Background
Brief overview of PARIHS
Purpose | "...to provide a map to enable others to make sense of [the] complexity [of implementation], and the elements that require attention if implementation is more likely to be successful" [5] |
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Proposition |
Successful Implementation (SI) is a (f)unction of Evidence (E), Context (C), and Facilitation (F). The actual complexity of this formula is represented in the framework through the following: |
• Its numerous, potentially applicable sub-elements within its three overarching elements | |
• Its recognition of the nature of complex and dynamic inter-relationships among E, C, and F
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Core elements | • Evidence (E) = "codified and non-codified sources of knowledge," as perceived by multiple stakeholders |
• Context (C) = quality of the environment or setting in which the research is implemented | |
• Facilitation (F) = a "technique by which one person makes things easier for others," achieved through "support to help people change their attitudes, habits, skills, ways of thinking, and working" | |
Each element can be assessed for whether its status is weak ("low" rating) or strong ("high" rating) and thus can have a negative or positive influence on implementation. For Facilitation, the focus is on rating "appropriateness." |
PARIHS limitations and related issues
Conceptual clarity | • Ambiguity in certain terms and phrases; for example, when assessing Evidence, one criterion for "high" research evidence is that "social construction [is] acknowledged." Cross-country and philosophical differences may contribute to this perception of "obscurity" in such language. |
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• Lack of specificity in element/sub-element names and definitions, making it unclear what is actually included/excluded; for example, one of the elements is titled Context, as is one of its sub-elements, Receptive Context. | |
• Lack of transparency or specificity in how to operationalize various sub-elements, such as clinical experience or patient experience. | |
"Missing" components | • Lack of a definition for Successful Implementation (SI). |
• Need to explicitly designate motivation for change/importance of a "recognized need for change" [34], as pointed out by Ellis et al. | |
• Potential value of making more explicit a critical set of innovation attributes (e.g., per Rogers' diffusion of innovation theory [33]). | |
• Removal of clearly stated attributes of a facilitator after earliest version of PARIHS (i.e., general credibility, authenticity, and respect). | |
• Insufficient guidance or clarification under Facilitation regarding the task of developing needed "change...strategies" [5], based on suggested diagnostic analysis of E and C--and lack of inclusion of common implementation interventions that a Facilitator employs, reinforces, or proposes to enhance adoption. | |
Under-developed evaluation and related instrumentation/measures | • Few well-developed PARIHS-related instruments or other evaluative approaches to identify related barriers/facilitators during diagnostic analysis or to evaluate successful implementation. |
• Limited evaluation or means for evaluation of the theory's use/usefulness. |
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Lack of conceptual clarity, specificity, and transparency, which results in different interpretations of PARIHS concepts by different researchers
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Lack of inclusion of relevant elements perceived to be critical to implementation and congruent with the main intent of PARIHS
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Lack of well-developed instrumentation and evaluation measures, as well as limited evaluation of actual use or perceived usefulness of the framework.
Methods
Revising PARIHS for use in task-oriented implementation
Types of implementation
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one with a task-oriented purpose, where a specific intervention is being implemented within a relatively short timeframe (such as implementing a new procedure or care process)
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one with a broader "organizational" purpose, where implementation strategies are targeted at transformational change within one or more levels of an institution (such as changing culture to be more receptive to using EBPs on a routine basis [17]).
Innovative, action-oriented QUERI concepts
Results
Revisions to PARIHS
Elements | Sub-elements |
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E: Evidence and EBP Characteristics
| • Research and published guidelines |
• Clinical experiences and perceptions | |
• Patient experiences, needs, and preferences | |
• Local practice information | |
• Characteristics of the targeted EBP: | |
• Relative advantage | |
• Observability | |
• Compatibility | |
• Complexity | |
• Trialability | |
• Design quality and packaging | |
• Costs | |
C: Contextual Readiness for Targeted EBP Implementation
| • Leadership support |
• Culture | |
• Evaluation capabilities | |
• Receptivity to the targeted innovation/change | |
F: Facilitation
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Role of facilitator:
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• Purpose, external and/or internal role | |
• Expectations and activities | |
• Skills and attributes of facilitator | |
Other implementation interventions suggested per site diagnostic assessment or relevant sources (e.g., prior research/literature and supplementary theories) and used by the Facilitator and others | |
• Related to E
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• Related to C
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• Other | |
SI: Successful Implementation
| • Implementation plan and its realization |
• EBP innovation uptake: uptake of clinical interventions and/or delivery system interventions | |
• Patient and organizational outcomes achievement |
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Changes were made both to wording and ordering of a few elements/sub-elements, as can be seen in comparing Table 3 to Figure 1. For example, the name of the Context element was amended (Contextual Readiness for Targeted EBP Implementation) to clearly indicate our task-oriented focus; and Leadership became the first sub-element under Context, indicating its prime importance in implementation. Nonetheless, it is important to note that the original PARIHS sub-elements of transformational leadership are still reflected within the Guide (e.g., role clarity and effective teamwork).
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A few items were added to core elements to reflect relevant features critical to implementation but missing from the framework (Table 2); for example, EBP Characteristics within Evidence now highlights attributes of an implementable form of "evidence" (i.e., the full form of an "EBP" innovation, such as a policy, procedure, or program). These additions were drawn from Roger's diffusion of innovation work [33] and the CFIR [7]. Some of these additions were already implicit within other Evidence sub-elements. As a result there may appear to be some overlap. However, these attributes were considered important enough to be expanded and made explicit, thus ensuring their consideration. This is particularly important because implementation decisions flow first from the nature of the implementable form of the Evidence and its characteristics.
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Successful Implementation is now visualized as an explicit part of the revised PARIHS "figure" (Table 3), with detailed definitions provided in the Guide (Additional File 4). This first effort at explicating the meaning of Successful Implementation is only preliminary and will benefit from ongoing attempts to operationalize it.
• E element and related sub-elements |
• Conceptual definitions |
• Detailed observations/tips regarding sub-elements and measurement |
• Sample, optional questions to guide formative evaluation |
• C element and related sub-elements |
• Conceptual definitions |
• Detailed observations/tips regarding sub-elements and measurement |
• Sample, optional questions to guide formative evaluation |
• F element and related sub-elements |
• Conceptual definitions |
• Detailed observations/tips regarding sub-elements and measurement |
• Sample, optional questions to guide the team's project planning |
• SI sub-elements |
• Conceptual definitions |
• Detailed observations/tips regarding sub-elements and measurement |
• Sample, optional questions to guide the team's development of an evaluation plan |
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Conceptual and operational definitions: This includes refined meanings of constructs within the framework, reflecting the team's interpretation of each element and related sub-element. These definitions are intended to facilitate in-depth understanding of each concept, guide application of the various elements, and identify potential questions for diagnostic analysis and planning.
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Observations and tips: This additional information, from the implementation literature and authors' experiences, is designed to enhance researchers' nuanced understanding of PARIHS elements/sub-elements. Tips also may facilitate design decisions.
Element | Reference tool content |
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C: Contextual Readiness for Targeted EBP Implementation
| Information in this and the other tools in this Revised PARIHS Guide can be used to prepare a proposal, including related methodology, and follow-up reports. More specifically, this Context tool can be used to: |
• Leadership support | • Think more specifically about the nature of Context and enhance communication of that understanding to reviewers and other readers. |
• Culture | • Identify potential Contextual barriers that may need to be better understood and/or addressed in the implementation strategy (e.g., thinking through the type of leadership support that will be needed given the type of innovation to be implemented). |
• Evaluation capabilities | • Identify diagnostic/evaluative questions for a semi-structured interview relevant to the need to understand selected aspects of the Context, applicable to this specific EBP change. |
• Receptivity to the targeted innovation/change | • Develop and organize a retrospective interpretive evaluation [20] to explore the perceived influence of Contextual features on implementation of the targeted EBP. |
NOTE: In all cases, the list of multiple items should be considered an optional menu from which to choose components of prime relevance to implementation of the targeted EBP. |
Element | Conceptual definitions | Related observations/tips | Measurement |
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Evidence & EBP Characteristics
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Evidence = Specified sources of information relevant to a specific EBP, including research/published guidelines, clinical experience, patient experience, and/or local practice information. | As "evidence" is socially constructed [4], the perceptions of targeted stakeholders regarding the nature and quality of these varying sources of evidence are key to development of an implementation strategy. | |
• These sources have presumably been subjected to scrutiny (e.g., by the research team or a national body) and are judged to support or refute effectiveness of a targeted EBP intervention/recommendation. | • This includes perception of the form of the evidence-based clinical recommendation/intervention (i.e., the recommended practice as a guideline, policy, procedure, protocol, program, optional or forced function clinical reminder, decision algorithm, etc.). At times such transformed findings/"evidence" is supplemented with additional content based on the judgment or consensus of its creator (e.g., consider the mixed nature of various guidelines or protocols). | Sample qualitative diagnostic questions for use in task-oriented projects are listed for each element/sub-element and are, for the most part, based on adaptations of items from the Kitson et al. Appendix related to Evidence [5]. Their 2008 Appendix is said to outline "diagnostic and evaluative measures," but it is not a formal "tool." | |
EBP Characteristics = Attributes describing the nature of the implementable form of the evidence/practice recommendation. | • Initial, diagnostic evaluation is herein referenced as the first stage of an implementation project's formative evaluation [20]. |
Related Sub-elements | Conceptual definitions | Detailed observations regarding sub-elements | Sample, optional questions to guide formative evaluation |
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Leadership support
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Leadership = Individuals in designated positions "...at any level of the organization including executive leaders, middle management, front-line supervisors, and team leaders, who have a direct or indirect influence on the implementation" [7]
Leadership Support = Behaviors, [verbalized] attitudes, and actions of leaders that reflect readiness or receptivity to a change [17] | • In general, relevant leaders' "supportive" actions can be characterized by various types of managerial behaviors or responsibilities, within a change/innovation situation such as EBP, as listed below. These are not directly taken from the original PARIHS framework but rather have been adapted based on the following: a task-oriented view of related PARIHS sub-elements, supplemental information from relevant papers [17][36, 37], relevant EBP behaviors of transformational leaders [17], and an effort to use language more familiar to targeted researchers. • Role clarity, e.g., ensuring transparency regarding both project-related and relevant change-related role responsibilities and accountabilities. | • To what extent do leaders show active and visible support for this change or this type of EBP and implementation? ○ Is the leader willing to engage with the study team for planning? ○ Is the leader willing to provide connections/entrees for the study team? ○ Does the leader have experience/comfort in this role? ○ Does the leader hold service directors accountable for collaboration and coordination in such change efforts/in this effort? • To what extent are appropriate stakeholders or teams held accountable and incentivized or rewarded to carry out the implementation? ○ What about past experiences with this type of change? • To what extent does the leader indicate the willingness to and in fact does the leader communicate the priority of this implementation? |
Summary and conclusions
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The Guide relies on basic elements of PARIHS, as well as updates provided in Kitson and colleagues' 2008 paper and its appendix, specifically its diagnostic approach [5].
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A key revision objective was to minimize the original framework's limitations and related issues (Table 2).
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Our modifications are consistent with the general nature and intent of the PARIHS framework.
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Basic expectations for applying any framework, theory, or model were a guiding influence, that is, the need for clear conceptual and operational definitions, measurement approaches, and additional practical information about the realities of application.
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QUERI frames of reference and concepts affected development of Guide content, as did supplemental information from complementary theories such as Rogers, the Stetler model of EBP, and other selected concepts from implementation science. Modifications are thus responsive to the PARIHS team's suggestion [5] to draw on other theoretical perspectives; for example, "What theories would inform the way evidence has been conceptualized within the PARIHS framework?"
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The implementation knowledge and experience-based lessons of the author team (published implementation scientists in the VA) influenced consensual judgments underlying the Guide.
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Our addition of "other implementation interventions" to the Facilitation element draws, in part, from a QUERI evaluation on facilitation wherein data suggested the following: "external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role" [19].
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Guiding new investigators looking for "theoretical" assistance
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Simplifying selection of diagnostic/evaluative questions relevant to a targeted EBP, followed by organization of those questions into a semi-structured interview
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Defining specifics of an external facilitation intervention (e.g., the level of interaction and type of external facilitator needed), thus making formative evaluation easier [20]
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Facilitating thinking about what Successful Implementation would look like in a study and how that would be measured
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Assisting in the preparation of a proposal wherein use of a theoretical framework and related design decisions could more clearly be explained to reviewers.