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      Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review

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          Abstract

          Background

          Organizational contextual features have been recognized as important determinants for implementing evidence-based practices across healthcare settings for over a decade. However, implementation scientists have not reached consensus on which features are most important for implementing evidence-based practices. The aims of this review were to identify the most commonly reported organizational contextual features that influence the implementation of evidence-based practices across healthcare settings, and to describe how these features affect implementation.

          Methods

          An integrative review was undertaken following literature searches in CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane databases from January 2005 to June 2017. English language, peer-reviewed empirical studies exploring organizational context in at least one implementation initiative within a healthcare setting were included. Quality appraisal of the included studies was performed using the Mixed Methods Appraisal Tool. Inductive content analysis informed data extraction and reduction.

          Results

          The search generated 5152 citations. After removing duplicates and applying eligibility criteria, 36 journal articles were included. The majority ( n = 20) of the study designs were qualitative, 11 were quantitative, and 5 used a mixed methods approach. Six main organizational contextual features (organizational culture; leadership; networks and communication; resources; evaluation, monitoring and feedback; and champions) were most commonly reported to influence implementation outcomes in the selected studies across a wide range of healthcare settings.

          Conclusions

          We identified six organizational contextual features that appear to be interrelated and work synergistically to influence the implementation of evidence-based practices within an organization. Organizational contextual features did not influence implementation efforts independently from other features. Rather, features were interrelated and often influenced each other in complex, dynamic ways to effect change. These features corresponded to the constructs in the Consolidated Framework for Implementation Research (CFIR), which supports the use of CFIR as a guiding framework for studies that explore the relationship between organizational context and implementation. Organizational culture was most commonly reported to affect implementation. Leadership exerted influence on the five other features, indicating it may be a moderator or mediator that enhances or impedes the implementation of evidence-based practices. Future research should focus on how organizational features interact to influence implementation effectiveness.

          Electronic supplementary material

          The online version of this article (10.1186/s13643-018-0734-5) contains supplementary material, which is available to authorized users.

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          Most cited references55

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

          Background The 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. Discussion Building 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. Summary This 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. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0398-2) contains supplementary material, which is available to authorized users.
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            Implementation, context and complexity

            Background Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. Discussion We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. Conclusion Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of ‘real world’ contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants’ discretion over resource mobilisation and actors’ contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
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              Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework

              Background The effectiveness of complex interventions, as well as their success in reaching relevant populations, is critically influenced by their implementation in a given context. Current conceptual frameworks often fail to address context and implementation in an integrated way and, where addressed, they tend to focus on organisational context and are mostly concerned with specific health fields. Our objective was to develop a framework to facilitate the structured and comprehensive conceptualisation and assessment of context and implementation of complex interventions. Methods The Context and Implementation of Complex Interventions (CICI) framework was developed in an iterative manner and underwent extensive application. An initial framework based on a scoping review was tested in rapid assessments, revealing inconsistencies with respect to the underlying concepts. Thus, pragmatic utility concept analysis was undertaken to advance the concepts of context and implementation. Based on these findings, the framework was revised and applied in several systematic reviews, one health technology assessment (HTA) and one applicability assessment of very different complex interventions. Lessons learnt from these applications and from peer review were incorporated, resulting in the CICI framework. Results The CICI framework comprises three dimensions—context, implementation and setting—which interact with one another and with the intervention dimension. Context comprises seven domains (i.e., geographical, epidemiological, socio-cultural, socio-economic, ethical, legal, political); implementation consists of five domains (i.e., implementation theory, process, strategies, agents and outcomes); setting refers to the specific physical location, in which the intervention is put into practise. The intervention and the way it is implemented in a given setting and context can occur on a micro, meso and macro level. Tools to operationalise the framework comprise a checklist, data extraction tools for qualitative and quantitative reviews and a consultation guide for applicability assessments. Conclusions The CICI framework addresses and graphically presents context, implementation and setting in an integrated way. It aims at simplifying and structuring complexity in order to advance our understanding of whether and how interventions work. The framework can be applied in systematic reviews and HTA as well as primary research and facilitate communication among teams of researchers and with various stakeholders. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0552-5) contains supplementary material, which is available to authorized users.
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                Author and article information

                Contributors
                shellyanne.li@mail.utoronto.ca
                jeffsl@smh.ca
                melanie.barwick@sickkids.ca
                b.stevens@utoronto.ca
                Journal
                Syst Rev
                Syst Rev
                Systematic Reviews
                BioMed Central (London )
                2046-4053
                5 May 2018
                5 May 2018
                2018
                : 7
                : 72
                Affiliations
                [1 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Lawrence S. Bloomberg Faculty of Nursing, , University of Toronto, ; Toronto, ON Canada
                [2 ]GRID grid.415502.7, St Michael’s Hospital Volunteer Association Chair in Nursing Research, , Li Ka Shing Knowledge Institute, ; Toronto, ON Canada
                [3 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Lawrence S. Bloomberg Faculty of Nursing and Institute of Health, Policy Management and Evaluation, , University of Toronto, ; Toronto, Canada
                [4 ]ISNI 0000 0004 0473 9646, GRID grid.42327.30, Child Health Evaluative Sciences, Research Institute, Peter Gilgan Centre for Research and Learning, , The Hospital for Sick Children, ; Toronto, ON Canada
                [5 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Department of Psychiatry, , University of Toronto, ; Toronto, Canada
                [6 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, The Dalla Lana School of Public Health, , University of Toronto, ; Toronto, Canada
                [7 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Faculties of Medicine and Dentistry, University of Toronto Centre for the Study of Pain, , University of Toronto, ; Toronto, Canada
                Author information
                http://orcid.org/0000-0002-0189-0880
                Article
                734
                10.1186/s13643-018-0734-5
                5936626
                29729669
                1d6a040c-5154-421a-b6b7-43e142ba833a
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 19 December 2017
                : 18 April 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Award ID: 148452
                Award Recipient :
                Funded by: Pain in Child Health
                Award ID: 53885
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2018

                Public health
                organizational context,implementation,knowledge translation,evidence-based practice,healthcare,adoption,organization,context,integrative review

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