tasksWhile having someone to lead the change was important, many partici-

pants expressed a view that involving all members of staff through task del-egation was also an essential component of successful implementation. Thisappeared to have 3 main outcomes: increasing the motivation of staff bythem having some ownership over a task, creating a sense of being part ofa team, and releasing pharmacists from duties that do not require a pharma-cist’s involvement, allowing them to concentrate on professional activities,such as HMR. The concept of task delegation was particularly relevantfor QCPP, which specifically involves all staff. For HMR, reducing thepharmacist’s time spent on nonprofessional issues was a positive outcomeof delegation:

‘‘[the dispensary technician] takes a lot of pressure off.just gettingall that humdrum stuff away from the pharmacist’s role, things thepharmacist doesn’t need to do. You can then concentrate a bit moreon actually talking to people and doing stuff that you have to do.’’(Pharmacy Ldowner)

4. Discussion

4.1. The process of practice change

The qualitative interview data provided insight into the practice changeprocess in community pharmacy. The narrower social network described



by pharmacists compared with strategists was not surprising, as others havehighlighted the importance to pharmacists of being able to network withother pharmacists for encouragement and support.4,38 Being aware of thesedifferences is important and necessary if policy (designed by strategists) is tobe effectively linked to practice (implemented by pharmacists), and forchange to be successful.5

The results of the interviews also showed that both process- and behav-iorally oriented change strategies were used by participants, depending onthe program being implemented. Other researchers have recommended thata combination of these strategies is important for successful change.14

4.1.1. DriversGovernment policy, particularly in relation to declining profit margins on

dispensing, and an increase in funding opportunities for CPS as a result ofthe Third Community Pharmacy Agreement,39 was a factor mentioned byboth pharmacists and strategists as a driver for change. This concurs withprevious research suggesting that government policy can drive the changeagenda.40 Importantly, however, it is how this policy is reacted to and usedby the pharmacy leadership that is critical. Professional pharmacy organiza-tions and academics were also proffered by participants as groups creatingpressure for the profession to change, indicating that future change effortsshould take account of the influence and input of these groups.

Demand for services by consumers, although highlighted in some otherstudies as a driving factor for pharmacists to implement CPS,4,16,41 wasnot a feature in this study. This may be because in Australia, the direct pro-motion to consumers of community pharmacy services is limited, both at theindividual pharmacy level and at a profession-wide level. The communitypharmacists in this study, therefore, may not have experienced any demandfor CPS from consumers and therefore did not report feeling any pressurecoming from this sector.

An awareness of these drivers is important because they create the envi-ronment in which change can occur. The qualitative data suggest, however,that their presence alone does not necessarily translate into ‘‘action’’ at theindividual pharmacy level or even provide the motivation to change, andthat the issue of separation of policy and practice requires deeperinvestigation.

4.1.2. MotivatorsWhile there was awareness among participants of certain forces driving

change, these were not necessarily the factors that were likely to make phar-macists or pharmacy staff become active and actually start the change pro-cess. The interview data suggest that there exists a spectrum of motivationfor pharmacists to change. At one extreme of this spectrum, there are thosewho are more likely to be motivated by professional satisfaction and a beliefin their role as a health care provider, and at the other end, there are those



who feel the pressure to change is being forced upon them and are more like-ly to be motivated by threats to their business. It would seem, however, thatmost pharmacists actually exist somewhere along the continuum of these 2extremes. Such categorizations have also been documented in the litera-ture,4,42,43 with the suggestion that recognizing such motivations or valuesin pharmacists may also be an important predictor of the pharmacy’s suc-cess in implementing and sustaining CPS.27,44 Participants outlined a num-ber of factors that, once they were motivated to change, had enabled themto go ahead and implement CPS and related programs.

4.2. Facilitators of practice change

Facilitators identified from the interviews included remuneration, reorga-nization, communication, leadership, external support, and task delegation.It was interesting to note that although remuneration was identified as a fa-cilitator, participants did not raise it as a barrier to practice change whendiscussing their experiences, in contrast to previous research.45,46 This ismost likely due to the fact that the 2 programs being discussed in the inter-views, HMR and QCPP, currently have remuneration and incentive struc-tures in place. Similarly, participants did not highlight education andtraining as facilitators of practice change, despite these being identified inprevious research.47,48 This may be because education and training are anintegral part of the HMR program (they are mandatory for a pharmacistto become accredited to undertake medication reviews49) and thereforemay not have been seen as important factors, or because some of the phar-macies were using an external provider to undertake their HMRs so the ed-ucation and training component was not relevant to them. The interviewdata suggest that even with appropriate training and remuneration, the sus-tainability of these programs is at risk if pharmacists do not make compro-mises with their existing activities and reorganize to give themselves theappropriate space, time, and resources to deliver new services. In additionto financial resources, the value of working as a team and involving all staffin the process of practice change was highlighted in the interviews throughthe themes of communication, leadership, and task delegation, which havebeen proposed by others as facilitators.16,48,50,51

Outside the pharmacy practice literature, several similar factors forsuccessful program development and implementation have been identified,including obtaining the active commitment of senior leadership and settingup systematic communications with all stakeholders involved.17,52 These fa-cilitators were, however, part of an integrated framework for implementa-tion. This is a significant point and highlights the importance of viewingthe facilitators identified in this qualitative study as part of an overall strategyfor achieving practice change. This notion is supported by organizational the-ory, which suggests that the identified elements have the capacity to affect andbe affected by one another53 and therefore must not be viewed in isolation.



5. Conclusion

The use of an organizational perspective in this exploratory study yieldedrich data from which not only facilitators of practice change but also driversand motivators were identified (Table 1). The value of identifying these isthat they should all be included as part of a comprehensive implementationstrategy for future CPS.

By examining the change process for CPS implementation, a greater un-derstanding of the values of participants was gained, together with knowl-edge of their preferred change strategies. This information is also valuablefor planning future change efforts, as the values that a pharmacist has, orhis/her motivations for wanting to change, appear to be an important factorin predicting the success of the change. The relative importance of the iden-tified facilitators for pharmacists and pharmacies at different stages of prac-tice change and with different motivations or values is an area warrantingfurther investigation. The qualitative data obtained in this study providea good foundation for such an investigation, using quantitative methodsand random sampling techniques, to obtain generalizable results. Sucha study would also allow differences between the participant groups to beidentified from representative populations.

What this research showed is that current programs for the implementa-tion and delivery of CPS have not taken into account all of the factorsoutlined above, which have the ability to facilitate change in communitypharmacy. Without the right drivers, motivators, and facilitators, the pro-grams are bound to fail. Not only do future programs need to be under-pinned by these elements, but policy makers must include them whenplanning remuneration and dissemination strategies.

Acknowledgments

Financial support for this project was provided by the CommonwealthDepartment of Health and Ageing, through the Third Community Pharma-cy Agreement Research and Development Grants Program administered bythe Pharmacy Guild of Australia. This research has also formed part of aninternational research collaboration, and we wish to acknowledge the inputof Ellen Westh Sørensen and Hanne Herborg.

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