What PARIHS is about

1. What PARIHS is about

2. Introducing thePARIHS Group Brendan McCormack Jo Rycroft-Malone Alison Kitson Angie Titchen Kate Seers Gill Harvey

3. 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)

4. PromotingActiononResearch Implementation inHealthServices SI = f(E,C,F) SI = successful implementation E = evidence C = context F = facilitation

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

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

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

8. ‘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’).

9. High Evidence Facilitation Low Context High

10. The Nature of Evidence Information and knowledge upon which decisionsabout care are based: • Research • Clinical Experience • Patient Experience • Local Information/Data

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

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

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

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

15. Receptive context High Low 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

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

17. 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 Evaluation High Low

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

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

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

21. 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

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

23. 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?

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

25. 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, 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.