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CIPRS: Stetler/Damschroder, Theoretical Frameworks
Implementation Implementation Research Theoretical Research Theoretical
FrameworksFrameworksCyberSeminar Series CyberSeminar Series
4-Part Series:1.April 72.April 143.May 54.May 12
CIPRS: Stetler & Damschroder Theoretical Frameworks
ObjectivesObjectives
Purpose/potential value and uses Process for selection and use Nature and underlying rationale of
specific frameworks/approaches Evaluation
CIPRS: Stetler & Damschroder Theoretical Frameworks
APRILAPRIL April 7: Foundations
Cheryl Stetler & Laura Damschroder
April 14: Applying a Framework
Phil Ullrich
A Mixed-model Approach-Intro
Jeffrey Smith
CIPRS: Stetler & Damschroder Theoretical Frameworks
MAYMAY
May 5: A Mixed-model Approach-Cont. Jeffrey Smith
Applying the CFIRLaura Damschroder & Teresa
Damush
May 12: Respond to Participant Interests/
Dialogue with Presenters The “Theory” Team
CIPRS: Stetler & Damschroder Theoretical Frameworks
Your Active Your Active ParticipationParticipation
Track questions & observations General & per framework/approach
DISCUSSION/REACTION FORM page 1 DISCUSSION/REACTION FORM page 2
Send your suggestions for discussion at the May 12th session
Send as early as possible to:[email protected]
CIPRS: Stetler & Damschroder Theoretical Frameworks
FoundationsFoundations
What are implementation “theories”?
How and why are they useful?
CIPRS: Stetler & Damschroder Theoretical Frameworks
Foundations Foundations TerminologyTerminology
Theory Theoretical/conceptual
framework Model
CIPRS: Stetler & Damschroder Theoretical Frameworks
HandoutHandout THEORY: “A set of logical constructs that jointly offer
answers to the questions ‘why’ and ‘how,’ as in ‘why would someone change their behavior in this way?’ and ‘how could this behavior/situation/ outcome be changed” (Sales, et al, 2006)
THEORETICAL/CONCEPTUAL FRAMEWORK: “…identifies a set of variables and relationships that should be examined in order to explain the phenomena”; “…need not specify the direction of relationships or identify critical hypotheses” (Kitson et al, 2008)
CIPRS: Stetler & Damschroder Theoretical Frameworks
TheoryTheory
Provides a denser and logically coherent set of relationships
Sheds light on causal relationships and seeks to explain the phenomena
Offers explanations, predictions and thus “control”
CIPRS: Stetler & Damschroder Theoretical Frameworks
Theoretical or Theoretical or Conceptual Conceptual FrameworkFramework
More specific and concrete than theory Can usually be shown in a
diagram/picture “… could be populated by multiple
theories, at multiple levels” (Kitson et al, 2008)
CIPRS: Stetler & Damschroder Theoretical Frameworks
ModelModel Represents a specific situation Narrower in scope More precise in their assumptions –
including relationships (Kitson et a, 2008)
May be used interchangeably with “framework” (Sales, et al., 2006)
CIPRS: Stetler & Damschroder Theoretical Frameworks
No Commonality… No Commonality… IllustrationIllustration11!!
Conceptual models Theories of change Frameworks
1. Ref: Graham & Tetroe, in press
CIPRS: Stetler & Damschroder Theoretical Frameworks
Why “Theory”?Why “Theory”?
Theories, models, frameworks provide a systematic method:
… for identifying, understanding, operationalizing & evaluating the black box phenomenon =
“IMPLEMENTATION”
CIPRS: Stetler & Damschroder Theoretical Frameworks
Why NOT Theory?Why NOT Theory? Just “use common sense”1
Using theory doesn’t make it any easier to judge applicability of evidence
It isn’t clear how to translate theory reliably to study design
So many theories why should any one of them be given supremacy?
BUTBUT: “Common Sense” alone hasn’t worked so far…
Trial & error approach Reinventing the wheel Cherry-picking interventions Retrospectively trying to understand the black box
1. Bhattacharyya O, Reeves S, Garfinkel S, Zwarenstein M. Designing theoretically-informed implementation interventions: fine in theory, but evidence of effectiveness in practice is needed. Implement Sci 2006;1:5.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Why “Theory”:Why “Theory”:QUERI Dual ObjectivesQUERI Dual Objectives
1. Generalize knowledge about how to implement and sustain interventions
Facilitate systematic accumulation of generalizable knowledge Across studies Across settings Across interventions …other salient characteristics/factors
CIPRS: Stetler & Damschroder Theoretical Frameworks
QUERI Dual ObjectivesQUERI Dual Objectives
2. Replicate successful implementation
Help navigate complexity of implementation & sustainability
Tailor essential factors to fit the context
CIPRS: Stetler & Damschroder Theoretical Frameworks
Using Theory for Implementation Using Theory for Implementation PlanningPlanning
Select theory of planned behaviorchange
Assess fit with initial theory
Identify potential strategies for achieving change
Select interventionsthat fit with plannedstrategies (based on theory)
Identify interventiontools that fit bothstrategy and theory
Launch interventionusing identified toolsand strategies
Evaluate effectivenessof intervention,strategies, tools
See references: Sales et al., 2006
CIPRS: Stetler & Damschroder Theoretical Frameworks
Select theory of planned behaviorchange
Using Theory for Implementation Using Theory for Implementation PlanningPlanning
See references: Sales et al., 2006
Assess fit with initial theory
Identify potential strategies for achieving change
Select interventionsthat fit with plannedstrategies (based on theory)
Identify interventiontools that fit bothstrategy and theory
Launch interventionusing identified toolsand strategies
Evaluate effectivenessof intervention,strategies, tools
Select theory of planned behavior
change
Theories
Models
Frameworks
CIPRS: Stetler & Damschroder Theoretical Frameworks
Selecting a Theory - 1Selecting a Theory - 1 Consider Context
Study characteristics Professional discipline/perspective Intervention characteristics Inner and outer setting Individuals involved Implementation process
Consider Level Individuals Teams Organization System
CIPRS: Stetler & Damschroder Theoretical Frameworks
Selecting a Theory - 2Selecting a Theory - 2
Multiple theories often needed Process theories
How implementation should be planned, organized and scheduled
Impact theories Hypotheses and assumptions about how
implementation activities will facilitate a desired change, as well as the facilitators and barriers for success
Adapted from: Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85(1):93-138.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Theories re:Theories re:ImplementationImplementation NOT: Patient care models
Self management; e.g., health belief model NOT: Practice delivery models
Chronic care model IT support: clinical reminders Collaborative care models
Implementation models Individual adoption/uptake Maintenance for sustained use
CIPRS: Stetler & Damschroder Theoretical Frameworks
TYPES: Process TYPES: Process TheoriesTheories
Aka: Planned Action Theories1
Policy level (example) QUERI core 6-step process
Study level (examples) Graham & Logan’s Ottawa Model of Research Uptake
2
Grol, et al’s model for effective implementation 3
Mendel, et al’s Dissemination Framework 4
Stetler’s Model of Research Utilization/EBP 5
1. See references: Graham & Tetroe, in press2. Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.3. Grol, et al. 20074. Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB. Interventions in organizational and community context: a framework for building evidence on
dissemination and implementation in health services research. Adm. Policy Ment. Health 2008;35(1-2):21-37.5. Stetler C. Updating the Stetler model of research utilization to facilitate evidence-based practice. Nurs Outlook 2001;49/6, 272-278.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Ottawa Model ofOttawa Model ofResearch UseResearch Use
Action-oriented
Prescribes 3 main steps
Assess Monitor Evaluate
Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Framework of Dissemination in Health Framework of Dissemination in Health Services Intervention ResearchServices Intervention Research
Mendel et al, 2008
CIPRS: Stetler & Damschroder Theoretical Frameworks
2001
CIPRS: Stetler & Damschroder Theoretical Frameworks
Impact Theories - 1Impact Theories - 1
Individual-level theories Stage of change Cognitive Educational Motivational
Grol et al, 2007
CIPRS: Stetler & Damschroder Theoretical Frameworks
Individual Level: Stage of Individual Level: Stage of ChangeChange
Stage of change Assumptions about the phases individuals
go through to achieve desired behavior change
General phases common to all1: Awareness Insight Acceptance Actual Change Maintenance
Grol et al, 2007
CIPRS: Stetler & Damschroder Theoretical Frameworks
Literature synthesis of SCT to explain clinician behavior
Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories. Implement Sci 2008;3(1):36.
Social Cognitive TheorySocial Cognitive Theory
http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/
Organizational Setting
CIPRS: Stetler & Damschroder Theoretical Frameworks
Theory of Planned Theory of Planned BehaviorBehavior
Motivational theory
Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211.http://people.umass.edu/aizen/tpb.diag.htm l
CIPRS: Stetler & Damschroder Theoretical Frameworks
Impact Theories - 2Impact Theories - 2 Social context theories
Social Marketing Social learning Communication Social network & influence Teamwork Professional development Leadership
Grol et al, 2007.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Social Network TheorySocial Network Theory
Tailor engagement strategy to social networks
http://www.istheory.yorku.ca/socialnetworktheory.htm
CIPRS: Stetler & Damschroder Theoretical Frameworks
Impact Theories - 3Impact Theories - 3 Organizational Context Theories
Innovative organizations Quality management Integrated care Complexity Organizational learning Organizational culture
Political & Economic Context Theories Reimbursement Contracting
Grol et al, 2007.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Roger’s Theory of Roger’s Theory of DiffusionDiffusion
Characteristics of the intervention
Organizational characteristics
Environmental context
Adoption decision
Effective implementation
Outcomes
Application to infection prevention practicesKrein SL, Olmsted RN, Hofer TP, Kowalski C, Forman J, Banaszak-Holl J, et al. Translating infection prevention evidence into practice using quantitative and qualitative research. Am. J. Infect. Control 2006;34(8):507-12.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Greenhalgh, et al’s Greenhalgh, et al’s Conceptual ModelConceptual Model
CIPRS: Stetler & Damschroder Theoretical Frameworks
PARiHS PARiHS FrameworkFramework 3 major domains
Evidence Context Facilitation
Continuums of high and low values that interrelate to influence implementation
Low
Evidence
High
HighContext
Facilitation
High
Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual. Health Care 1998;7(3):149-58.
Positive influence
Negative influence
CIPRS: Stetler & Damschroder Theoretical Frameworks
PRISM: PRISM: Practical, Robust Practical, Robust Implementation and Sustainability Implementation and Sustainability ModelModel
4 Domains: Intervention
Design Recipients External
Environment Implementation
& Sustainability Infrastructure
See references: Feldstein & Glasgow, 2008
CIPRS: Stetler & Damschroder Theoretical Frameworks
Implementation Implementation Effectiveness ModelEffectiveness Model
Quantitative measures of predictors of implementation effectiveness Strength of relationships empirically
estimated
Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: An organizational analysis. J Appl Psychol. 2001;86(5):811-824.
CIPRS: Stetler & Damschroder Theoretical Frameworks
CFIRCFIRConsolidated Framework for Consolidated Framework for
Implementation ResearchImplementation Research
List of 39 constructs that influence implementation
No specific relationships defined
Reflects theory from multiple disciplines and findings from empirical research
Code
ABCDEF
Complexity
GDesign Quality and Packaging
HCost
II. OUTER SETTING
APatient Needs & Resources
BCosmopolitanism
CPeer Pressure
DExternal Policies & Incentives
III. INNER SETTING
A
Structural Characteristics
BNetworks & Communications
CCulture
DImplementation Climate
1Tension for Change
2Compatibility
3Relative Priority
4Organizational Incentives & Rewards
5Goals and Feedback
6Learning Climate
DReadiness for Implementation
123
ABCDE
AB
2
CD
See references: Damschroder et al. Under Review.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Dual QUERI Objectives: Dual QUERI Objectives: RevisitedRevisited
Generalize knowledge about how to implement and sustain interventions
Replicate successful implementation
CIPRS: Stetler/Damschroder, Theoretical Frameworks
Selecting &Selecting & Using a Using a Theoretical Theoretical FrameworkFramework
CIPRS: Stetler & Damschroder Theoretical Frameworks
Uses/Potential Value Uses/Potential Value [PDI*][PDI*]
Provide a way of thinking about a study/project/implementation
Focus the user on what is important to the issue
Understand your EB-innovation/ recommendation/change
Develop a plan for formative evaluation; e.g., diagnostic analysis of barriers to and influences on using targeted best practices and applying an implementation strategy
Select and tailor interventions to promote the use of evidence [Intervention mapping]
Assist with operational definitions of intervention element
Describe relationships among elements/constructs
Guide development of hypotheses to test implementation science
Identify concepts that may be of importance and need to be statistically controlled or tracked
Help with measurement Facilitate interpretation re:
influences and meanings Identify boundaries around the
project/study Provide a framework for
summarizing, reporting findings
CIPRS: Stetler & Damschroder Theoretical Frameworks
Specific Selection and Specific Selection and Use: QUERI CentersUse: QUERI Centers
Use: Facilitate strategic planning overall Guide implementation science goals
Study, understand, predict causal mechanisms/paths
Evaluate chosen framework/s Selection:
Open selection; one or multiple “NO NEW THEORIES” [Banff, International
Conference, 2008]
CIPRS: Stetler & Damschroder Theoretical Frameworks
““Theoretical” SelectionTheoretical” Selection Origins of the
framework Meaning of the
framework Logical consistency Generalizability Parsimony Testability Usefulness
[Grol et al., 2007]
“QUERI” Evaluation:• In-depth
understanding• Theory criteria• Overall strengths• Overall limitations
• Missing elements
[QUERI PDI Working Group]
CIPRS: Stetler & Damschroder Theoretical Frameworks
Specific Selection and Specific Selection and Use: QUERI ProjectsUse: QUERI Projects
Use: Assessment Intervention planning Hypothesis generation Evaluation
Black box of implementation and progressive/interim outcomes
Usefulness of chosen theories
Selection: Based on the issue at hand Apparent relevance of your “broad” center
framework Strengths, limitations, relevance
CIPRS: Stetler & Damschroder Theoretical Frameworks
Project: Theory Selection and Project: Theory Selection and
UseUse 1. Your targeted EBP recommendation:
a. Explore others’ relevant experiences and results (Grey & published literature):Did they use process/impact theories? Which and to what
effect?Evidence of WHY and HOW a particular intervention/ strategy
did or did not work therein?Did they use isolated, atheoretical interventions or a multi-
faceted strategy?Evidence of WHY and HOW a particular intervention did or did
not work therein?What related barriers, facilitators, determinants have been
identified?Outside of QUERI?Prior Center work, including Step 3 activity?
CIPRS: Stetler & Damschroder Theoretical Frameworks
Project: Theory Selection and Use Project: Theory Selection and Use cont’dcont’d
b. Understand the nature of your innovation (e.g., per Rogers):
What are its attributes/characteristics? “Core/peripheral” to the clinician’s sense of their practice Complex or “simple” Obvious appeal or the reverse; etc.
What are the potential targets of change? Per Level/s: Individual, team, clinic, organization?
[CAVEAT: “Individuals” work in a context] Per Stage/focus of change: Awareness, knowledge,
skills, self-perception, attitude, behavior, systems, structures, etc.
Given this information, have potentially influential factors been clearly identified?
CIPRS: Stetler & Damschroder Theoretical Frameworks
Project: Theory Selection and Use Project: Theory Selection and Use cont’dcont’d
2. Choose “2” implementation theories to “try” as a “way of thinking” about your particular issue:
Per your general knowledge of their focus and or prior use
Per their strengths, limitations, potential usefulness for your issue
3. Assess “fit” of these various frameworks and make selection/s of one or more, as appropriate
CIPRS: Stetler & Damschroder Theoretical Frameworks
4.4. Plan your implementation project Plan your implementation project in context of the selected in context of the selected frameworkframework
a. Define relevant terms Conceptually Operationally /measurement and/or actions
b. Develop formative evaluation questions/tools [E.g., if PARIHS-related]
Local diagnostic analysis: E.g., assess likely barriers (How do stakeholders perceive the attributes of the expected change?)
Implementation-focused: E.g., actual barriers (To what extent does leadership actually support the new practice or adoption efforts?)
Progress-focused: E.g., interim staff performance on the new, expected innovation (Relates to designated outcomes or “successful implementation”)
Theoretical/Interpretive: E.g., to what extent did the framework provide an adequate description of results and related influential factors? (Were any significant factors missing?)
CIPRS: Stetler & Damschroder Theoretical Frameworks
4. Plan… Plan… cont’dcont’d
c. Select interventions, per theory/theories and in light of:
Expected barriers Prior studies’ findings Local diagnostic data
(Simple example: Complex E-B delivery system) Per PARIHS model, consider use of an external facilitator & routine
audit/feedback system; based on identified concerns of clinicians regarding strength of the evidence, additionally use social marketing actions/theory; based on prior similar study findings, use other “facilitation” techniques such as clinical reminder.
d. Identify “theory-related” hypotheses to be tested(Simple example: Complex E-B delivery system)
Test hypothesis that sites with an external facilitator will be more successful than comparison sites under analogous conditions of limited resources and passive leadership.
CIPRS: Stetler & Damschroder Theoretical Frameworks
Application ExamplesApplication Examples
April 14: Applying a Framework
Phil Ullrich A Mixed-model Approach-Intro
Jeffrey Smith
May 5: A Mixed-model Approach-Cont.
Jeffrey Smith Applying the CFIR
Laura Damschroder & Teresa Damush
CIPRS: Stetler & Damschroder Theoretical Frameworks
Challenges of Challenges of Understanding the Black Understanding the Black BoxBox
Implementation theories under-studied May be “borrowed” Few have been critically analyzed for
strengths/limitations Measurement tools limited Published studies use of theory
often unclear or absent
CIPRS: Stetler & Damschroder Theoretical Frameworks
QUERI’s Dual FunctionQUERI’s Dual Function
Improve practice through scientifically-based implementation
Increase understanding of implementation science
Transp
arent
Select
ion, U
se,
Evaluatio
n &
Explicit
Reporting o
f
THEORETICAL
FRAMEW
ORKS
CIPRS: Stetler & Damschroder Theoretical Frameworks
DISCUSSION/REACTION FORM