Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: a conceptual framework.
, 149-158. DOI: 10.1136/qshc.7.3.149
Relevance for Public Health
This method would be relevant for public health practitioners devising a knowledge translation strategy to implement research into practice. For instance, by considering the different kinds of evidence on a public health issue and the context of the organization, practitioners can determine the most appropriate facilitation method to change practice.
The PARiHS (Promoting Action on Research Implementation in Health Services) framework provides a way to implement research into practice. With case studies of teams implementing evidence, it examines the interactions between three key elements for knowledge translation. Three factors determine research use:
- Evidence (E)
- Context (C)
- Facilitation (F)
Significantly, this framework argues that successful implementation (SI) of evidence into practice had as much to do with the context or setting where the new evidence was being introduced and how that new evidence was introduced (facilitated into practice) as it had to do with the quality of the evidence.
The PARiHS framework incorporates themes from the literature on research use, such as:
- Implementing research into practice is an organizational issue rather than an individual issue.
- The research evidence must be strong (such as a systematic review of methodologically sound studies) before implementation is justified.
- Strategies for implementation require careful planning and need to consist of a range of interventions that address the need for education, audit and the management of change.
- Criteria for evaluating the impact of the intervention must be identified and agreed upon before implementing any change.
The main features of the PARiHS framework include:
- Evidence encompasses codified and non-codified sources of knowledge, including research evidence, practitioner experience, community preferences and experiences, and local information.
- Melding and implementing such evidence in practice involves negotiating and developing a shared understanding about the benefits, disadvantages, risks and losses of the new practice over the old.
- Some contexts are more conducive to the successful implementation of evidence into practice than others, such as organizations that have transformational leaders, elements of learning organizations and evaluation mechanisms.
- The framework emphasizes the need for appropriate facilitation to improve the likelihood of success. The needs of the organization determine the type of facilitation and the role and skill of the facilitator. Facilitators work with individuals and teams to enhance the implementation process.
Accessing the Method/Tool
Implementing the Method/Tool
Time for Participation/Completion
Information not available
Additional Resources and/or Skills Needed for Implementation
Steps for Using Method/Tool
The PARiHS (Promoting Action on Research Implementation) framework proposes that successful implementation of research in practice is a function of the relation between the nature of the evidence, the context in which the proposed change is to be implemented and the mechansims by which the change is facilitated. The framework is expressed as:
SI = f (E, C, F)
where SI=successful implementation, E=evidence, C=context, F=facilitation and f=function of.
Each factor, evidence, context and facilitation consists of sub-elements that can be rated on a scale from low to high. High ratings on each factor are more likely to produce successful implementation results (Kitson et al., 1998; Kitson et al., 2008).
1. Evidence: to assess the nature and strength of the evidence and its potential for implementation. There are four evidence bases:
- Research - evidence needs to be translated and adapted so it makes sense in the local context. Research evidence is less certain and less value-free than is often acknowledged.
- Practitioner expertise and experience - the tacit knowledge of practitioners, or 'practical know-how' needs to be made explicit for practitioner expertise to be shared, critiqued and developed.
- Community/intended population - groups and communities need to be included in decision making.
- Local context and environment - data on the local context such as evaluation data, local community stories and knowledge of the organizational culture needs to be considered.
2. Context: the context is the environment or setting in which the proposed change is to be implemented. Context is subdivided into three core elements: an understanding of the prevailing culture, leadership roles and the organization's approach to measurement (evaluation). Other key aspects of context include:
- relevance of the innovation to the organization
- organizational fit of the innovation to organizational structures and procedures such that the innovation is more likely to be adopted
- adequate resources for implementation, where resources are appropriately allocated, targeted and managed
- use of implementation strategies with a multi-disciplinary focus.
3. Facilitation: facilitation describes the type of support needed to help people change their attitudes, habits, skills and ways of thinking and working. Facilitators help people understand what they have to change and how to change it to achieve the desired outcome. The following dimensions are identified within the facilitation role: personal characteristics (openness, credible, authentic,etc.); role characteristics (clarity of role, authority, etc.); and facilitation style (range and flexibility of style, consistent and appropriate presence, etc.). The key features of facilitation within this framework include the following:
- Facilitation is a process that depends upon the person (the facilitator) carrying out the role with the appropriate skills, personal attributes and knowledge.
- The purpose of facilitation varies from providing help and support to achieve a goal to enabling individuals and teams to analyze, reflect and change their own attitudes, behaviours and ways of working.
- A 'facilitation continuum' distinguishes between a 'doing for others' role (more discrete, practical, technical and task driven) on the one side to an 'enabling and empowering' role that is developmental and seeks to mentor and support others in their learning and change processes.
- Facilitation skills are developed through experiential learning and through acquiring key facilitation competencies.
- Facilitation is a discrete intervention (knowledge translation strategy).
Four case studies are presented where the evidence is rated high and context and facilitation range from low to high ratings. Successful implementation of evidence is most likely to occur when the context is receptive to change and when there is appropriate facilitation of change.
The framework does not consider wider organizational and political factors in the local situation, including the presence of incentives or sanctions for change. The facilitator as the agent of change in the implementation process would need to consider these issues.
Who is involved
Various roles would be involved in planning and implementing this framework, including program directors and managers, supervisors, public health nurses, health promotion officers, community development workers and others.
Conditions for Use
Evaluation and Measurement Characteristics
Has been evaluated.
This framework was evaluated in a case study of nurses in a clinical setting. The evaluation found that evidence, context and facilitation are key elements in implementing evidence in practice (Rycroft-Malone et al., 2004). However, the content, purpose and dynamics of this framework require further consideration to ensure its appropriateness, comprehensiveness and accuracy. This study found that practitioners are challenged in using robust evidence across all four differents types of evidence (research, clinical experience, patient experience and local data/information). Also, implementation of evidence is dependent on organizational factors in addition to individual factors.
Kitson et al. (2008) articulate that the PARiHS framework is a useful tool for research implementation, but it remains largely untested. They also state that the PARiHS framework may be best used as a two-stage process: use it as a preliminary measure of evidence and context, and then use the aggregated data from these measures to determine the most appropriate facilitation method. By using the framework in this manner, decision-makers can tailor any knowledge translation interventions to the local context. Kitson and colleagues also identified three challenges of the framework in implementation science:
- the need to integrate theoretical perspectives into the framework to explore what works in knowledge translation
- the need to develop and test diagnostic and evaluative instruments for the three elements and sub-elements of the framework
- the need to test how the different elements of the framework are interrelated, and how their interrelationships impact on knowledge translation outcomes.
Method of Development
The PARiHS (Promoting Action on Research Implementation in Health Services) framework examines factors at play in the implementation of evidence in practice. There are three phases in the development of the PARiHS framework:
- Phase 1: Development and Concept Analysis (1998-2002)
- Phase 2: Empirical Case Studies (2001-2003)
- Phase 3: Development of Diagnostic/Evaluation Tool (2003-Present)
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These summaries are written by the NCCMT to condense and to provide an overview of the resources listed in the Registry of Methods and Tools and to give suggestions for their use in a public health context. For more information on individual methods and tools included in the review, please consult the authors/developers of the original resources.