The PARiHS Framework (Promoting Action on Research Implementation in Health Services)

This journal club entry isn’t about a single article but a suite of articles spanning 1998-2011, all relating to the PARiHS framework (Promoting Action on Research Implementation in Health Services). There are three journal articles (two of them open access) and an accompanying additional file (also open access).

Kittson and colleagues developed the PARiHS framework (not a model or a theory…see below) to help understand the elements that contribute to successful implementation of evidence into practice in health care settings. The PARiHS framework is a function of the interplay of three core elements: 1) the level and nature of the evidence; 2) the context or environment into which the evidence is to be placed; and 3) the method or way in which the process is facilitated (Kitson et al, 1998).  As explained by Kitson et al (1998):
Evidence: research evidence may be presented as unsystematic, anecdotal, and descriptive (low evidence), or as a rigorous systematic (quantitative or qualitative) evaluation (high evidence). Similarly, professional consensus may be widely divided (low evidence) or high levels of consensus may exist (high evidence), and patients’ opinions may range from being completely overlooked (low evidence) to a process of systematic feedback and input into decision making (high evidence).
Context: Context implies an understanding of the forces at work which give the physical environment a character and a feel. Context has been subdivided into three core elements: an understanding of the prevailing culture, the nature of human relationships as summarized through leadership roles, and the organization’s approach to routine monitoring of systems and services-that is, measurement.
Facilitation: Facilitation is a technique by which one person makes things easier for others. The term describes the type of support required to help people change their attitudes, habits, skills, ways of thinking, and working.
Before PARiHS, evidence was considered most important element with some attention paid to context and little to facilitation. PARiHS looks at all three and considers situations where each may be on a scale of low to high. The most effective implementation of evidence to practice is where high (i.e. strong) evidence is applied in a high (i.e. supportive) context using high (i.e. effective) facilitation.
In 2008 Kitson released refinements to PARiHS and in 2011 Stetler et al published a revised framework and detailed guides for additional consideration of evidence, context and facilitation (all these are referenced above). Stetler’s 2011 revision is a reflection of a systematic review of the literature citing PARiHS published in 2010 [Helfrich et al, Implementation Science 2010, 5(1):82]. This 2010 paper reviewed 24 articles that met their inclusion criteria.  There were an additional eight commentaries and a doctoral thesis written about PARiHS.  But here’s the thing for brokers: it’s only a framework. It’s a framework for heling you to think about the factors that might (stress *might*) influence the success of implementation of evidence into practice. According to Stetler (2011), “No published studies were identified that used the framework comprehensively and prospectively to develop an implementation project. The ability to fully evaluate its usefulness thus has been limited.” I checked in with the KTE Community of Practice on this and members of the steering committee agreed.

  • People have not used it to design an intervention (use the model to decide which sites should trial the implementation) but rather a way to understand and compare how and perhaps why implementation interventions have varying degrees of success.
  • None of these models describe HOW to do anything, and that’s what people want – especially in practice.
  • The model informed research, but I don’t know to what extent we can say we are ‘using it’ in practice
  • The major contribution it has made is that there is a focus on the intensity of the facilitation. People, organizations and workplaces change reluctantly. It is only with leadership buy-in, management commitment, and often the input of a knowledge broker, will you have change in practice and policy.

Since 1998 there have been at least 33 papers written about PARiHS, a doctoral thesis, a systematic review and it has been twice revised to improve its utility but it has yet to be evaluated in practice. Much of our brokering practice is supporting the co-production of knowledge between researchers and decision makers and thus has nothing to do with implementing “evidence”. We also work in policy as well as practice settings and in settings other than health; therefore, we can only take away generalities and not specifics from this body of work [specifics like the 2.5 pages of discussion of the subtleties of frameworks, models and theories (Kittson, 2008)…2.5 pages]. All of this might be ok as a thought piece to inform research but what are we to take away from this for brokering practice? As brokers we act as facilitators, not of evidence but of relationships; therefore, the descriptions of facilitation (which are much more robust in 2011 than in 1998) are potentially of use.
Key Points for brokers:

  1. The general concepts of paying attention to evidence, context and facilitation are good and can be used when supporting collaborations arising from brokering practice. As one of your brokered collaborations grows recommend that the collaborators discuss the PARiHS framework as they begin to co-produce their own evidence and move that evidence into policy or practice. Recommend that they pay attention to evidence, context and facilitation including reviewing the sub-elements of each in Figure 1 in Stetler et al, 2011.
  2. Reflect on the roles of brokers as outlined in the additional file to Stetler, 2011. Reflect on your brokering team. Do they or should they play the following roles?
    1. Regular, goal-focused contact and communications
    2. Technical/practice assistance
    3. Interactive, contingent problem-solving
    4. Use of formative data
    5. Enabling, through establishing and maintaining a supportive relationship
    6. Doing for others
  3. As we pursue our brokering practices consider developing and/or hiring for attributes identified as useful for facilitators in the additional file to Stetler, 2011. These include:
    1. Authenticity, realness and openness
    2. Respect and general credibility, e.g. seen to understand the evidence and change processes
    3. Accessibility, approachability, and empathy, e.g., open to being contacted, friendly and outgoing, and can establish good rapport Flexibility, e.g., ability to think laterally and non-judgmentally
    4. Responsiveness and reliability, e.g., having answers to questions or can easily find.
    5. Self confidence
  4. As we pursue our brokering practices consider developing and/or hiring for skills identified as useful for facilitators in the additional file to Stetler, 2011. These include:
    1. Communication skills, including listening, teaching, negotiating, networking and persuasion/marketing skills
    2. Implementation science expertise, including competency related to use of applicable individual and organizational change interventions
    3. Organizing skills
    4. Marketing skills
    5. Subject/technical skills
    6. Problem-solving skills

RIR is producing this journal club series as a way to make the evidence and research on KMb more accessible to knowledge brokers and to create on line discussion about research on knowledge mobilization. It is designed for knowledge brokers and other knowledge mobilization stakeholders. Read the articles. Then come back to this post and join the journal club by posting your comments.