The Role of Evidence, Context, and Facilitation in an Implementation Trial: Implications for the Development of the PARIHS Framework

Roycroft-Malone, J., Seers, K., Chandler, J., Crichton, N., Allen, C. & Strunin, L. (2013). The role of evidence, context, and facilitation in an implementation trial: Implications for the development of the PARIHS framework. Implementation Science, 8(28), 1-13. doi:10.1186/1748-5908-8-28
Background: The case has been made for more and better theory-informed process evaluations within trials in an effort to facilitate insightful understandings of how interventions work. In this paper, we provide an explanation of implementation processes from one of the first national implementation research randomized controlled trials with embedded process evaluation conducted within acute care, and a proposed extension to the Promoting Action on Research Implementation in Health Services (PARIHS) framework.
Methods: The PARIHS framework was prospectively applied to guide decisions about intervention design, data collection, and analysis processes in a trial focussed on reducing peri-operative fasting times. In order to capture a holistic picture of implementation processes, the same data were collected across 19 participating hospitals irrespective of allocation to intervention. This paper reports on findings from data collected from a purposive sample of 151 staff and patients pre- and post-intervention. Data were analysed using content analysis within, and then across data sets.
Results: A robust and uncontested evidence base was a necessary, but not sufficient condition for practice change, in that individual staff and patient responses such as caution influenced decision making. The implementation context was challenging, in which individuals and teams were bounded by professional issues, communication challenges, power and a lack of clarity for the authority and responsibility for practice change. Progress was made in sites where processes were aligned with existing initiatives. Additionally, facilitators reported engaging in many intervention implementation activities, some of which result in practice changes, but not significant improvements to outcomes.
Conclusions: This study provided an opportunity for reflection on the comprehensiveness of the PARIHS framework. Consistent with the underlying tenant of PARIHS, a multi-faceted and dynamic story of implementation was evident. However, the prominent role that individuals played as part of the interaction between evidence and context is not currently explicit within the framework. We propose that successful implementation of evidence into practice is a planned facilitated process involving an interplay between individuals, evidence, and context to promote evidence-informed practice. This proposal will enhance the potential of the PARIHS framework for explanation, and ensure theoretical development both informs and responds to the evidence base for implementation.
This paper is important as it uses the PARIHS framework to prospectively evaluate the implementation of a new peri-operative feeding/watering protocol: how long before surgery does a patient need to stop eating and drinking? This is important because despite all the attention PARIHS has received it has never been tested in practice. Using PARIHS as a framework to evaluate implementation of a new peri-operative protocol also tests the usefulness of the PARIHS framework in practice. For more on the The PARIHS (Promoting Action on Research Implementation in Health Services) framework please see an earlier journal club post. The PARIHS framework goes into excruciating detail about three factors hypothesized to be critical to implementation science: evidence, context and facilitation. The current paper critically assesses the utility of PARIHS to evaluate the implementation of a new peri-operative protocol.
The paper opens with a definition of implementation science: « the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practice into routine practice, and hence improve the quality…of healthcare« .  This complements and simplifies an earlier definition of implementation science. Important here is the uptake into routine practice…this is not simple end user uptake, this is implementing into a system of health care.
One conclusion of the paper is that « A robust and uncontested evidence base was a necessary but not sufficient condition for practice change« . To put it another way, translating and packaging evidence in easily transferable formats is necessary but not sufficient for effective knowledge mobilization. Regular readers of this journal club (see especially the post about co-production in social work) and Mobilize This! will know about the evidence that co-production is the most robust knowledge mobilization practice. This paper clearly shows that even when the evidence is uncontested it needs to be placed in context and purposefully facilitated in that context in order to inform practice change.
The authors confirmed that the evidence was robust, uncontested and broadly accepted. They then moved to looking at context and facilitation in depth.
Context was examined at the individual (micro), team/department (meso) and hospital (macro) levels. Issues related to ownership, decision making authority, communication, commitment and buy in were identified. Interestingly and importantly different trial sites were at different starting points and therefore had different ability to engage with the evidence regardless of facilitation.  « In summary, the implementation context was challenging, proving resistant to the implementation interventions in this study. » Institutional and individual inertia in the local contexts seem to create barriers to implementation.
Sobering for facilitators (i.e. knowledge brokers) is that many different methods of facilitation were tried including « amendment of information; dissemination of information; awareness raising; individual review of patient fast; educational meetings; policy development; promotion of guidance; teaching/training (formal and informal); and using role models of good practice…In summary, many activities were recorded for those in facilitator roles, but their relative and direct impact on policy and practice changes were difficult to judge« .
The authors then examined the role of individuals in the implementation settings. They point out that « the main interactions in this study were between individuals and teams and context. Currently individuals are not explicitly part of the PARIHS framework but are embedded implicitly within evidence (individuals interact with evidence), context (individuals are part of context), and facilitation (facilitators work with individuals and teams). » They recommend that individuals are a missing element in PARIHS and further define « the successful implementation of evidence into practice is a planned facilitated process involving an interplay between individuals, evidence, and context to promote evidence informed practice. »
Bottom line: include consideration of the roles of individuals along with evidence, context and facilitation when trying to implement evidence into practice and policy. As we know, knowledge mobilization is a social process and it is individuals who socialize.
Questions for brokers:

  1. If packaged evidence is necessary but not sufficient to effect change why are you relying on less effective knowledge translation and transfer techniques to move evidence towards implementation? Or are you using co-production to support your knowledge mobilization?
  2. Implementation science and PARIHS are mostly associated with health care. Outside of health care do you think that evidence, facilitation, context and individuals are also the key elements for implementation in education or agriculture? How effectively might PARIHS translate into different disciplines?
  3. How are you supporting individuals in your knowledge mobilization practice? What does capacity building for knowledge mobilization look like?

ResearchImpact-RéseauImpactRecherche (RIR) is producing this journal club series as a way to make evidence 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 this open access article. Then come back to this post and join the journal club by posting your comments.