What PARIHS is about

Introducing the PARIHS Group Alison Kitson Brendan McCormack Kate Seers Angie Titchen Jo Rycroft-Malone Gill Harvey

Despite growing acknowledgement within the research community that the implementation of research into practice is a complex and messy task, conceptual models describing the process still tend to be uni-dimensional, suggesting some linearity and logic. (Kitson, Harvey & McCormack, 1998)

Promoting Action on Research Implementation in Health Services SI=f(E,C,F) SI=successful implementation E=evidence C=context F=facilitation

-the nature of the evidence -the context or environment in which the proposed change is to be implemented and -the way or method by which the change is facilitated Successful implementation is a function of the relation between:

Framework Development Practical experience from: Practical experience from: –Research projects –Quality Improvement initiatives –Practice Development programme Theoretical - concept development Theoretical - concept development Empirical inquiry - content validity Empirical inquiry - content validity Developing & testing interventions Developing & testing interventions Tool and ‘toolkit’ development Tool and ‘toolkit’ development

Checking out the framework Numerous conference presentations Numerous conference presentations Workshop/Group exercises Workshop/Group exercises 1998 publication in Quality in Health Care 1998 publication in Quality in Health Care Establishing a level of face validity Establishing a level of face validity Concept analysis of evidence, context and facilitation – published in Journal of Advanced Nursing Concept analysis of evidence, context and facilitation – published in Journal of Advanced Nursing 2002 publication in Quality in Health Care 2002 publication in Quality in Health Care Focus groups Focus groups Case study Case study 2004 publication in Journal of Clinical Nursing 2004 publication in Journal of Clinical Nursing 2008 publication in Implementation Science 2008 publication in Implementation Science

‘Hypothesis’ The successful implementation of evidence into practice is more likely to occur in situations where the research evidence is strong (‘high’), there is consensus about it and it matches patients’ preferences, the context is conducive to change/the new practice (‘high’), and appropriate approaches and mechanisms of facilitation are in place (‘high’).

Context LowHigh Evidence Facilitation

The Nature of Evidence Information and knowledge upon which decisions about care are based: Research Clinical Experience Patient Experience Local Information/Data

1. Research evidence Low High Well conceived & robust research One part of the decision Social construction acknowledged Lack of certainty acknowledged Importance weighted Conclusions drawn Poorly conceived & conducted research Social construction not acknowledged Lack of certainty not acknowledged Importance not weighted Conclusions not drawn 2. Clinical experience Low High Not reflected on or tested Lack of consensus Not viewed as part of the decision Importance not weighted Conclusions not drawn Reflected on, tested by individuals and groups Consensus between similar groups Seen as one part of the decision Importance weighted Conclusions drawn

3. Patient experience Low High Not valued as evidence Multiple biographies not used Lack of partnership working Importance not weighted Conclusions not drawn Valued as evidence Multiple biographies used Partnerships with hc professionals Importance weighted Conclusions drawn 4. Local information/data Low High Not valued as evidence Not systematically or rigorously collected & analysed Not evaluated & reflected upon Importance not weighted Conclusions not drawn Valued as evidence Collected & analysed systematically & rigorously Evaluated & reflected upon Importance weighted Conclusions drawn

Evidence-informed practice is…. Context Shared decision-making Context Evidence from research Evidence from patients’ experience Evidence from clinical experience Evidence from other sources of robust information Outcome person-centred, evidence- informed care Rycroft-Malone et al 2004

Context of Implementation The environment or setting in which the proposed changes is to be implemented: Culture Leadership Evaluation

Receptive context Low High Cultural Physical Social Cultural System Professional/social networks Boundaries clearly defined & acknowledged Appropriate & transparent decision-making processes Resources – human, financial, equipment – allocated Integrates & fits with organisation’s strategic goals Receptive context

Culture Low High Not valued as evidence Not systematically or rigorously collected & analysed Not evaluated & reflected upon Importance not weighted Conclusions not drawn Valued as evidence Collected & analysed systematically & rigorously Evaluated & reflected upon Importance weighted Conclusions drawn Leadership Low High Command & control Lack of role clarity Ineffective team work Ineffective organisational structures Hierarchical, autocratic decision- making processes Transformational leadership Role clarity Effective team work Effective organisational structures Democratic, inclusive decision- making processes

Evaluation Low High Evaluation methods and sources of information limited No/limited feedback on performance Feedback on individual, team, system performance Use of multiple sources of info- mation for evaluation Use of multiple methods: clinical, performance, economic, experience

Facilitation The process of enabling or making things easier Appropriate Purpose Role Skills

Low High No mechanisms or inappropriate approach and/or methods of facilitation in place Appropriate mechanisms of facilitation in place Purpose, Role, Skills

TaskHolistic Purpose Role Doing for others Episodic contact Practical/technical help Didactic, traditional approach to teaching External agents Low intensity - extensive coverage Sustained partnership Developmental Adult learning approach to teaching Internal/external agents High intensity - limited coverage Enabling others Skills & Attributes Doing for others Project management skills Technical skills Marketing skills Subject/technical/clinical credibility Co-counselling Critical reflection Giving meaning Flexibility of role Realness/authenticity Enabling others

Working hypotheses Most successful implementation will occur when evidence is ‘high’, practitioners agree about it, the context is developed, and where there is appropriate facilitation Least successful implementation occurs when context and facilitation are inadequate Poor contexts can be overcome by appropriate facilitation Chances of successful implementation are still weak, even in an adequate context, but where there’s inappropriate facilitation

How is/has it been used? As a conceptual framework As a conceptual framework As an evaluative framework As an evaluative framework As a map As a map As a set of hypotheses As a set of hypotheses See the world map for examples!

Questions/challenges Is it greater than the sum of its parts? How do the elements interact? What factors are more important – weighting? Dynamics of high to low – do they work? Is it comprehensive (enough)? How does the individual fit into the framework?

Next steps PARIHS collaboration Tool development –M–M–M–Measuring/evaluating evidence, context, facilitation Intervention research –e–e–e–e.g. FIRE – EU grant Capability building through education & training opportunities

Publications Kitson A, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A (2008) Evaluating the successful implementation of evidence into practice using the PARIHS framework: Theoretical and practical challenges, Implementation Science, 3(1), 7th January 2008 Rycroft-Malone J, Harvey G, Seers K, Kitson A. McCormack B, & Titchen A. (2004) An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13, Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B (2004) What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47(1): Rycroft-Malone J. (2004) The PARIHS framework – A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19(4), Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B, Seers K (2002) Getting evidence into practice: the role and function of facilitation. Journal of Advanced Nursing, 37(6): McCormack B, Kitson A, Harvey G, Rycroft-Malone J, Titchen A, Seers K (2002) Getting evidence into practice: the meaning of context. Journal of Advanced Nursing, 38(1): Rycroft-Malone J, Kitson A, Harvey G, McCormack B, Seers K, Titchen A, Estabrooks C (2002) Ingredients for change: revisiting a conceptual framework. Quality in Healthcare, 11(2): Rycroft-Malone J, Harvey G, Kitson A, McCormack B, Seers K, Titchen A (2002) Getting evidence into practice: ingredients for change. Nursing Standard, 16(37): Kitson A, Harvey G, McCormack B (1998) Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care, 7,3: