What PARIHS is What PARIHS is aboutabout

Introducing theIntroducing thePARIHS GroupPARIHS Group

Alison Kitson

Brendan McCormack

Kate Seers

Angie Titchen

Jo Rycroft-Malone

Gill Harvey

Despite growing acknowledgement within theresearch community that the implementation ofresearch 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)

PPromotingromoting AActionction onon RResearch esearch IImplementation inmplementation in HHealthealth SServiceservices

SI = f(E,C,F)

SI = successful implementationE = evidenceC = contextF = 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 projectsResearch projects– Quality Improvement initiativesQuality Improvement initiatives– Practice Development programmePractice Development programme

Theoretical - concept developmentTheoretical - concept development Empirical inquiry - content validityEmpirical inquiry - content validity Developing & testing interventionsDeveloping & testing interventions Tool and ‘toolkit’ developmentTool and ‘toolkit’ development

Checking out the framework

Numerous conference presentationsNumerous conference presentations

Workshop/Group exercisesWorkshop/Group exercises 1998 publication in Quality in Health Care1998 publication in Quality in Health Care Establishing a level of face validityEstablishing a level of face validity Concept analysis of Concept analysis of evidence, context evidence, context and and facilitation facilitation

– published in Journal of Advanced Nursing– published in Journal of Advanced Nursing 2002 publication in Quality in Health Care2002 publication in Quality in Health Care Focus groupsFocus groups Case study Case study 2004 publication in Journal of Clinical Nursing2004 publication in Journal of Clinical Nursing 2008 publication in Implementation Science 2008 publication in Implementation Science

‘‘Hypothesis’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’).

ContextLow High

High

Evidence

Facilitatio

n

The Nature of The Nature of EvidenceEvidence

Information and knowledge upon which Information and knowledge upon which

decisionsdecisions about care are based:about care are based:

1. Research2. Clinical Experience3. Patient Experience4. 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 experienceLow 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 experienceLow 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/dataLow 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 fromresearch

Evidence frompatients’ experience

Evidence fromclinical experience

Evidence from other sourcesof robust information

Outcomeperson-centred,evidence-informedcare

Rycroft-Malone et al 2004

Context of Context of ImplementationImplementation

The environment or setting in which The environment or setting in which the proposed changes is to be the proposed changes is to be implemented: implemented:

CultureCulture LeadershipLeadership EvaluationEvaluation

Receptive contextReceptive context

Low High

CulturalPhysicalSocialCulturalSystemProfessional/social networks

Boundariesclearly defined &acknowledged

Appropriate & transparent decision-making processesResources – human, financial, equipment – allocatedIntegrates & fits with organisation’s strategic goals

Receptive context

CultureLow 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

LeadershipLow 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

EvaluationLow High

•Evaluation methods and sources ofinformation 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

FacilitationFacilitation

The process of enabling or making things easier

Appropriate Purpose Role Skills

Low HighNo mechanisms or inappropriate approach and/or methods offacilitation in place

Appropriate mechanisms of facilitation in place

Purpose, Role, Skills

Task Holistic

Purpose

RoleDoing 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 & AttributesDoing for others

•Project management skills•Technical skills•Marketing skills•Subject/technical/clinicalcredibility

•Co-counselling•Critical reflection•Giving meaning•Flexibility of role•Realness/authenticity

Enabling others

Working hypothesesWorking hypotheses

Most successful implementation will occur Most successful implementation will occur when evidence is ‘high’, practitioners agree when evidence is ‘high’, practitioners agree about it, the context is developed, and where about it, the context is developed, and where there is appropriate facilitationthere is appropriate facilitation

Least successful implementation occurs Least successful implementation occurs when context and facilitation are inadequatewhen context and facilitation are inadequate

Poor contexts can be overcome by Poor contexts can be overcome by appropriate facilitationappropriate facilitation

Chances of successful implementation are Chances of successful implementation are still weak, even in an adequate context, but still weak, even in an adequate context, but where there’s inappropriate facilitationwhere there’s inappropriate facilitation

How is/has it been How is/has it been used?used?

As a conceptual frameworkAs a conceptual framework As an evaluative frameworkAs an evaluative framework As a mapAs a map As a set of hypothesesAs a set of hypotheses

See the world map for examples!See the world map for examples!

Questions/challengesQuestions/challenges

Is it greater than the sum of its Is it greater than the sum of its parts?parts?

How do the elements interact?How do the elements interact? What factors are more important – What factors are more important –

weighting?weighting? Dynamics of high to low – do they Dynamics of high to low – do they

work? Is it comprehensive (enough)?work? Is it comprehensive (enough)? How does the individual fit into the How does the individual fit into the

framework?framework?

Next stepsNext steps

PARIHS collaboration PARIHS collaboration Tool developmentTool development

– Measuring/evaluating evidence, Measuring/evaluating evidence, context, facilitationcontext, facilitation

Intervention researchIntervention research– e.g. FIRE – EU grante.g. FIRE – EU grant

Capability building through Capability building through education & training opportunitieseducation & training opportunities

PublicationsPublications

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, 913-924

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): 81-90.

Rycroft-Malone J. (2004) The PARIHS framework – A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19(4), 297-304.

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): 577-588.

 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): 94-104.

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): 174-180.

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): 38-43.

Kitson A, Harvey G, McCormack B (1998) Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care, 7,3: 149-158.