Promoting Action On Research Implementation In Health Services Framework Research Articles

A prospective assessment of readiness to implement an early detection of cerebral palsy pathway in a neonatal intensive care setting using the PARIHS framework

BackgroundEarly detection of cerebral palsy (CP) is possible through targeted use of assessment tools. Changes in practice are needed to facilitate this shift towards earlier diagnosis of CP in New Zealand. The aim of this study was to prospectively evaluate readiness to implement an early detection of CP pathway within a level 3 neonatal intensive care unit (NICU) setting prior to any implementation taking place. The PARIHS (Promoting Action on Research Implementation in Health Services) framework was engaged to assess readiness by highlighting determinants that influence implementation outcomes as either barriers or enablers.MethodsA mixed methods approach was used. Firstly, an online staff survey assessed PARIHS sub-elements using Likert scores and free text with the intent to develop a baseline understanding of staff views. Secondly, focus groups were conducted to gain deeper understanding of barriers and enablers to implementation. Participants included health professionals involved in the first 6 months of life. Data were analysed to outline the barriers and enablers of implementation under the Evidence and Context constructs of the PARIHS framework.ResultsTwenty-seven participants completed the survey, and 20 participants participated in eight focus groups and two individual interviews. Quantitative (survey) findings found 65% agreement around the usefulness of research evidence on early CP detection; however, ≤ 45% felt current resources (i.e. human, financial and IT) were sufficient for implementation. Qualitative findings (survey and focus groups) highlighted key staff concerns around resources, family impact (creating unnecessary stress), and equity (barriers to participation). Staff wanted information regarding how international evidence translates to the local context and availability of timely follow-up services. Sub-elements within the Evidence and Context constructs were rated as either mixed or low (except for Evidence - Research, rated as high), overall indicating that Auckland NICU is at the early stages of readiness to implement the early CP detection pathway.ConclusionThis work may resonate with other neonatal services preparing to implement CP early detection pathways. Resourcing has a major role in facilitating implementation of pathways and uncertainty about resources is a barrier to implementation. Ongoing focus on building consensus and funding is required to ensure optimal uptake.

Measuring and Evaluating Clinical Context in Implementation Science Research.

Measuring and Evaluating Clinical Context in Implementation Science Research.

Evaluating factors that influenced the successful implementation of an evidence-based neonatal care intervention in Chinese hospitals using the PARIHS framework

BackgroundEvidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting.MethodWe conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants.ResultsUsing KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level.ConclusionBased on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting.

Knowledge implementation in health care management: a qualitative study

BackgroundThe gap between knowledge and practice is a global issue, which increases wasteful spending in healthcare. There are several models and frameworks to address this gap and try to solve the challenge. Promoting Action on Research Implementation in Health Services (PARIHS) framework highlights the interaction of three main elements: evidence, context and facilitation, to implement research into practice, successfully. This framework can use as a tool to evaluate the situation and guide the changing. This study conducted to explain the status of knowledge implementation in Iran’s healthcare management system.MethodsThis qualitative study was done by using a directive content analysis approach through conducting in-depth, structured interviews with 15 health managers based on the PARIHS framework. Guiding questions were based on the three main elements of the framework: evidence, context and facilitation. The content of the interviews entered into the Qualitative Data Analysis software (MAXQDA version 10) and, then, analyzed.ResultsThe most common source of evidence used by managers for decision-making was local information and previous experience. Evaluation more emphasized compared to other sub-elements of context, i.e. culture and leadership. In terms of facilitation, performing tasks by others was the dominant opinion.ConclusionOur results showed that managers in the healthcare system of Iran use their own and other manager’s experience and the local information for decision-making and have no ideas about facilitation.

Implementation and development of guidelines in the emergency services in Kosovo – PARIHS framework

Abstract Background The aim of this project is to create understanding on the determinant factors enhancing adherence to treatment guidelines for the emergency medical services in Kosovo (EMSK). Focus is on barriers, and enablers while introducing the guidelines. It is aiming to create clearance and understanding of how and why the implementation outcomes are achieved. The factors influencing implementation will be mapped in three main domains. The domains are part of the determinant framework Promoting Action on Research Implementation in Health Services (PARIHS). Each of the domains is further divided into sub-constructs. Methods The process of implementing treatment guidelines into the emergency medical services in Kosovo was observed and documented by 4 researchers, using a participatory research design. The PARIHS framework that consists of three core components: evidence, context, and facilitation was applied to make clarity on what works better and why, in order to achieve the outcomes of the implemented guidelines. Results The preliminary results have shown that the three constructs have an important role in the process of implementation. The domain evidence determined the way the evidence based practice is conceived in this particular setting. The domain context concerns the organization and teamwork shaped challenges and possibilities for adherence to the guidelines. The role of an external facilitator was of specific importance. Conclusions The PARIHS framework serves in both practical and theoretical planning of an intervention. In the present project it provides clarity on planning of the process, while also offer understanding of the elements that contribute to the sustainability of the intervention. Finally the lessons from the approach can be replicated in similar context. Key messages Implementation projects can be more successful suing a framework to direct the effort. Such interventions should be premised with clarity on the evidence, the local context, and facilitation factors.

Danish Translation and Adaptation of the Context Assessment Index With Implications for Evidence-Based Practice.

Healthcare contexts are rapidly changing, with growing demand for health services to accommodate an aging population and financial pressures. Assessment of context in healthcare settings has been the subject of increasing debate. The Context Assessment Index (CAI) examines three interconnected contextual elements derived from the Promoting Action on Research Implementation in Health Services (PARIHS) framework to provide practitioners with an understanding of the context in which they work. (a) To describe the translation of the CAI into Danish and adapt the instrument for use in Danish hospitals and (b) to evaluate the psychometric properties of the Danish version of the CAI. Translation and adaptation included an expert panel and a translation and back-translation process. The CAI was then sent to 4,416 nurses in the Region Zealand, Denmark. There are two alternative measurement models to explain the factor structure of the CAI, the five-factor model and the three-factor model. To provide the best explanation for the data, both measurement models were examined using confirmatory factor analysis. The CAI was translated and modified based on expert review and usability testing. Completing the CAI were 2,261 nurses. For both models, factor loadings and fit statistics were acceptable, appropriate, and statistically significant, and the measurement models were confirmed (five-factor model: root mean square error of approximation [RMSEA] 0.07, comparative fit index [CFI]=0.923; three-factor model: RMSEA 0.07, CFI=0.924). Cronbach's alpha scores showed the models to have broadly acceptable scores (five-factor model 0.64-0.89; three-factor model 0.72-0.89). The three-factor model can advantageously be used when the PARIHS framework is part of the project. In a translation process, differences in cultural specificity, language, and working environment have to be considered. By understanding the context of practice, nurses may enable person-centered care and improve patient outcomes.

Facilitating change from a distance - a story of success? A discussion on leaders' styles in facilitating change in four nursing homes in Norway.

To examine the influence of leadership when facilitating change in nursing homes. The study is a part of an education intervention for care staff to prevent the use of restraint in nursing home residents with dementia in 24 nursing homes (NHs) in Norway. Leadership is known to be a fundamental factor for success of evidence-based practice (EBP) implementation in health services. However, the type of leadership that strengthens the processes of change remains to be clarified. A multi-site comparative ethnography was performed in four nursing homes to investigate how contextual factors influenced the implementation. The analysis was informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and in particular the sub-element of leadership. Different leadership styles to facilitate change were identified. Paradoxically, a strong collective and collaborative leadership style was found to hamper change in one particular home, whereas a remote leadership style combined with almost no cooperation with staff proved successful in another setting. The study indicates that leadership cannot be understood on a low-high continuum as suggested by the PARIHS framework, but rather as a factor characterised by diversity. Our study indicates, as a minimum, that a leader's presence is necessary to facilitate the internal processes in order more successfully to implement EBP.

To Assess Prerequisites Before an Implementation Strategy in an Orthopaedic Department in Sweden.

Promoting Action on Research Implementation in Health Services (PARiHS) asserts that the success of knowledge implementation relates to multiple factors in a complex and dynamic way, and therefore the effects of implementation strategies vary by method and context. An instrument based on the PARiHS framework was developed to help assess critical factors influencing implementation strategies so that strategies can be tailored to promote implementation.The purpose of this study was to use the Evaluation Before Implementation Questionnaire (EBIQ), to describe staff perceptions in one orthopaedic department, and to investigate differences between wards.Staff members in four different wards at one orthopaedic department at a university hospital in Sweden were invited to complete a questionnaire related to planning for the implementation of a clinical practice guideline. The 23 items in the EBIQ were expected to capture staff perceptions about the evidence, context, and facilitation factors that influence the implementation process. Descriptive statistics and differences between wards were analyzed. Although the overall response rate was low (n = 49), two of the four wards accounted for most of the completed questionnaires (n = 25 and n = 12, respectively), enabling a comparison of these wards. We found significant differences between respondents' perceptions at the two wards in six items regarding context and facilitation in terms of receptiveness to change, forms of leadership, and evaluation and presence of feedback and facilitators.The EBIQ instrument requires further testing, but there appears to be initial support for pre-implementation use of the EBIQ as a means to enhance planning for implementation.

A cluster-randomized controlled knowledge translation feasibility study in Alberta community pharmacies using the PARiHS framework: study protocol.

BackgroundDespite evidence of benefit for pharmacist involvement in chronic disease management, the provision of these services in community pharmacy has been suboptimal. The Promoting Action on Research Implementation in Health Services (PARiHS) framework suggests that for knowledge translation to be effective, there must be evidence of benefit, a context conducive to implementation, and facilitation to support uptake. We hypothesize that while the evidence and context components of this framework are satisfied, that uptake into practice has been insufficient because of a lack of facilitation. This protocol describes the rationale and methods of a feasibility study to test a facilitated pharmacy practice intervention based on the PARiHS framework, to assist community pharmacists in increasing the number of formal and documented medication management services completed for patients with diabetes, dyslipidemia, and hypertension.MethodsA cluster-randomized before-after design will compare ten pharmacies from within a single organization, with the unit of randomization being the pharmacy. Pharmacies will be randomized to facilitated intervention based on the PARiHS framework or usual practice. The Alberta Context Tool will be used to establish the context of practice in each pharmacy. Pharmacies randomized to the intervention will receive task-focused facilitation from an external facilitator, with the goal of developing alternative team processes to allow the greater provision of medication management services for patients with diabetes, hypertension, and dyslipidemia. The primary outcome will be a process evaluation of the needs of community pharmacies to provide more clinical services, the acceptability and uptake of modifications made, and the willingness of pharmacies to participate. Secondary outcomes will include the change in the number of formal and documented medication management services in the aforementioned chronic conditions provided 6 months before, versus after, the intervention between the two groups, and identification of feasible quantitative outcomes for evaluating the effect of the intervention on patient care outcomes.ResultsTo date, the study has identified and enrolled the ten pharmacies required and initiated the intervention process.ConclusionThis study will be the first to examine the role of facilitation in pharmacy practice, with the goal of scalable and sustainable practice change.Trial registrationClinicaltrials.gov identifier NCT02191111.

What is the Evidence and Context for Implementing Family-Centered Care for Older Adults?

ABSTRACTAims: This project used the Promoting Action on Research Implementation in Health Services (PARIHS) knowledge translation framework to better understand the evidence and context for implementing family-centered care for older adults in rural home-based rehabilitative practices. Methods: A case-study design with multiple data collection methods was used to examine rural home-based rehabilitative care for older adults and their caregivers within one provincial healthcare system. Results: The study findings indicated therapists questioned whether their scope of practice should include addressing caregiver needs outside of implementing the therapist's care plan for the client. Therapists also confirmed that multiple contextual levels influence the provision of family-centered care. Conclusions: The PARIHS framework made it easier for the academic and non-academic partners to collaborate; furthermore, the framework identified that the practitioner's clinical experience is an essential component to evaluating and implementing evidence into practice.

Expanding the PARiHS framework: thinking more broadly about context and facilitation

Background The movement of innovations (i.e., new knowledge and tools) into healthcare settings is a significant challenge. The Promoting Action on Research Implementation in Health Services (PARiHS) framework proposes that the successful implementation of research into practice is a function of the interaction between three elements: 1) evidence; 2) context; and 3) facilitation. The objective of this paper is to present data from a study of innovation implementation in Nova Scotia, Canada, which extends and refines our understanding of PARiHS.

Implementation of Evidence-Based Practice for a Pediatric Pain Assessment Instrument

The purpose of this project was to facilitate the successful implementation of an evidence-based practice (EBP) change to the Faces Pain Scale-Revised (FPS-R) using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Accurate pain assessment is a high priority in the clinical setting. Despite the availability of valid pain assessment instruments, use in practice remains deficient. Compared with the Wong-Baker FACES Pain Scale, the FPS-R has stronger evidence for validity and reliability and is identified as a preferred instrument to measure children's pain. The PARIHS framework, developed to guide the change process of EBP implementation through strong evidence, quality of context, and type of facilitation, was used in the development and implementation of the project. The clinical nurse specialist implemented an education program about EBP and FPS-R for nurses, followed by a 2-week pilot using FPS-R to assess children's pain. We measured perceptions of strength of evidence, quality of context, and barriers to research utilization. Nurses reported positive perceptions about the strength of evidence for FPS-R and identified unit context as moderately receptive to change before the project. Nurses' perceived barriers to research utilization did not significantly change after the project. Nurses' positive perceptions about the use of FPS-R were based on strong evidence, quality context, and type of facilitation. The PARIHS framework supported this successful EBP change. The PARIHS framework can be applied by the clinical nurse specialist in the clinical setting, with minimal effort, to facilitate EBP implementation.

Using Implementation Science to Facilitate Evidence-Based Practice Changes to Promote Optimal Outcomes for Orthopaedic Patients

Implementation Science is a relatively new field that focuses on discovering strategies to reduce the gap between research and practice. The revised Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to evaluate implementation of an evidence-based project that was designed to reduce the impact of delirium on hospitalized, older, orthopaedic patients. Interventions used in the pilot project were compared with the core elements of the PARIHS framework: evidence, context, facilitation, and successful implementation. Strategies to improve hospital-wide adoption of the evidence-based delirium prevention and treatment protocols centered on providing adequate and appropriate resources and clarifying roles. Specific recommendations to promote hospital-wide adoption and maintenance included enhancing training and improving integration of the assessments and protocols into overall workflow.

Barriers and Enablers to Implementation of a New Zealand‐Wide Guideline for Assessment and Management of Cardiovascular Risk in Primary Health Care: A Template Analysis

The aim of this study was to identify the enablers and barriers to guideline implementation in a primary healthcare setting by employing the Promoting Action on Research Implementation in Health Services (PARIHS) framework as a template for data analysis and interpretation. The use of clinical practice guidelines is pivotal to improving health outcomes. However, the implementation of guidelines into practice is complex, unpredictable, and, in spite of much investigation, remains resistant to explanation of what works and why. Optimising the enablers and minimising the barriers to implementation of a guideline for reducing cardiovascular disease risk has the potential to significantly reduce the burden of disease. The PARIHS framework has been successfully applied in a number of clinical contexts and has been found useful in illuminating the barriers and enablers to evidence implementation. This qualitative study involved focus groups with 20 primary healthcare nurses, 4 general practitioners, 5 managers, and individual interviews with 3 funder/planners who discussed their contribution to the use of a guideline for the assessment and management of cardiovascular risk. Template analysis based on the PARIHS framework was applied to semi-structured narrative data to provide an in-depth analysis of the barriers and enablers to implementation of the guideline. The lack of facilitation of the guideline into practice was a major barrier to implementation. Implementation plans that address the concerns and complexities of everyday practice are an essential aspect of guideline development. The PARIHS framework was found to be comprehensive and accommodating of the complexity of everyday practice associated with guideline implementation in primary health care. The pertinence of the framework confirms its usefulness as a tool to guide implementation.

Evaluating the context within which continence care is provided in rehabilitation units for older people

Aim. This paper presents the first phase of an all Ireland 2-year study between the University of Ulster and University College Cork, to determine the contextual indicators that enable or hinder person centred continence care and management in rehabilitation settings for older people. The primary outcome of the study was the development of a tool to enable practitioners to assess the practice context within which continence care is provided. The main focus of this paper is the value of understanding practice 'context' (culture, leadership and evaluation) and its impact to the provision of person centred continence care. Background. The literature highlights the effect of continence problems on the quality of life of older people. Incontinence is often seen by health care professionals and older people as an inevitable consequence of ageing and difficult to treat. Furthermore, health care professionals do not always have the necessary skills and knowledge of best practice in continence care and treatments. The Promoting Action on Research Implementation in Health Services (PARIHS) framework utilized in the study proposes that successful implementation of evidence in practice is dependent on the inter-relationship of three key elements; the nature of the evidence, the quality of the context and expert facilitation. Kitson etal. propose that for successful implementation, evidence needs to be robust, the context receptive to change and appropriate facilitation is needed. Consequently understanding practice 'context' and its impact on the provision of person centred continence care is of value. Methods. Case study methodology with several data collection methods was utilized to measure all aspects of 'context' as identified by the PARIHS framework. Methods include: Royal College of Physicians Audit Scheme, Staff Knowledge questionnaire, semi-structured observation of practice and multidisciplinary focus groups. Findings. The data were analysed in two stages. Stage 1 using both qualitative and quantitative (SPSS 12) methods. Stage 2 analysed all the data utilizing the characteristics of context from the PARIHS framework in order to identify the strong and weak characteristics of the context within which continence care was provided. Continence care and management in this study was found to be focused on continence containment rather than proactive management. The evidence suggests that the context (leadership, culture and evaluation) was weak and not conducive to person centred continence care and management. Conclusion. An analysis of the data using the context framework provided a picture of the context within the units and the identification of the specific contextual issues hindering and enabling the delivery of person centred continence care. This process has thus, added to our understanding of the importance of context to the provision of person-centred care.

From Workshop to Work Practice: An Exploration of Context and Facilitation in the Development of Evidence‐Based Practice

This article examines the process of translating evidence into practice using a facilitation model developed by the Western Australian Centre for Evidence Based Nursing and Midwifery. Using the conceptual framework Promoting Action on Research Implementation in Health Services (PARIHS), the aims of the study were (1) to explore the relative and combined importance of context and facilitation in the successful implementation of a new evidence-based clinical practice protocol and (2) to examine the establishment of more lasting change to individuals and organizations that resulted in greater incorporation of the principles of evidence-based practice (EBP). A pre-workshop, semi-structured telephone survey with 16 nurse managers in six rural hospitals; a summative evaluation immediately post-workshop with 54 participants; and follow-up, semi-structured interviews with 23 workshop participants. The contexts in each of the participating hospitals were very different; of the six hospitals, only one had not implemented the new protocol. Five had reviewed their practices and brought them in line with the protocol developed at the workshop. The rate of adoption varied considerably from 2 weeks to months. The participants reported being better informed about EBP in general and were positive about their ability to improve their practice and search more efficiently for best practice information. Underlying motivations for protocol development should be included in the PARIHS framework. IMPLICATIONS FOR EDUCATION: Good facilitation appears to be more influential than context in overcoming the barriers to the uptake of EBP.