Unravelling facilitation complexity in community pharmacy: A pragmatic tool for implementation strategy selection.

Introduction: Pharmacy practice is becoming increasingly patient-centric with the development of community pharmacy services. Their implementation appears to be affected by causal relationships and interdependencies of determinants. To address these determinants, change agents need to select, operationalise strategies, and measure their impact. However, there is little real-world guidance on efficiently selecting strategies tailored to determinants.

Objectives: The aims of this study were to (1) explore the relationships between determinants and implementation strategies identified during the implementation of a Minor Ailment Service in Spanish community pharmacies and (2) develop a visual tool that links implementation strategies tailored to specific determinants for change agents to use during the facilitation process.

Methods: The study employed a mixed methods approach within a three-year pragmatic type 3 hybrid effectiveness-implementation design. Data collection was facilitated by change agents, who utilised on-site and remote communication methods. The objectives of the change agents were to identify determinants, design and operationalise tailored implementation strategies. These data were documented and transformed into Sankey diagrams.

Results: Ten change agents systematically documented 4236 determinant-strategy relationships in 92 pharmacies. The most common primary determinant domain they identified was "intervention characteristics" (n = 1843, 43.5 %). The most common secondary determinant domain was "characteristics of the individuals involved" (n = 3069, 72.5 %). The most common strategy category was "other" (n = 1808, 42.7 %). A Sankey diagram tool was developed to allow change agents to receive feedback on the effect of their strategies and select appropriate future implementation strategies.

Conclusions: The findings of this study inform the development of future visual tools for assisting change agents during the facilitation process. Sankey diagrams act as a generic and real-time tool, which will reduce the complexity inherent to the facilitation activity. This will facilitate prospective implementation researchers to plan implementation interventions and train change agents more efficiently, thereby optimising the change management process.