The focus groups and interviews brought reflections to the implementation of CPS in certain public health units of a city in northeast Brazil. The accredited pharmacists showed themselves as protagonists in the situation, proposing facilitators inherent to the own attitudes. On the other hand, non-accredited pharmacists held a secondary role in which they attributed the protagonism to other people, such as the health team.
Tsoi et al.  explored factors related to motivation in clinical practice, and according to the authors, autonomy, personal desire, and pleasure in learning are related to motivation. These factors are considered essential facilitators in the professional development process and implementation services. While the lack of motivation is a state of passive behavior, in which pharmacists cannot achieve the expected results. In this way, the motivation can be influenced by factors of their own behavior or external factors and should be encouraged in the implementation process.
Local healthcare managers focused on factors related to the organizational structure of the municipal healthcare network. However, by the influence of their political positions, they may have overestimated some facilitators, such as emphasizing the adequate number of pharmacists available in the local healthcare networks. Political discourse can often be influenced according to the manager’s interest and/or the power of that position can be conveniently applied to emphasize some specific item or detail [42,43,44]. Therefore, it is necessary to pay attention to the influence political office has on managers’ speeches.
Facilitators related to the local healthcare network
Similar to this study, several studies have shown that factors related to the commitment of healthcare managers, such as the availability of time and material resources, may contribute to an increase in the satisfaction of pharmacists, as well as encourage their autonomy and initiative to perform clinical activities [45,46,47]. Tapia-Conyer et al.  identified political support to be one of the key facilitators for the implementation of services. For these authors, when there is political support, innovative models are likely to be implemented more fully and more quickly. Thus, the involvement of managers in practice should be encouraged in order to ensure the resources needed for the successful implementation of CPS.
Regarding the physical structure, according to the model proposed by Donabendian , the implementation of health services, including CPS, can be carried out through three perspectives: structure (physical and human resources), processes (denotes what is actually done in giving and receiving care), and outcome (changes in the health status attributed to the interventions performed). According to this model, improvements in structure reflect improvements in the processes, and consequently, in patient outcomes [49, 50]. Therefore, it is fundamental to plan the structure of health services to be provided, as these can directly impact the quality of care given to the patient.
The clinical profile of care of certain health units at Brazil’s Mental Health Services (CAPS) was a facilitator. CAPS promote public comprehensive care for people with severe and persistent mental disorders in Brazil in a humane and integral way, holding a holistic view of the patient . Silva and Lima , in a structural analysis performed at CAPS, identified a good functioning structure with individual treatment rooms, living space for the patient and professional interaction, and accessible medical records. Such factors make these centers conducive to the flow of patients requiring integrated services, including CPS [53, 54]. Due to the demand for integrated services, the healthcare team can be sensitized to the clinical performance of pharmacists with patients, families, and the community.
The presence of trained teams with defined and organized practices improves the work process of pharmacists, facilitating the implementation and ensuring quality in the services provided [55, 56]. The pharmacy technicians can assist pharmacists with their functions by performing drug-related managerial and administrative activities. The literature reveals that there is growing interest in using technicians as support for pharmacists to have more time to invest in activities centered on patient care [57,58,59]. As a result, it is necessary to invest in the qualifications of these professionals so that they realize safe practices. In Brazil, there is still no regulation for the role of pharmacy technicians.
Facilitators related to healthcare team
All participants of this study reported the collaboration with the health team as a facilitator. The literature has discussed the growing role of pharmacists as members of the healthcare team in primary care, contributing and acting directly on patient care [6, 60, 61]. Fazel et al.  performed a systematic review with meta-analysis to assess the effects of pharmacists’ interventions with the healthcare care team on patients with diabetes. The authors observed improvement in clinical outcomes with significant reduction in glycated hemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol. Troung et al.  evaluated the satisfaction of healthcare professionals, most of them physicians, about the perceived impact of CPS in the management of diseases in primary care. They reported high satisfaction and improvement of patients with diabetes, hypertension, and pain management. Therefore, interdisciplinary practices should be encouraged as they may raise awareness of the role of the pharmacist in the health care team, as well as the importance of CPS implementation.
Facilitators related to pharmacists
The facilitators inherent to the pharmacists in the present study were related to knowledge, skills, and attitudes. These elements form the basis of clinical pharmacists’ competencies and directly reflect on patient care . The clinical profile reported by pharmacists was in fact individual factors, such as willpower, motivation, knowledge, and proactivity, differ in each individual and are shaped by beliefs, education, training, and personal experiences of pharmacists, considered essential for service implementation [56, 65]. Patterson et al.  revealed some individual factors that can contribute to CPS provision, such as proactivity to create knowledge and to apply it in overcoming challenges, positive self-esteem, versatility, availability, and intellectual and personal commitment. Such factors can help the pharmacist become proficient, interact better with the healthcare team and patients, and perform better at work.
A point highlighted in the present study was the motivation generated by the positive results. The positive results (clinical, humanistic, and economic) generated by CPS can sensitize managers, the healthcare team, and the pharmacists by motivating them in the implementation process . Motivation is a dynamic process that can be modified at any time depending on professional satisfaction . Thus, motivation may be related to the way pharmacists deal with external circumstances and with factors they cannot control.
Another topic addressed in this study was the knowledge of pharmacists related to previous experiences with CPS. Alcântara et al.  investigated the perceptions of a group of pharmacists and other professionals about the implantation of the clinical pharmacy in a high complexity public hospital. Most emphasized that the clinical pharmacy experience of some pharmacists at the institution was one of the key facilitators to implement the CPS. In this way, pharmacists who have gained knowledge of past experiences may feel more prepared to implement CPS.
In relation to the work process, some pharmacists were included in healthcare teams composed of professionals from different areas of knowledge, who acted in an integrated way, sharing experiences with patients, families, and the community . In the study by Reis et al. , the interdisciplinary characteristic of the healthcare team, combined with the fact that some pharmacists were included in the healthcare team before the implementation of the service, increased the team’s awareness of the importance of CPS that would be developed. In addition, the working process of pharmacists in contact with interdisciplinary groups may provide more learning opportunities . In this sense, the implementation of CPS can be favored in places where there is an integrated interdisciplinary team.
Access to patients’ clinical information was considered a facilitator. The literature shows that one of the major limitations for pharmacists to provide care to patients in primary care is the lack of access to patients’ clinical information, such as medical records [72,73,74]. Thus, access to this information may facilitate the work process of pharmacists, as well as the implementation of CPS.
Facilitators related to the CPS implementation process
Pharmacists were assisted by specialists who trained them and offered mentoring activities in order to obtain the best performance in providing CPS. In studies on pharmacists receiving training, advantages in the provision of services, improved professional practice, and feeling more confident in patient care, were recognized [75,76,77]. Mentoring works as a dynamic and reciprocal relationship between a specialist with experience and expertise (mentor) and a beginner (the mentee), in order to guide and share experiences, is important to enhance the mentee’s professional development [78, 79]. In the health field, mentoring tools help practitioners improve patient outcomes as well as develop specific skills and behaviors [80,81,82]. Thus, mentoring may increase the impact of positive actions and contribute to the transition of a new leadership profile of pharmacists.
In this study, the systematization of the new work process through medical records was reported as a facilitator. A roadmap for advancing implementation of services in primary care described by Blanchard et al.  demonstrated that one of the main components necessary for the implementation of healthcare services was the systematization of the work process. In this way, it is essential to ensure that the work process is capable of being taught, is understandable, reproducible, and achievable. The authors also showed that it is important to follow a philosophy of practice as it guides a pharmacist’s behavior to be ethically appropriate, clinically accurate, and legal. Thus, it is necessary for processes to be well articulated to ensure that a common language is established.
In addition, according to the implementation process, the fact that the project started with the support of the Ministry of Health was considered an indispensable facilitator. Penm et al.  investigated factors that influenced the implementation of CPS from the point of view of pharmacists; it was observed that most reported that government support was crucial for the promotion of pharmacy services. Some studies show that it is in the interest of the government to implement these services, since they can reduce costs and improve the access of population to health [84, 85]. Therefore, support from government agencies may help accelerate the implementation of CPS.
In this study, voluntary participation of the pharmacists in the process of implementation of CPS was placed as positive. In a review, Luetsch et al.  explored pharmacists’ attitudes and attributes in relation to the implementation of cognitive services or role extension. For the authors, flexible and non-imposing attitudes, which make the pharmacists feel that they have control over their actions, positively influenced this behavior. Thus, letting pharmacists choose to participate in the service can positively influence their behavior.
Strategies related to the local healthcare network
Pharmacists attributed guarantee of minimum physical structure and effective participation of local health managers as local healthcare network strategies. Similarly, Minard et al.  explored the pharmacists’ perceptions of barriers and facilitators in the Implementation of Clinical Pharmacy Key Performance Indicators. Support before the implementation process was indicated as a facilitator. This support included the assistance of managers, technical support (physical structure), guidelines on how to participate in clinical activities, and inclusion of these clinical activities in working hours. Therefore, health authorities should ensure sufficient physical and human resources to collaborate with pharmacists in administrative and clinical tasks.
Another strategy reported to support pharmacists’ working process was the collaboration of interns. The main objectives of interns in pharmacies are defined between the training institution and the university. Overall, assignments are designed to cover key areas of pharmaceutical competence on-site training, providing support to pharmacists working process [88, 89]. Thus, investment in recruiting interns may support pharmacists and facilitate the implementation process.
Strategies attributed to pharmacists
One of the strategies mentioned by accredited pharmacists was the proactivity in the implementation of CPS, the engagement in the process in an attentive and humane manner, recognizing the patients’ needs and seeking to assist them. With these attitudes, pharmacists can impact the quality of service provided, recruit patients more easily, and stimulate the building of a relationship of trust between the patient and the pharmacist [90,91,92]. On the other hand, some non-accredited pharmacists pointed out strategies that reflected their passive attitudes in the implementation process, transferring some of their attributions to other actors, such as the health and pharmacy teams [30, 93]. This passive attitude may be related to the fact that pharmacists still feel insecure about their role and these issues can affect the delivery of CPS.
The training of pharmacy staff was mentioned as a strategy to support the provision of CPS. Similarly, Mackeigan et al.  performed a qualitative study to describe strategies used by community pharmacies to implement a medication review service. The strategies were related to human resource management, such as staff training, to give support in administration. Such strategies can reduce the technical activities of pharmacists, freeing them to perform cognitive activities related to patient care.
Raising awareness among the health team through the disclosure of CPS has been reported as an essential strategy. To sensitize the healthcare team, the disclosure of the impact of pharmaceutical services through media, posters, and lectures was used as a strategy. Such marketing strategies have been successful in other similar studies [95, 96]. According to Ung, Harnett and Hu , the healthcare team’s ability to understand the role of pharmacists is important in order to avoid possible barriers. Finally, the dissemination of CPS can be a valid strategy to give visibility to pharmacists both for the healthcare team and the community, as well as to improve health team adherence.
The non-accredited pharmacists mentioned that a valid strategy for the implementation of CPS would be a reconciliation between logistics and clinical activities. Some professionals may see the insertion of new activities in their routine as increasing workload . Similarly, some studies show that one of the main difficulties in this process is to reconcile clinical and logistic activities. [84, 87, 98]. For Garcia-Cardenas et al. , several factors can contribute to the lack of time, such as lack of priority, commitment, and poor distribution of activities. In this way, it is fundamental to understand the specific causes that contribute to the lack of time, so that measures are developed to remedy this problem.
Strategies related to the CPS implementation process
A suggestion of strategy to ensure that CPS were implemented in this study was the adequacy of the type of service according to the social demands of the setting where it will be provided. Latif et al.  explored factors related to implementing a new community pharmacy service. Pharmacists reported the need to simplify and adapt the service to find the way that best suited the needs of local reality, since the processes involved in the implementation are complex and multifaceted. Thus, ensuring that services match the social needs of the place where it will be implemented can be a relevant strategy.
Factors related to the professionals’ profile were reported as a strategy to be performed. Elvey, Hassell e Hall  examine pharmacists’ perceptions of their professional identity employed in the community, hospital, and primary care sectors, both in terms of how they see themselves and how they think others view their profession. The study identified the presence of nine identities for pharmacists: the scientist, the medicine adviser, the clinical practitioner, the social care-giver, the medicine maker, the medicine supplier, the manager, the businessman, and the unremarkable character. According to the authors, many profiles can be found for a single profession. Thus, it may be a viable strategy to select profiles that are suitable for CPS in order to ensure a higher participation rate and reduce withdrawals.
Strengths and limitations
This study used triangulation of methods and sources in order to increase the reliability of the results. These may have helped to get a comprehensive understanding of the facilitators and strategies related to the implementation process. Moreover, this may allow the minimization of political influences in the results of the study, since the implementation process was observed from the standpoint of accredited, non-accredited pharmacists, and local health managers, who operated in different settings in the municipal healthcare network.
One of the limitations of this study was the refusal of some non-accredited pharmacists to participate in the focus groups. If more pharmacists had participated, new implementation factors could have arisen. Another limitation was that we exclusively investigated the perception of strategies of pharmacists on the implementation of CPS in healthcare systems, rather than evaluating the perception of other actors involved in the process, such as local health managers. In addition, this study did not investigate whether the strategies listed can actually bring real benefits to the implementation process.