http://www.implementationscience.com The most accessed research articles published by Implementation Science 2012-05-11T00:00:00Z Background: A growing body of work on knowledge translation (KT) reveals significant gaps betweenwhat is known to improve health, and what is done to improve health. The literature andpractice also suggest that KT has the potential to narrow those gaps, leading to moreevidence-informed healthcare. In response, Canadian health research funders and agencieshave made KT a priority. This article describes how one funding agency determined its KTrole and in the process developed a model that other agencies could use when considering KTprograms.DiscussionWhile 'excellence' is an important criterion by which to evaluate and fund health research, italone does not ensure relevance to societal health priorities. There is increased demand forreturn on investments in health research in the form of societal and health system benefits.Canadian health research funding agencies are responding to these demands by emphasizingrelevance as a funding criterion and supporting researchers and research users to use theevidence generated.Based on recommendations from the literature, an environmental scan, broad circulation ofan iterative discussion paper, and an expert working group process, our agency developed aplan to maximize our role in KT. Key to the process was development of a model comprisingfive key functional areas that together create the conditions for effective KT: advancing KTscience; building KT capacity; managing KT projects; funding KT activities; and advocatingfor KT. Observations made during the planning process of relevance to the KT enterprise are:the importance of delineating KT and communications, and information and knowledge;determining responsibility for KT; supporting implementation and evaluation; and promotingthe message that both research and KT take time to realize results.SummaryChallenges exist in fulfilling expectations that research evidence results in beneficial impactsfor society. However, health agencies are well placed to help maximize the use of evidence inhealth practice and policy. We propose five key functional areas of KT for health agencies,and encourage partnerships and discussion to advance the field. http://www.implementationscience.com/content/7/1/39 Bev Holmes Gayle Scarrow Megan Schellenberg Implementation Science 2012, null:39 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-39 /content/figures/1748-5908-7-39-toc.gif Implementation Science 1748-5908 ${item.volume} 39 2012-04-24T00:00:00Z PDF Background: Realist synthesis is an increasingly popular approach to the review and synthesis of evidence,which focuses on understanding the mechanisms by which an intervention works (or not).There are few published examples of realist synthesis. This paper therefore fills a gap bydescribing, in detail, the process used for a realist review and synthesis to answer the question'what interventions and strategies are effective in enabling evidence-informed healthcare?'The strengths and challenges of conducting realist review are also considered. Methods: The realist approach involves identifying underlying causal mechanisms and exploring howthey work under what conditions. The stages of this review included: defining the scope ofthe review (concept mining and framework formulation); searching for and scrutinising theevidence; extracting and synthesising the evidence; and developing the narrative, includinghypotheses. Results: Based on key terms and concepts related to various interventions to promote evidenceinformedhealthcare, we developed an outcome-focused theoretical framework. Questionswere tailored for each of four theory/intervention areas within the theoretical framework andwere used to guide development of a review and data extraction process. The search forliterature within our first theory area, change agency, was executed and the screeningprocedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area,data were extracted by one reviewer and validated by a second reviewer. Synthesis involvedorganisation of extracted data into evidence tables, theming and formulation of chains ofinference, linking between the chains of inference, and hypothesis formulation. The narrativewas developed around the hypotheses generated within the change agency theory area. Conclusions: Realist synthesis lends itself to the review of complex interventions because it accounts forcontext as well as outcomes in the process of systematically and transparently synthesisingrelevant literature. While realist synthesis demands flexible thinking and the ability to dealwith complexity, the rewards include the potential for more pragmatic conclusions thanalternative approaches to systematic reviewing. A separate publication will report thefindings of the review. http://www.implementationscience.com/content/7/1/33 Jo Rycroft-Malone Brendan McCormack Alison Hutchinson Kara DeCorby Tracey Bucknall Bridie Kent Alyce Schultz Erna Snelgrove-Clarke Cheryl Stetler Marita Titler Lars Wallin Valerie Wilson Implementation Science 2012, null:33 2012-04-19T00:00:00Z doi:10.1186/1748-5908-7-33 /content/figures/1748-5908-7-33-toc.gif Implementation Science 1748-5908 ${item.volume} 33 2012-04-19T00:00:00Z PDF Background: Change management experts have emphasized the importance of establishing organizational readiness for change and recommended various strategies for creating it. Although the advice seems reasonable, the scientific basis for it is limited. Unlike individual readiness for change, organizational readiness for change has not been subject to extensive theoretical development or empirical study. In this article, I conceptually define organizational readiness for change and develop a theory of its determinants and outcomes. I focus on the organizational level of analysis because many promising approaches to improving healthcare delivery entail collective behavior change in the form of systems redesign--that is, multiple, simultaneous changes in staffing, work flow, decision making, communication, and reward systems.DiscussionOrganizational readiness for change is a multi-level, multi-faceted construct. As an organization-level construct, readiness for change refers to organizational members' shared resolve to implement a change (change commitment) and shared belief in their collective capability to do so (change efficacy). Organizational readiness for change varies as a function of how much organizational members value the change and how favorably they appraise three key determinants of implementation capability: task demands, resource availability, and situational factors. When organizational readiness for change is high, organizational members are more likely to initiate change, exert greater effort, exhibit greater persistence, and display more cooperative behavior. The result is more effective implementation.SummaryThe theory described in this article treats organizational readiness as a shared psychological state in which organizational members feel committed to implementing an organizational change and confident in their collective abilities to do so. This way of thinking about organizational readiness is best suited for examining organizational changes where collective behavior change is necessary in order to effectively implement the change and, in some instances, for the change to produce anticipated benefits. Testing the theory would require further measurement development and careful sampling decisions. The theory offers a means of reconciling the structural and psychological views of organizational readiness found in the literature. Further, the theory suggests the possibility that the strategies that change management experts recommend are equifinal. That is, there is no 'one best way' to increase organizational readiness for change. http://www.implementationscience.com/content/4/1/67 Bryan Weiner Implementation Science 2009, null:67 2009-10-19T00:00:00Z doi:10.1186/1748-5908-4-67 /content/figures/1748-5908-4-67-toc.gif Implementation Science 1748-5908 ${item.volume} 67 2009-10-19T00:00:00Z XML Background: Clinical practice guidelines are developed to improve the quality of healthcare. However,clinical guidelines may contribute to health inequities experienced by disadvantaged groups.This study uses an equity lens developed by the International Clinical Epidemiology Network(INCLEN) to examine how well clinical guidelines address inequities experienced byindividuals with intellectual disabilities. Methods: Nine health problems relevant to the health inequities experienced by persons withintellectual disabilities were selected. Clinical guidelines on these disorders were identifiedfrom across the world. The INCLEN equity lens was used as the basis for a purposedesigned,semistructured data collection tool. Two raters independently examined eachguideline and completed the data collection tool. The data extracted by each rater werediscussed at a research group consensus conference and agreement was reached on a finalequity lens rating for each guideline. Results: Thirty-six guidelines were identified, one of which (2.8%) explicitly excluded persons withintellectual disabilities. Of the remaining 35, six (17.1%) met the first criterion of the equitylens, identifying persons with intellectual disabilities at high risk for the specific healthproblem. Eight guidelines (22.9%) contained any content on intellectual disabilities. Sixguidelines addressed the fourth equity lens criterion, by giving specific consideration to thebarriers to implementation of the guideline in disadvantaged populations. There were noguidelines that addressed the second, third, and fifth equity lens criteria. Conclusions: The equity lens is a useful tool to systematically examine whether clinical guidelines addressthe health needs and inequities experienced by disadvantaged groups. Clinical guidelines arelikely to further widen the health inequities experienced by persons with intellectualdisabilities, and other disadvantaged groups, by being preferentially advantageous to thegeneral population. There is a need to systematically incorporate methods to considerdisadvantaged population groups into the processes used to develop clinical guidelines. http://www.implementationscience.com/content/7/1/42 Lindsay Mizen Marjorie Macfie Linda Findlay Sally-Ann Cooper Craig Melville Implementation Science 2012, null:42 2012-05-11T00:00:00Z doi:10.1186/1748-5908-7-42 /content/figures/1748-5908-7-42-toc.gif Implementation Science 1748-5908 ${item.volume} 42 2012-05-11T00:00:00Z PDF Background: An integrative theoretical framework, developed for cross-disciplinary implementation and other behaviour change research, has been applied across a wide range of clinical situations. This study tests the validity of this framework. Methods: Validity was investigated by behavioural experts sorting 112 unique theoretical constructs using closed and open sort tasks. The extent of replication was tested by Discriminant Content Validation and Fuzzy Cluster Analysis. Results: There was good support for a refinement of the framework comprising 14 domains of theoretical constructs (average silhouette value 0.29): 'Knowledge', 'Skills', 'Social/Professional Role and Identity', 'Beliefs about Capabilities', 'Optimism', 'Beliefs about Consequences', 'Reinforcement', 'Intentions', 'Goals', 'Memory, Attention and Decision Processes', 'Environmental Context and Resources', 'Social Influences', 'Emotions', and 'Behavioural Regulation'. Conclusions: The refined Theoretical Domains Framework has a strengthened empirical base and provides a method for theoretically assessing implementation problems, as well as professional and other health-related behaviours as a basis for intervention development. http://www.implementationscience.com/content/7/1/37 James Cane Denise O'Connor Susan Michie Implementation Science 2012, null:37 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-37 /content/figures/1748-5908-7-37-toc.gif Implementation Science 1748-5908 ${item.volume} 37 2012-04-24T00:00:00Z PDF Background: There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. Methods: The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? Results: A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. Conclusions: We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process. http://www.implementationscience.com/content/7/1/38 Simon French Sally Green Denise O'Connor Joanne McKenzie Jill Francis Susan Michie Rachelle Buchbinder Peter Schattner Neil Spike Jeremy Grimshaw Implementation Science 2012, null:38 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-38 /content/figures/1748-5908-7-38-toc.gif Implementation Science 1748-5908 ${item.volume} 38 2012-04-24T00:00:00Z PDF Background: Middle managers have received little attention in extant health services research, yet they may have a key role in healthcare innovation implementation. The gap between evidence of effective care and practice may be attributed in part to poor healthcare innovation implementation. Investigating middle managers' role in healthcare innovation implementation may reveal an opportunity for improvement. In this paper, we present a theory of middle managers' role in healthcare innovation implementation to fill the gap in the literature and to stimulate research that empirically examines middle managers' influence on innovation implementation in healthcare organizations.DiscussionExtant healthcare innovation implementation research has primarily focused on the roles of physicians and top managers. Largely overlooked is the role of middle managers. We suggest that middle managers influence healthcare innovation implementation by diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation.SummaryTeamwork designs have become popular in healthcare organizations. Because middle managers oversee these team initiatives, their potential to influence innovation implementation has grown. Future research should investigate middle managers' role in healthcare innovation implementation. Findings may aid top managers in leveraging middle managers' influence to improve the effectiveness of healthcare innovation implementation. http://www.implementationscience.com/content/7/1/28 Sarah Birken Shoou-Yih Daniel Lee Bryan Weiner Implementation Science 2012, null:28 2012-04-03T00:00:00Z doi:10.1186/1748-5908-7-28 /content/figures/1748-5908-7-28-toc.gif Implementation Science 1748-5908 ${item.volume} 28 2012-04-03T00:00:00Z PDF Background: The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified.DiscussionThis being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation.Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place.In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally.SummaryThe paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches.We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives. http://www.implementationscience.com/content/3/1/1 Alison Kitson Jo Rycroft-Malone Gill Harvey Brendan McCormack Kate Seers Angie Titchen Implementation Science 2008, null:1 2008-01-07T00:00:00Z doi:10.1186/1748-5908-3-1 /content/figures/1748-5908-3-1-toc.gif Implementation Science 1748-5908 ${item.volume} 1 2008-01-07T00:00:00Z XML Background: To address the problem of translation from research-based evidence to routine healthcare practice, the Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire, and Lincolnshire (CLAHRC-NDL) was funded by the National Institute for Health Research as one of nine CLAHRCs across England. This paper outlines the underlying theory and its application that CLAHRC-NDL has adopted, as a case example that might be generalised to practice outside the CLAHRC, in comparison to alternative models of implementation.DiscussionConventional approaches to health research frequently generate evidence in isolation from the environment in which it is intended for use. The premise of the CLAHRC-NDL model is that barriers to implementation can be overcome if knowledge is co-produced by academic and clinical service staff, taking account of the organisational context in which it is to be applied. This approach is founded on organisational learning theory, recognising that change is a social and political phenomenon. Evidence is produced in real time, taking full account of the environment in which it is to be implemented. To support this process, senior health service staff are seconded to the CLAHRC as 'diffusion fellows' (DFs) to actively bridge the research to practice gap by being a full member of both the research team and their area of clinical practice. To facilitate innovation and embed change in the local health community, existing communities of practice are enhanced and new ones are fostered around specific themes. Our approach has been adopted by 16 clinical research studies in the areas of mental health, children and young people, primary care, and stroke rehabilitation.SummaryThe CLAHRC-NDL model of implementation applies organisational learning theory by addressing the social and situational barriers and enablers to implementation, and adopting a philosophy of co-production. Two key mechanisms for translation of innovation have been utilised: DFs, to actively bridge the research to practice gap, and communities of practice, to underpin and sustain improvements in healthcare. The model shows promising results in putting research into practice, which may be transferable to other healthcare contexts. http://www.implementationscience.com/content/7/1/40 Emma Rowley Richard Morriss Graeme Currie Justine Schneider Implementation Science 2012, null:40 2012-05-03T00:00:00Z doi:10.1186/1748-5908-7-40 /content/figures/1748-5908-7-40-toc.gif Implementation Science 1748-5908 ${item.volume} 40 2012-05-03T00:00:00Z PDF Background: Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods: We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results: The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion: The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings. http://www.implementationscience.com/content/4/1/50 Laura Damschroder David Aron Rosalind Keith Susan Kirsh Jeff Alexander Julie Lowery Implementation Science 2009, null:50 2009-08-07T00:00:00Z doi:10.1186/1748-5908-4-50 /content/figures/1748-5908-4-50-toc.gif Implementation Science 1748-5908 ${item.volume} 50 2009-08-07T00:00:00Z XML