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Research Fellow, The University of Sydney, New South Wales, Australia
Pro-Vice-Chancellor (Strategic Planning), The University of Sydney
Senior Lecturer, Faculty of Pharmacy, The University of Sydney
Lecturer, Faculty of Pharmacy, The University of Sydney
Senior Lecturer, Faculty of Pharmacy, The University of Sydney
Reprints: Dr. Roberts, The University of Sydney, NSW 2006 Australia, fax 61 2 93514391, roberts_alison{at}bigpond.com
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Abstract |
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OBJECTIVE: To quantify facilitators of practice change in Australian community pharmacies.
METHODS: We employed a literature review and qualitative study to
facilitate the design of a 43-item "facilitators of practice
change" scale as part of a quantitative survey instrument, using a
framework of organizational theory. The questionnaire was pilot-tested (n =
100), then mailed to a random sample of 2000 community pharmacies, with a copy
each for the pharmacy owner, employed pharmacist, and pharmacy assistant. The
construct validity and reliability of the scale were established using
exploratory factor analysis and Cronbach's 
, respectively.
RESULTS: A total of 735 (37%) pharmacies responded, with 1303
individual questionnaires. Factor analysis of the scale yielded 7 factors,
explaining 48.8% of the total variance. The factors were: relationship with
physicians (item loading range 0.59–0.85; Cronbach's 0.90),
remuneration (0.52–0.74; 0.82), pharmacy layout (0.52–0.79; 0.81),
patient expectation (0.52–0.85; 0.82), manpower/staff (0.49–0.66;
0.80), communication and teamwork (0.37–0.65; 0.77), and external
support/assistance (0.47–0.69; 0.74).
CONCLUSIONS: All of the factors demonstrated good reliability and construct validity and explained approximately half of the variance. Implementing CPS requires support not only with the clinical aspects of service delivery, but also for the process of implementation itself, and remuneration models must reflect this. The identified facilitators should be used in a multilevel strategy to integrate professional services into the community pharmacy business, engaging pharmacists and their staff, policy makers, educators, and researchers. Further research is required to determine additional factors impacting the capacity of community pharmacies to implement change.
Key Words: cognitive pharmaceutical services, community pharmacy
Published Online, May 13, 2008. www.theannals.com, DOI 10.1345/aph.1K617
CPS programs appear to have been developed and disseminated individually, without a framework underpinning their implementation or inclusion of factors that might facilitate practice change. One of the major implications of this is reduced uptake of CPS. Significant attention has been given to barriers to CPS adoption, focusing largely at the practitioner level. A review of facilitators of practice change in community pharmacy concluded that there is a need to clarify how identified facilitators (defined as elements that make adopting a new behavior or practice easier) can be used in practice to accelerate the implementation of CPS.2 The factors affecting change are more than just those confined to the individual pharmacist who is being trained through traditional, clinically focused, didactic education programs to provide CPS. Broader educational, social, and financial factors are involved,4 and thus research that adopts an organizational perspective is needed. This approach, successfully used in other healthcare settings,5-7 allows the identification of factors affecting practice change beyond the perspective of the individual pharmacist, as aspects such as culture, structure, and the environment are brought into consideration.8,9 The aim of our research, therefore, was to identify the key components needed for the development of a practice change model for Australian community pharmacies. The specific objectives were to develop and validate an instrument to allow the identification and quantification of facilitators of practice change, drawing on the experiences of those involved with existing community pharmacy services and programs (Table 110). This approach was different from that of previous studies in which services have been more loosely defined, and the proportion of respondents with experience of the services has been low; hence, facilitators have sometimes been based on perception rather than experience.2,11
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INSTRUMENT DESIGN
Literature
reviews2,13
and data from the qualitative
study12
facilitated the design of a structured questionnaire, with sections that
include adoption of Third Agreement
Programs4
(Table 1), facilitators of
practice change scale (facilitators scale) consisting of 74 items based on 13
constructs that are measured using a 5-point Likert scale ranging from
Strongly Disagree (1) to Strongly Agree (5), individual respondent and
pharmacy demographics, and free comments.
INSTRUMENT VALIDITY AND RELIABILITY TESTING
The content and construct validity of the questionnaire were established in
a pilot mail survey of a random sample of Australian community pharmacies (N =
100).14 To
test construct validity, factor analysis was performed on the data from the
facilitators scale. Factor analysis is a technique used to reduce a set of
observed variables to a smaller number of underlying
factors.15
The internal consistency or reliability of the factors was measured using
Cronbach's . The results of these analyses allowed changes to be made
to the research instrument and a sample size to be calculated for the main
study.14
POPULATION AND SAMPLE
Ethics approval for the research was obtained from the Human Research
Ethics Committee at the University of Sydney. Contact details of all
Australian community pharmacies (N = 4926) were obtained from the Pharmacy
boards and the telephone directory. (Pharmacy boards are regulatory
authorities in the 6 states and 2 territories within Australia and are
responsible for the registration of pharmacists and approval of pharmacy
premises.) Calculations were based on the sample needed to detect
statistically significant differences (p < 0.05) between mean facilitator
factor scores for certain individual variables (eg, role) and pharmacy
variables (eg, adopter category) deemed to be of practical importance, based
on data from the pilot
study.14 At
80% power (p = 0.05), 1130 individual responses were needed, more than that
required to perform factor
analysis.16
Based on the pilot survey, there was an expectation of receiving 1.7
individual responses per pharmacy; therefore, to achieve the required sample
size of 1130, 657 pharmacies would need to respond. At an anticipated response
rate of 33%, a total of 2000 pharmacies were randomly sampled (stratified by
state).
The mail survey was conducted using the standardized process described by Dillman.17 In keeping with the organizational perspective, each pharmacy was sent 3 questionnaires, one each for a pharmacy owner, an employed pharmacist, and a pharmacy assistant (including technicians).
RESPONSE
A total of 735 pharmacies responded (37% response rate), with 1303
individual responses received (Table
2). Of the respondents, 957 (73%) were pharmacists, who were
representative of the total population in terms of age and
sex.18 Of
that group, 585 (61%) were proprietors. This proportion was significantly
higher than the 45% in the population of community pharmacists
(
2 = 10.34; p = 0.001), which may be due to the fact
that the questionnaire was sent to pharmacies, not to individual pharmacists,
and not all pharmacies returned multiple questionnaires.
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DATA ANALYSIS
Factor analysis was performed on the facilitators scale. Examination of the
correlation matrix indicated that all items had a correlation greater than or
equal to |0.30| with at least 3 other items in the
matrix.15
Bartlett's Test of Sphericity was significant (2 =
17655.21; p < 0.001), and the KMO measure of sampling adequacy was 0.89.
Principle axis factoring was the method of extraction used, with equamax
orthogonal rotation, as many correlations were less than
0.32.19 The
eigenvalue greater than 1 rule, visual inspection of the scree plot, and the
number of items loading well on the factor were all used to determine how many
factors to
retain.15,20
Some items were removed due to poor loading (<0.30) or cross-loading. The
decision of item retention was assisted by the use of Cronbach's , to
see whether the coefficient would be positively affected by the removal of an
item.15
Factor scores were calculated using the weighted factor-based scales method,
which takes the factor loadings into account so that items with the highest
loadings contribute the most to the factor
score.16,21
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of
greater than 0.7 (Table 4). In
all cases, the factor-based scales were non-normally distributed. The median
factor score was higher than the midpoint of the new scale range, which
indicated that the majority of respondents were in agreement with the items
forming that factor.
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RELATIONSHIP WITH PHYSICIANS
Items that constituted this factor referred to the role of
pharmacist–physician relationships for the implementation of new
programs, suggesting that building rapport with local physicians was important
to the program's success. This factor contributed almost half of the total
solution, which is not surprising given that the main CPS experience for most
pharmacies related to home medicines review (HMR), a service involving
collaboration between physicians and pharmacists
(Table 1). There needs to be
greater focus on the development and maintenance of cooperative relationships
between pharmacists and physicians at the local level; this relationship is
known to be a key facilitator in the shift toward a greater service
orientation and for a range of programs and
services.2 At
the political level, policies need to be developed and corresponding
structures put in place to connect pharmacists and physicians across all
levels, from professional organizations to local networks. Pharmacists
themselves need to work toward this goal. For example, the
"arms-length" model of medication review delivery adopted by many
pharmacies, which essentially sees a third party having the main communication
with
physicians,23
could hinder the development of collaborative relationships.
REMUNERATION
Statements in the questionnaire referred to remuneration either as
incentive payments to assist with the implementation process or payment for
the delivery of a service itself, with both concepts shown to be important. In
the case of HMR, remuneration was provided for delivery of the service only
and did not address wider issues related to implementation and sustainability.
This is evident from the data on HMR delivery, showing that, although nearly
all Australian community pharmacies had registered to be part of the HMR
program, the actual rate of participation and service delivery appeared to be
low.23
PHARMACY LAYOUT
The items that made up this factor referred to the importance of the
physical layout of the pharmacy relative to the implementation of programs.
Some items specifically referred to the need for a private or designated area
for delivery of certain services. An appropriate pharmacy layout, in terms of
space and privacy, has been highlighted in the literature as a potential
facilitator concerning a range of
CPS.2 Many
European countries have designated areas in pharmacies specifically for the
delivery of services such as disease state management. Policy makers in
Australia have reacted to this research and have adopted the position that an
appropriate pharmacy layout is a prerequisite for participation in a number of
remunerated
programs.24
PATIENT EXPECTATION
The concept of consumer demand for services was explored in the items that
made up this factor, suggesting not only that there is a perception that the
public expects pharmacies to offer certain services, but also that this acts
as a facilitator in the implementation of those services. This finding is
consistent with the traditional functions of pharmacies as part of their
supply role and place in a retail environment, that is, reacting to the needs
of their customers or facing negative financial consequences. It follows that,
if patients expect a certain service, the pharmacy will feel both obliged and
motivated to provide it.
MANPOWER/STAFF
Items loading on this factor suggested that having sufficient and
appropriately trained staff was a key element of, and necessary for,
successful implementation. Workforce shortages were a particular problem in
Australia at the time of the
study,25 and
discussions in the literature suggest that it is also a problem
internationally, with few solutions
proposed.26-30
Closely linked to this issue is the workload generated by the implementation
of new programs and the resultant need for additional staff. However, this is
not the complete solution. If new initiatives are introduced to community
pharmacy in an ad hoc manner, without any integration, the workload will
simply increase each time a new program is commenced. This is important for
policy makers to consider during the planning phases; they should assess the
workforce requirements not only in terms of numbers, but also with regard to
knowledge, skills, and competencies. To avoid putting existing services at
risk, pharmacies must be assisted in preparing for the adoption of each new
service prior to its dissemination.
COMMUNICATION AND TEAMWORK
Statements that made up this factor referred to the importance of
communicating the reasons for change internally, working as a team to make it
happen, and having someone to lead the change. Previous strategies for
implementing CPS in community pharmacy seem to have largely focused on the
pharmacy owner as the agent of change. It is now clear that, although the
owners may take a leadership role at the pharmacy level, the change process is
facilitated by engaging the entire pharmacy team and allowing the development
of common goals toward which all members of the organization are working.
These concepts, together with leadership, are common elements among many
organizational change
models.13
Policy makers should be aware of this in developing strategies for the
dissemination of new programs or services, and educators should include these
elements in training provided to pharmacists. Pharmacy owners should also be
cognizant of the need to include their entire staff in the implementation
process, even for a service that is ostensibly delivered only by the
pharmacist, and should include staff members in the processes of planning and
goal setting.
EXTERNAL SUPPORT AND ASSISTANCE
For this factor, items highlighted the importance of being able to call on
experts and/or consultants, often from outside pharmacy, when planning and
implementing change. This finding is of particular relevance to professional
pharmacy organizations in that they play a key role in providing support to
pharmacists. Implementing new CPS requires support not only with the clinical
aspects of service delivery, but also with the process of implementation. For
example, pharmacies may need assistance in the process of common goal setting
or changing the pharmacy layout and workflow. Mentoring programs, which allow
pharmacists to gain assistance from other pharmacists and have been
highlighted by others as facilitators of change, should be supported by policy
makers and the profession as a
whole.2
Although further research is required to determine additional factors that are affecting the implementation of CPS, the facilitators identified in this study have been adopted by policy makers in Australia as components of a multilevel practice change strategy for the implementation of remunerated CPS in Australian community pharmacies.31 The findings also have international applicability; while previous research has identified some of these facilitators individually in other countries,2 this study provides a practical framework for their application by the different organizational players.
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The facilitators identified in this study reinforce the notion that successful practice change requires a multifactorial approach. It is clear that remuneration alone, for example, although a key factor, is not sufficient to achieve widespread change. Future programs for delivery in community pharmacy must address the wider issues of sustainability in calculating the rates of remuneration or incentive payments. Moreover, remuneration is only one factor within a broader solution incorporating elements relating to the overall organization—its individuals and environment. Implementing new CPS requires support not only with the clinical aspects of service delivery, but also for the process of implementation. Engagement of other healthcare providers and consumers is critical. Enhancing pharmacist–physician collaboration and consumer awareness of CPS will facilitate their uptake by community pharmacies.
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Footnotes |
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This project was funded by the Australian Government Department of Health and Ageing as part of the Third Community Pharmacy Agreement
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