Evidence-based healthcare has featured as a policy concern in many healthcare systems for over a decade driven by a growing recognition and concern that healthcare practice does not always reflect what is known to be best practice. Some studies [1
] suggest that twenty to forty per cent of patients receive harmful care or care that is inconsistent with scientific evidence. Responding to these concerns, policy makers have increasingly sought ways to narrow the research-practice gap and ensure that research is translated into clinical practice as effectively and efficiently as possible. Initiatives have included the establishment of national guideline development and technology assessment bodies [3
] knowledge and skills development of healthcare staff [5
], and research programmes to investigate effective implementation methods and processes [7
Despite significant investment, translating research in to healthcare decision making and practice remains a considerable challenge. In the United Kingdom (UK), a national evaluation of the extent and pattern of implementation of guidance issued by the National Institute for Health and Clinical Excellence (NICE) demonstrated a highly variable level of uptake, ranging from no change to significant changes in practice in line with the guidance [9
]. Additionally the literature contains numerous examples of attempts to implement evidence into practice; with mixed success [10
Translating and using research in practice is complex, involving significant and planned individual, team, and organisational change. A case study meta analysis of evidence into practice projects highlights the social, organisational, and professional factors that mediate evidence use [15
] and are consistent with a review of the diffusion of innovations literature, which emphasised the complex interactions between clinicians and their practice settings [16
], illustrating that there are no simple solutions to complex healthcare problems.
The complexities inherent in the implementation of evidence into practice are represented in the Promoting Action on Research Implementation in Health Services (PARIHS) framework [17
]. In contrast to previous frameworks that had represented implementation as a linear and rationale process, PARIHS was developed to demonstrate the complex interplay of a number of factors that influence the successful implementation of evidence in practice [17
]. Successful implementation is represented as a function of the nature of evidence being implemented, the context in which implementation takes place, and the way in which that process is facilitated: SI = f(e, c, f).
The subsequent development and refinement of the framework has been comprehensively described in recent publications [19
]. This development has included concept analyses of the core concepts within the framework: evidence [22
], context [23
], and facilitation [24
]. As a result, the framework has evolved to provide a map to enable others to make sense of the complexities of implementation and the elements that require attention if implementation is more likely to be successful [21
The PARIHS framework has been well received by those working in the field of evidence-based healthcare, and has been used by others as a heuristic to guide implementation efforts at the point of care delivery [25
] and as the conceptual underpinning of a variety of tools and measures [28
]. A critical synthesis of empirical studies in which the PARIHS framework was used highlighted its strengths and issues. Their conclusions included the need for further delineation of the elements within the framework, and a call for the framework to be used prospectively in implementation studies [30
]. The FIRE study is one attempt to do this, with a particular focus on the facilitation dimension of the PARIHS framework.
A key element of the PARIHS framework is facilitation, which could be described as a mechanism or intervention for the implementation of evidence into practice. A facilitator is an individual who is skilled in working with the concepts of change management and individual and organisational development. Facilitation involves the facilitator working with individuals, teams, and organisations to prepare, guide, and support them through the implementation process. This involves attentiveness to both the context (including barriers and enablers of change) and to the evidence to be implemented and how it fits with local circumstances. Two important features were identified in a concept analysis of facilitation [24
]. Firstly, not all efforts to get research evidence into practice explicitly engage processes to support implementation. In such cases, implementation involved discrete interventions, such as the distribution of printed materials or the provision of targeted educational meetings, the assumption being that on learning about the new evidence, practitioners would change their practice accordingly. Secondly, in cases where interventions to promote implementation did involve an individual taking on a facilitator role (for example, a dedicated project lead, educational outreach worker, or practice development facilitator), two models of facilitation were apparent. These different models were represented along a continuum, ranging from a largely task-focused, project manager role, to a more holistic, enabling approach to facilitation where the facilitator worked at the level of individuals, teams, and organisations to create and sustain a supportive context for evidence based care [31
The findings from the concept analysis of facilitation suggest that the key to successful implementation is matching the purpose, role, and skills of the facilitator to the specific needs of the situation, i.e., appropriate facilitation [24
]. A systematic review of 26 studies concluded that whilst tailored interventions can change practice, there is a lack of evidence about how interventions should be selected to address barriers, and no evidence on cost effectiveness [33
]. Given the increasingly recognised complex nature of implementing research evidence into practice and the need to address the interplay between individuals and the organisation [15
], it is reasonable to suggest that skilled facilitators need to be able to move across different points of the facilitation continuum to meet the different requirements of individuals, teams, and organisations at different points in time. However, this requires facilitators to possess a sophisticated range of knowledge and skills, including, for example, diagnostic skills (to assess the organisational context and the needs of individuals and teams within that context), project management skills, and a range of skills to support individual, team, and organisational development and learning. In turn, this requires significant investment of resources and time, both in preparing and supporting individuals to take on the facilitator role and in creating time for individuals and teams to work with the facilitator to implement research evidence into practice. Other issues to consider include the need to distinguish between the facilitator role and the methods that the facilitator uses, the complexity of the role and how much facilitation is needed in a given situation, and the need to better understand the relationship between facilitation, context, and evidence.
Despite the increasing use of facilitation type models and techniques within implementation projects, to date, facilitation has received little attention in the formal classification of methods and interventions to change professional and organisational behaviour (for example, by the Cochrane review group on Effective Practice and Organisation of Care). Systematic reviews of various implementation interventions across a variety of settings show mixed effects [35
]. There is some evidence to support the use of discrete interventions such as the distribution of printed materials, the use of reminders, audit and feedback, participative education programmes, and social marketing techniques. However, further research is needed into the effectiveness of such implementation interventions, and more specifically there has been a call for more theory informed interventions, and robust and methodologically sound research [36
This protocol describes a theory driven study to evaluate the effectiveness of facilitation as an intervention to implement evidence into practice. Drawing on the core elements of evidence, context, and facilitation, we will test a number of theoretical propositions about facilitation and the implementation of continence promotion evidence within nursing home settings across four European countries. The research will start to uncover the relationship between particular facilitation methods and the impact of the use of these methods on evidence use, contextual change, team effectiveness, and the creation of organisational infrastructures that support and enable knowledge utilisation.