Alison Kitson

Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges

BackgroundThe PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified.DiscussionThis being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation.Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place.In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally.SummaryThe paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches.We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.

Ingredients for change: revisiting a conceptual framework

Finding ways to deliver care based on the best possible evidence remains an ongoing challenge. Further theoretical developments of a conceptual framework are presented which influence the uptake of evidence into practice. A concept analysis has been conducted on the key elements of the framework—evidence, context, and facilitation—leading to refinement of the framework. While these three essential elements remain key to the process of implementation, changes have been made to their constituent sub-elements, enabling the detail of the framework to be revised. The concept analysis has shown that the relationship between the elements and sub-elements and their relative importance need to be better understood when implementing evidence based practice. Increased understanding of these relationships would help staff to plan more effective change strategies. Anecdotal reports suggest that the framework has a good level of validity. It is planned to develop it into a practical tool to aid those involved in planning, implementing, and evaluating the impact of changes in health care.

What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing

AIMnTo identify the common, core elements of patient-centred care in the health policy, medical and nursing literature.nnnBACKGROUNDnHealthcare reform is being driven by the rhetoric around patient-centred care yet no common definition exists and few integrated reviews undertaken.nnnDESIGNnNarrative review and synthesis.nnnDATA SOURCESnKey seminal texts and papers from patient organizations, policy documents, and medical and nursing studies which looked at patient-centred care in the acute care setting. Search sources included Medline, CINHAL, SCOPUS, and primary policy documents and texts covering the period from 1990-March 2010.nnnREVIEW METHODSnA narrative review and synthesis was undertaken including empirical, descriptive, and discursive papers. Initially, generic search terms were used to capture relevant literature; the selection process was narrowed to seminal texts (Stage 1 of the review) and papers from three key areas (in Stage 2).nnnRESULTSnIn total, 60 papers were included in the review and synthesis. Seven were from health policy, 22 from medicine, and 31 from nursing literature. Few common definitions were found across the literature. Three core themes, however, were identified: patient participation and involvement, the relationship between the patient and the healthcare professional, and the context where care is delivered.nnnCONCLUSIONnThree core themes describing patient-centred care have emerged from the health policy, medical, and nursing literature. This may indicate a common conceptual source. Different professional groups tend to focus on or emphasize different elements within the themes. This may affect the success of implementing patient-centred care in practice.

The need for systems change: reflections on knowledge translation and organizational change

BACKGROUNDnDespite over 40 years work on general systems theory, informed by critical social science, there is a mismatch between the theories used to explain and influence clinical practice in nursing and the way in which transferring new knowledge into practice is articulated.nnnDATA SOURCESnThe analysis and emerging propositions were based on a critique of seminal texts published in English up to 2008 covering critical social science, action science, diffusion of innovations, practice development and the management of innovations.nnnDISCUSSIONnThere is an implicit adherence to the world view that healthcare systems operate like machines, and much of the science generated around knowledge translation research tends to be logico-deductive. This is in direct contrast to the prevailing arguments of general systems theorists, who view the system more as an organism. Five propositions are posited: knowledge translation is a necessary but not sufficient mechanism to transform systems; the system-as-machine metaphor is profoundly unhelpful to knowledge translation; the healthcare system is best viewed as a complex entity; successful innovation is a function of the level of local autonomy experienced by individuals, teams and the unit involved; innovation is most effective when it involves key stakeholders.nnnCONCLUSIONnThe purposeful integration of systems theory with knowledge translation theories and models may enable the application of research and new knowledge to practice to be speeded up.

Nursing leadership: influencing and shaping health policy and nursing practice

Nursing leadership: influencing and shaping health policy and nursing practice¶ The leadership discourse in the United Kingdom has to date been concerned with professional issues and as a result has focused upon developing nurses and nursing. This paper reports on the findings of a research study which examined the broader socio-political factors impacting upon nursing leadership. The study forms an integral part of the Royal College of Nursings leadership programme. The principal aim of the research was to examine critically contemporary nursing leadership within the context of health policy. An ethnographic approach was used. Informal semi-structured interviews were undertaken with a purposive sample of 24 leaders who were recognized for their effectiveness in leading nursing. Data were analysed for themes. The main themes are presented and discussed here. The findings of the study question the political success which the internally focused nature of leadership has had for the profession. Nursing and therefore nursing leadership is shaped dramatically by the impact of politics and policy. The research discovered that in recognition of this, contemporary nursing leadership has both an internal and an external focus. That is, effective nursing leadership currently is a vehicle through which both nursing practice and health policy can be influenced and shaped. The research also identified the profile of the effective nurse leader, together with the processes through which leaders interpret and translate between the macro issues of policy and the micro issues of practice. In addition, an understanding of what nursing leadership is, has been proposed. Appropriate recommendations for the future of nursing and nursing leadership are outlined.

A comparative analysis of lay-caring and professional (nursing) caring relationships

Acceptable definitions of the terms care and nursing have yet to be reached. Some may feel that lack of agreement on the meaning of these concepts is a rather esoteric or academic point: the argument put forward in this paper is that until a clearer perception of the concepts of care and nursing is arrived at, the profession will be limited in its ability to develop its expertise or to set standards related to the quality of care. The paper outlines the extent to which these concepts have been explored and details the developments and some of the limitations of present modes of thought. An alternative perspective is offered, based on a comparative analysis of the professional (nursing care) and lay-caring relationships. By this means, a set of characteristics similar in both relationships, has been identified. Quality of care in the professional caring relationship is thought to relate to the extent to which aspects of caring activities implicit in the lay-caring relationship are carried into the professional nurse-patient relationship and made explicit. The ability of the nurse to do this emerges as one aspect of her therapeutic nursing function.

Anything but basic : Nursing’s challenge in meeting patients' fundamental care needs

Purpose nNursing has not explored the fundamental aspects of patient care in a systematic, conceptually coherent, scientific way, and this has created a number of ongoing challenges. n nOrganizing Construct nEach challenge is identified and addressed in the form of a proposition, with evidence provided to support the arguments put forward and defend the proposed actions. n nFindings nThe challenges include: the need for an integrated way of thinking about the fundamentals of care from a conceptual, methodological, and practical perspective; the ongoing and unresolved tension in nursing practice between a depersonalized and mechanistic approach (termed a “task and time” driven culture) and the need for consistency around understanding and managing the dynamics of the nurse–patient relationship or encounter (termed a “thinking and linking” approach); and the need for a systematic approach to the fundamentals or basics of care that combines the physical, psychosocial, and relational dimensions of the care encounter within the wider context of the care environment. Pragmatic and practical frameworks are needed to ensure that the basic physical and psychosocial needs of patients are embedded not only in the practice but also in the thinking, reflection, and assessment processes of the nurse. n nConclusions nNursings challenge to meet patients’ basic or fundamental needs is complex. Developing a knowledge base will include identifying researchable questions, using rigorous methodologies, ensuring the relational dimensions are not lost, and ensuring the new knowledge is applied in practice. This requires collaboration on an international scale to achieve improvements in care. n nClinical Relevance nTo work collaboratively to generate, test, and implement meaningful ways of capturing nursing practice around basic or fundamental care in order to ensure more integrated, holistic patient care nursing practices.PURPOSEnNursing has not explored the fundamental aspects of patient care in a systematic, conceptually coherent, scientific way, and this has created a number of ongoing challenges.nnnORGANIZING CONSTRUCTnEach challenge is identified and addressed in the form of a proposition, with evidence provided to support the arguments put forward and defend the proposed actions.nnnFINDINGSnThe challenges include: the need for an integrated way of thinking about the fundamentals of care from a conceptual, methodological, and practical perspective; the ongoing and unresolved tension in nursing practice between a depersonalized and mechanistic approach (termed a task and time driven culture) and the need for consistency around understanding and managing the dynamics of the nurse-patient relationship or encounter (termed a thinking and linking approach); and the need for a systematic approach to the fundamentals or basics of care that combines the physical, psychosocial, and relational dimensions of the care encounter within the wider context of the care environment. Pragmatic and practical frameworks are needed to ensure that the basic physical and psychosocial needs of patients are embedded not only in the practice but also in the thinking, reflection, and assessment processes of the nurse.nnnCONCLUSIONSnNursings challenge to meet patients basic or fundamental needs is complex. Developing a knowledge base will include identifying researchable questions, using rigorous methodologies, ensuring the relational dimensions are not lost, and ensuring the new knowledge is applied in practice. This requires collaboration on an international scale to achieve improvements in care.nnnCLINICAL RELEVANCEnTo work collaboratively to generate, test, and implement meaningful ways of capturing nursing practice around basic or fundamental care in order to ensure more integrated, holistic patient care nursing practices.

PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice

BackgroundThe Promoting Action on Research Implementation in Health Services, or PARIHS framework, was first published in 1998. Since this time, work has been ongoing to further develop, refine and test it. Widely used as an organising or conceptual framework to help both explain and predict why the implementation of evidence into practice is or is not successful, PARIHS was one of the first frameworks to make explicit the multi-dimensional and complex nature of implementation as well as highlighting the central importance of context. Several critiques of the framework have also pointed out its limitations and suggested areas for improvement.DiscussionBuilding on the published critiques and a number of empirical studies, this paper introduces a revised version of the framework, called the integrated or i-PARIHS framework. The theoretical antecedents of the framework are described as well as outlining the revised and new elements, notably, the revision of how evidence is described; how the individual and teams are incorporated; and how context is further delineated. We describe how the framework can be operationalised and draw on case study data to demonstrate the preliminary testing of the face and content validity of the revised framework.SummaryThis paper is presented for deliberation and discussion within the implementation science community. Responding to a series of critiques and helpful feedback on the utility of the original PARIHS framework, we seek feedback on the proposed improvements to the framework. We believe that the i-PARIHS framework creates a more integrated approach to understand the theoretical complexity from which implementation science draws its propositions and working hypotheses; that the new framework is more coherent and comprehensive and at the same time maintains it intuitive appeal; and that the models of facilitation described enable its more effective operationalisation.

Nursing leadership: bringing caring back to the future

Leadership, whether it is nursing, medical or healthcare leadership, is about knowing how to make visions become reality. The vision that many nurses hold dear to their hearts is one where patients are treated with dignity and respect at all times; where systems are designed for the benefit of individual needs; and where the work performed by nurses and other carers is valued and respected. Achieving such a vision will require a paradigm shift in the philosophy, priorities, policies, and power relationships of the health service. Fundamentally, it will require the rhetoric of patient centred care to become a reality. The following scenario is set in the UK in the year 2012 and describes a health service that is on the pathway to achieving this vision. It tells the story from a nursing perspective and outlines the three key foundation stones that helped nursing achieve the vision of a patient centred health service: (1) development of patient centred care measures as part of performance management and the clinical governance agenda; (2) leadership based on personal growth and development principles; (3) new clinical career and competency framework for nursing.

The clinical encounter - the focal point of patient-centred care

Central to the UK Government’s health-care modernization agenda, is the notion of patientcentred care. A plethora of initiatives have been spawned over the past few years with the objective of involving and empowering users of our health services in a more democratic, equitable and fair way. In parallel with this, the Government is introducing a raft of initiatives related to the need for accountability and for evidence-based medicine (EBM). However, issues of volume and velocity continue to defy any rational solutions and the difficulties experienced in the management of clinical risk, as well as the incorporation of individual preferences, attest to the complexity, uncertainty and fragility of our current healthcare system. It sometimes feels as if the National Health Service (NHS) is overheating through frantic attempts to evaluate the effectiveness and efficiency of its activity, practice EBM and accommodate the concept of patient-centred care. Furthermore, some people view the different initiatives alluded to above as potentially contradictory. For example, Bensing has suggested that EBM may make it more difficult to deliver patient-centred care and there is a risk that the drive towards accountability will reduce morale and disempower professionals to such an extent that they will be unable to respond to the demands for patient-centred care. Most of the current initiatives seem to be directed either at the patient or at the professional. Few of them recognize the importance of the interaction between the two. And yet human interactions are the essential element of humanitarian caring and of all health-care delivery. It is the clinical encounter, in other words, that is the point at which transactions between patients and professionals take place; it is the point at which decisions about diagnosis and treatment are made, and during which caring takes place. We know that patients value clinical encounters highly, and see them as central to their health-care. We also know that a good clinical encounter can have beneficial effects on health outcomes. Although much work remains to be done to explore which components of the clinical encounter are of utmost importance, current data suggest that positive effects occur when people feel empowered and that they have been heard . In contrast, if people feel they have not been listened to, or talked down to, health outcomes can be adversely affected. In addition, bad clinical encounters can lead to poor compliance with treatment and unwillingness to access services in the future. Despite the centrality of the clinical encounter, its scope and nature have not been well articulated in current health-care policy or practice. We know surprisingly little about it and it has not been a research priority. Surely, as part of our pursuit of a greater understanding of patient-centred care we need to define more clearly the nature and determinants of the clinical encounter, and its effects on health outcomes.