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.