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Background Although the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established committee, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting. Methods: how the study was performed and statistical tests used A qualitative case study approach was utilised. The study gathered and analysed data using observations of committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies. Results: the main findings An overarching theme was a strong shared commitment to supporting clinicians with difficult decisions about patient care, and with navigating difficult discussions with patients and families. The role of the new committee in providing a pathway to raise with senior managers system-wide issues experienced by clinicians was also a key theme. Consumer and community participation in the new service remained a challenge in spite of strong clinical engagement, as did unresolved governance issues and a need for clearer policy relationship between the committee and the organisation. Conclusions: brief summary and potential implications Considering these themes in relation to the national capacity building resources, three areas are likely to require ongoing negotiation and further development: the clinical ethics committee as link between workforce and Executive; incorporating consumers and patients; and ethical reasoning. There is scope to increase clarity for the committee on its role at a governance and policy level, and on how to engage consumers, patients and families in the practices of the service. The capacity of the committee to reflect on complex cases may be enhanced by explicitly discussing different ethical frameworks and ways of deliberating.

Family and religion have been shown to be important to the majority of people in both the United Kingdom and the United States. Numerous research studies suggest that childhood relationships and environment are influential to mental health and well-being, with research on religious families significantly increasing in the last few decades. The purpose of this study is to explore counselors’ experiences of the influence of a fundamentalist religious upbringing on mental health and well-being in adulthood, across the Abrahamic traditions within the United Kingdom. The primary objectives are to psycho-educate professionals to recognize and understand the influence of a fundamentalist religious upbringing on mental health and well-being in adulthood, and to add to the sparse literature on this largely hidden topic. In-depth, qualitative, non-structured interviews were conducted with eight counselors (one withdrew at pre-analysis stage), who were collaborative co-researchers throughout the process. The focus of this article aligns with one of the interpretative readings of the interview transcripts undertaken by the researcher and co-researchers during the research process, namely appraising issues of power and control. The author outlines her insider researcher background, chosen methodology, co-researcher recruitment, and ethical considerations, before sharing the co-researchers’ stories around the power and control dynamics of a fundamentalist religious upbringing. The co-researchers’ adult religiosity is briefly outlined, before some brief reflections conclude the article.

Background Implementing and sustaining innovations in clinical practice, such as evidence-based practices, programmes, and policies, is frequently described as challenging. Facilitation as a strategy for supporting implementation requires a facilitator, i.e. an individual with a designated role to support the implementation process. A growing number of studies report that facilitation can help tackle the challenges in implementation efforts. To optimise the potential contribution of facilitation as a strategy to improve the implementation of new practices, there is a need to enhance understanding about what training and support is required for individuals in the facilitator role. The objective of this scoping review is to map how facilitators have been trained for, and supported in, the facilitator role in implementation studies in health and community care. Specifically, the review aims to examine what is reported on training and support of facilitators in terms of learning outcomes, content, dose, mode of delivery, learning activities, and qualifications of the trainers and how the facilitators perceive training and support. Methods This scoping review will follow the guidance of the Joanna Briggs Institute and the PRISMA Extension for Scoping Review checklist. We will include articles in which (a) facilitation is deployed as an implementation strategy, with identified facilitator roles targeting staff and managers, to support the implementation of specified innovations in health or community care, and (b) training and/or support of facilitators is reported. We will exclude articles where facilitation is directed to education or training in specific clinical procedures or if facilitation supports the implementation of general quality improvement systems. All types of peer-reviewed studies and study protocols published in English will be included. A systematic search will be performed in MEDLINE (Ovid), Embase (embase.com), Web of Science Core Collection, and CINAHL (Ebsco). Discussion The proposed scoping review will provide a systematic mapping of the literature on the training and support of implementation facilitators and contribute useful knowledge within the field of implementation science to inform future facilitation initiatives. Systematic review registration Registered at Open Science Framework (registration https://doi.org/10.17605/OSF.IO/M6NPQ).

Objectives: The challenges of improving the integration of care for older people with complex care needs are well recognised. Evidence suggests that solutions should be co-designed with older people to ensure they are contextually relevant and person-centred. Methods: As a first step in a co-design project to improve integrated care for older people, seven interviews and three workshops were held with older people and service providers. Data collected via recordings, notes and journey maps were inductively analysed. Results: Five themes were identified: relationships and roles, patient capacity and safety, information and systems, multiway communication, and transitions and flow. This created a more holistic and person-centred picture of integrated care than typically derived from published literature. Conclusions: Older people perceive integrated care from relational, organisational, informational and individual viewpoints. This reinforces the central importance of adopting a person-centred, as opposed to health system-focused, approach to designing and implementing integrated care solutions Refereed/Peer-reviewed

Background On admission to Woodlands Hospice’s inpatient ward, every patient has an initial assessment carried out by a nurse. A section of this assessment includes a psychosocial and spiritual component but this component was often not fully completed, sometimes resulting in delays to accessing appropriate personalised support for the patient. Our Pastoral Support Worker met with nursing colleagues and members of the Quality and Improvement team to discuss potential ideas for improving the assessment. They agreed we needed to look again at the process for assessing patients’ spiritual needs and the supporting documentation. Aims To support patients to identify what gives their lives meaning and purpose. To enhance each patient’s experience of the admission process. Further develop holistic therapeutic intervention, individualised to each patient’s needs. Support the improvement of mental health and wellbeing for every patient. Methods Conducted a baseline of the original ‘Psychosocial and Spiritual Assessment’. Spoke with patients and staff about how the assessment could be improved. Piloted a draft, patient-centred, inclusive spirituality assessment. Developed a spirituality care plan that reflected the needs of the patient, identified during the nurse admission assessment. Developed an e-learning module to support training for relevant staff. Re-audited the use of the revised spirituality assessment. Results Following the results of the baseline audit which highlighted areas for improvement, we developed the ‘HOPE’ assessment model and accompanying care plan. The HOPE approach allows for an open-ended exploration of an individual’s spiritual resources including their belief in organised religion, personal spirituality and beliefs, and their effects and subsequent evaluation. Conclusion Supporting each patient‘s individual spirituality practice can be beneficial to their overall experience. The HOPE approach is particularly useful and important to understanding a patient‘s spiritual needs, enhancing their experience and can support the development of a personalised care plan.

PurposeThe study describes the implementation of a novel strategy, entitled the Action Learning Set Facilitation Model, to develop internal facilitation capability to lead change. The Model incorporated the Novice-Experienced-Expert pathway, a facilitation development approach underpinning the integrated-Promoting Action on Research Implementation in Health Services Implementation Framework, with action learning methodology.Design/methodology/approachA mixed-methods descriptive approach reports the results of 22 interviews, 182 Action Learning Sets and 159 post program survey data sets to explore facilitator experiences, strengths and potential application of the Model.FindingsAt program completion, five novice (of 174) and one experienced (of 27) facilitator transitioned to the next facilitation level. The three groups of facilitators described positive change in confidence and facilitation skill, and experience of action learning sets. Inconsistencies between self-report competence and observed practice amongst novices was reported. Novices had decreasing exposure to the Model due to factors related to ongoing organisational change. Internal facilitators were considered trusted and credible facilitators.Research limitations/implicationsThere are practical and resource implications in investing in internal facilitation capability, noting proposed and real benefits of similar development programs may be compromised during, or as a consequence of organisational change. Further research describing application of the facilitation model, strategies to enhance multisystemic support for programs and evaluation support are suggested.Practical implicationsThe Action Learning Set Facilitation Model offers promise in developing internal facilitation capability supporting change in organisations. Critical success factors include building broad scale internal capability, stable leadership and longitudinal support to embed practice.Originality/valueThis is the first application of the facilitation component of the integrated-Promoting Action on Research Implementation in Health Services implementation framework embedded to action learning sets as an implementation science strategy for leader development supporting organisational change.

Background An intervention ‘Better Oral Health in Home Care’ was introduced (2012–2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people’s oral health. Objective To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project. Design A Realist Evaluation applying Normalisation Process Theory within a single case study setting. Setting Community aged care (home care) provider in South Australia, Australia. Participants Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated. Methods Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012–December 2014) and Time 2 (Post-implementation July 2017–July 2018). Results At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice. Conclusion Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.

Background: The approach and style of leaders is known to be an important factor influencing the translation of research evidence into nursing practice. However, questions remain as to what types of roles are most effective and the specific mechanisms through which influence is achieved.Objectives: The aim of the study was to enhance understanding of the mechanisms by which key nursing roles lead the implementation of evidence-based practice across different care settings and countries and the contextual factors that influence them.Design: The study employed a qualitative descriptive approach.Settings: Data collection was undertaken in acute care and primary/community health care settings in Australia, Canada, England and Sweden.Participants: 55 individuals representing different levels of the nursing leadership structure (executive to frontline), roles (managers and facilitators), sectors (acute and primary/community) and countries.Methods: Individual semi-structured interviews were conducted with all participants exploring their roles and experiences of leading evidence-based practice. Data were analysed through a process of qualitative content analysis.Results: Different countries had varying structural arrangements and roles to support evidence-based nursing practice. At a cross-country level, three main themes were identified relating to different mechanisms for enacting evidence-based practice, contextual influences at a policy, organisational and service delivery level and challenges of leading evidence-based practice.Conclusions: National policies around quality and performance shape priorities for evidence-based practice, which in turn influences the roles and mechanisms for implementation that are given prominence. There is a need to maintain a balance between the mechanisms of managing and monitoring performance and facilitating critical questioning and reflection in and on practice. This requires a careful blending of managerial and facilitative leadership. The findings have implications for theory, practice, education and research relating to implementation and evidence-based practice.

PurposeThe purpose of this paper is to introduce a special issue on boundary organising in healthcare bringing together a selection of six leading papers accepted for presentation at the 12th Organisational Behaviour in Health Care (OBHC 2020) Conference. Design/methodology/approachIn this introductory paper, the guest editors position the special issue papers in relation to the theoretical literature on boundaries and boundary organising and highlight how these contributions advance our understanding of boundary phenomena in healthcare.FindingsThree strands of thinking – practice-based, systems theory and place-based approaches – are briefly described, followed by an analytical summary of the six papers included in the special issue. The papers illustrate how the dynamic processes of boundary organising, stemming from the dual nature of boundaries and boundary objects, can be constrained and enabled by the complexity of broader multi-layered boundary landscapes, in which local clinical and managerial practices are embedded.Originality/valueThe authors set the scene for the papers included in the special issue, summarise their contributions and implications, and suggest directions for future research.Research implications/limitationsThe authors call for interdisciplinary and multi-theoretical investigations of boundary phenomena in health organisation and management, with a particular attention to (1) the interplay between multiple types of boundaries, actors and objects operating in complex multi-layered boundary systems; (2) diversity of the backgrounds, experiences and preferences of patients and services users and (3) the role of artificial intelligence and other non-human actors in boundary organising.Practical implicationsDeveloping strategies of reflection, mitigation, justification and relational work is crucial for the success of boundary organising initiatives.

IMPORTANCE: Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging. OBJECTIVES: To implement and evaluate a ward-based improvement program (“Eat Walk Engage”) to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis. INTERVENTION: A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles. MAIN OUTCOMES AND MEASURES: Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering. RESULTS: A total of 265 participants on 4 intervention wards (124 women [46.8%]; mean [SD] age, 75.9 [7.3] years) and 274 participants on 4 control wards (145 women [52.9%]; mean [SD] age, 78.0 [8.2] years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions. CONCLUSIONS AND RELEVANCE: The Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12615000879561

Many representations of the movement of healthcare knowledge through society exist, and multiple models for the translation of evidence into policy and practice have been articulated. Most are linear or cyclical and very few come close to reflecting the dense and intricate relationships, systems and politics of organizations and the processes required to enact sustainable improvements. We illustrate how using complexity and network concepts can better inform knowledge translation (KT) and argue that changing the way we think and talk about KT could enhance the creation and movement of knowledge throughout those systems needing to develop and utilise it. From our theoretical refinement, we propose that KT is a complex network composed of five interdependent sub-networks, or clusters, of key processes (problem identification [PI], knowledge creation [KC], knowledge synthesis [KS], implementation [I], and evaluation [E]) that interact dynamically in different ways at different times across one or more sectors (community; health; government; education; research for example). We call this the KT Complexity Network, defined as a network that optimises the effective, appropriate and timely creation and movement of knowledge to those who need it in order to improve what they do. Activation within and throughout any one of these processes and systems depends upon the agents promoting the change, successfully working across and between multiple systems and clusters. The case is presented for moving to a way of thinking about KT using complexity and network concepts. This extends the thinking that is developing around integrated KT approaches. There are a number of policy and practice implications that need to be considered in light of this shift in thinking.

Kislov and colleagues draw on multiple qualitative case studies of evidence-based nursing conducted in Sweden, Canada, Australia and the UK to describe the chain of codified knowledge which reflects the institutionalisation of evidence-based practice as organisational “business as usual”. This chain is dominated by performance standards, policies and procedures and locally collected data, i.e. various forms of “evidence by proxy” which are, at best, informed by research only partly or indirectly, but are nevertheless perceived as credible evidence. This chapter reveals dual effects of this codification dynamic on evidence-based practice and highlights the influence of macro-level ideological, historical and technological factors on the composition and circulation of codified knowledge. It concludes by outlining the practical implications of the study for change agency in health-care reform.

ObjectiveTo identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. MethodsA qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. ResultsThree main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. ConclusionsSystematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic?High volume–low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add?Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners?New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

This paper considers an implication of the idea that proposals for integrated care for older people should start from a focus on the patient, consider co-production solutions to the problems of care fragmentation, and be at a system-wide, cross-organisational level. It follows that the analysis, design and therefore evaluation of integrated care projects should be based upon the journeys which older patients with multiple chronic conditions usually have to make from professional to professional and service to service. A systematic realistic review of recent research on integrated care projects identified a number of key mechanisms for care integration, including multidisciplinary care teams, care planning, suitable IT support and changes to organisational culture, besides other activities and contexts which assist care 'integration.' Those findings suggest that bringing the diverse services that older people with multiple chronic conditions need into a single organisation would remove many of the inter-organisational boundaries that impede care 'integration' and make it easier to address the interprofessional and inter-service boundaries.

Background A multitude of theories, models and frameworks relating to implementing evidence-based practice in health care exist, which can be overwhelming for clinicians and clinical researchers new to the field of implementation science. Clinicians often bear responsibility for implementation, but may be unfamiliar with theoretical approaches designed to inform or understand implementation. Main text In this article, a multidisciplinary group of clinicians and health service researchers present a pragmatic guide to help clinicians and clinical researchers understand what implementation theories, models and frameworks are; how a theoretical approach to implementation might be used; and some prompts to consider when selecting a theoretical approach for an implementation project. Ten commonly used and highly cited theoretical approaches are presented, none of which have been utilised to their full potential in the literature to date. Specifically, theoretical approaches tend to be applied retrospectively to evaluate or interpret findings from a completed implementation project, rather than being used to plan and design theory-informed implementation strategies which would intuitively have a greater likelihood of success. We emphasise that there is no right or wrong way of selecting a theoretical approach, but encourage clinicians to carefully consider the project’s purpose, scope and available data and resources to allow them to select an approach that is most likely to “value-add” to the implementation project. Conclusion By assisting clinicians and clinical researchers to become confident in selecting and applying theoretical approaches to implementation, we anticipate an increase in theory-informed implementation projects. This then will contribute to more nuanced advice on how to address evidence-practice gaps and ultimately to contribute to better health outcomes. Electronic supplementary material The online version of this article (10.1186/s12913-018-3671-z) contains supplementary material, which is available to authorized users.

Background: The 'Facilitating Implementation of Research Evidence' study found no significant differences between sites that received two types of facilitation support and those that did not on the primary outcome of documented compliance with guideline recommendations. Process evaluation highlighted factors that influenced local, internal facilitators' ability to enact the roles as envisaged. In this paper, the external facilitators responsible for designing and delivering the two types of facilitation intervention analyse why the interventions proved difficult to implement as expected, including the challenge of balancing fidelity and adaptation.Methods: Qualitative data sources included notes from monthly internal-external facilitator teleconference meetings, from closing events for the two facilitation interventions and summary data analyses from repeated interviews with 16 internal facilitators. Deductive and inductive data analysis was led by an independent researcher to evaluate how facilitation in practice compared to the logic pathways designed to guide fidelity in the delivery of the interventions.Results: The planned facilitation interventions did not work as predicted. Difficulties were encountered in each of the five elements of the logic pathway: recruitment and selection of appropriate internal facilitators, preparation for the role, ability to apply facilitation knowledge and skills at a local level, support and mentorship from external facilitators via monthly teleconferences, working collaboratively and enabling colleagues to implement guideline recommendations. Moreover, problems were cumulative and created tensions for the external facilitators in terms of balancing the logic pathway with a more real-world, flexible and iterative approach to facilitation.Conclusion: Evaluating an intervention that is fluid and dynamic within the methodology of a randomised controlled trial is complex and challenging. At a practical level, relational aspects of facilitation are critically important. It is essential to recruit and retain individuals with the appropriate set of skills and characteristics, explicit support from managerial leaders and accessible mentorship from more experienced facilitators. At a methodological level, there is a need for attention to the balance between fidelity and adaptation of interventions. For future studies, we suggest a theoretical approach to fidelity, with a focus on mechanisms, informed by prospective use of process evaluation data and more detailed investigation of the context-facilitation dynamic.

Background: The Carer Support Needs Assessment Tool (CSNAT) intervention is an evidence-based, person-centred approach to carer assessment and support within palliative care. As such, it requires a change in practice from a practitioner- to a carer-led assessment and support process. A paucity of studies have investigated factors affecting implementation of evidence based interventions within palliative care. Objectives: To examine differences between high and low adopters of the CSNAT intervention in terms of practitioner attitudes to the intervention and organisational context.Methods: Phase IV study of implementation of the CSNAT intervention at scale in 36 UK palliative care services over six months. Survey at baseline and six months of practitioners at implementation sites, informed by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework. Survey tools: (i) questionnaire to assess attitudes to the CSNAT intervention; (ii) Alberta Context Tool (ACT) to assess organisational context. Monthly data on intervention use enabled service classification as ‘high’ or ‘low’ adopters. Results: 157/462 surveys returned at baseline; 69/462 at six months. Compared with ‘low’ adoption services, ‘high’ adopters were more likely to be hospice at home and day services; have a higher ratio of internal facilitators to total staff numbers; and higher scores for ACT ‘informal interactions’ denoting more discussions about care between colleagues. Both had similarly positive attitudes to the CSNAT intervention pre-implementation, but by six months ‘low’ adoption services developed significantly more negative attitudes; while in ‘high’ adoption services attitudes mostly remained the same/improved.Linking evidence to action: Implementation may be more successful for services that offer regular opportunities to use the intervention in practice, have sufficient levels of facilitators, stimulate more staff discussion, and encourage maintenance of positive motivation. Implementation of person-centred interventions needs to plan for such factors. This has informed an implementation toolkit for the CSNAT intervention.

Objectives It is usually taken for granted that ‘the best available evidence’ is represented by the findings of rigorous scientific research which, in turn, directly inform the development of recommendations for practice in the form of clinical guidelines. We challenge this assumption and examine the role played in the enactment of evidence-based healthcare by other forms of codified knowledge, i.e. knowledge that is formal, systematic and expressible in language or numbers, making it easy to store, transfer and utilise across space. The study addresses the following research questions: What forms of codified knowledge are seen as credible evidence by practitioners? What are the relationships between these forms of knowledge in the enactment of evidence–based practice within healthcare organisations? What is the impact of these forms of knowledge on evidence–based practice? How do the composition and impact of codified knowledge vary across different high–income countries? Method This exploratory study emerged from a broader research programme examining leadership and facilitation in the implementation of evidence-based nursing across the UK, Australia, Canada and Sweden. Within each country, up to two organisations were selected based on the following criteria: self-declared adherence to the implementation of evidence-based nursing; adequate organisational performance; and broad access to several levels within the organisational hierarchy granted to the researchers. 55 research participants were recruited to represent different levels of the hierarchy, roles and sectors. Semi-structured interviews served as the main method of data collection. Data analysis was organised in two stages. The first stage, focusing on the construction of country-specific narratives, combined the codes derived from the interview guide with descriptive codes that emerged inductively. The second stage utilised the deductive coding framework informed by the literature and applied across all four datasets. Matrix analysis was deployed to facilitate cross-case analysis. Results We argue that research evidence and its direct derivatives, such as clinical guidelines, are NOT the dominant forms of codified knowledge deployed in the organisational enactment of evidence-based healthcare. We describe the chain of codified knowledge which reflects the institutionalisation of evidence-based healthcare as organisational ‘business as usual’. This chain is dominated by performance standards, policies and procedures, and locally collected (improvement and audit) data, i.e. various forms of ‘evidence by proxy’ which are, at best, informed by research partly or indirectly but are nevertheless perceived as credible evidence. Our cross-country analysis highlights the influence of macro-level ideological, historical and technological factors on the composition and circulation of codified knowledge. Prioritisation of ‘evidence’ by proxy’ and marginalisation of clinical guidelines are likely to be more prominent in those countries, whose healthcare sectors have historically been more engaged with the New Public Management logics of standardisation and performance measurement. Conclusions Our analysis reveals dual effects of this codification dynamic on evidence-based healthcare. On the one hand, the legitimisation and mobilisation of contextual and local knowledge counterbalance ‘dogmatic authoritarianism’ apparent in the more restrictive interpretations of ‘evidence’ and potentially enable bottom-up knowledge flows. On the other hand, this is achieved through a significant dilution of the initial paradigm, excessive formalisation, and detachment of frontline staff from the fundamental competencies and knowledge base of evidence-based decision-making, whereby direct use of research evidence and clinical guidelines is becoming a prerogative of experts, represented by professional elites and designated facilitators.

Background: \ud \ud Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy.\ud \ud Methods: \ud \ud The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data.\ud \ud Results: \ud \ud The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made\ud little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency’s intended roll out strategy using passive web-based facilitation appeared to have little impact.\ud \ud Conclusions: \ud \ud When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation\ud resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention.

This study examined how and why performance management works to achieve accountability and improvement among voluntary organizations, through the use of performance information. Applying realist evaluation methodology, initial programme theories of performance management were developed and tested against empirical data gathered from six case studies in the voluntary sector in Singapore. Considerable variation in implementation undermined the success of performance management, leading to the use of performance information primarily for reporting purposes rather than for learning and improvement. Findings highlight the need for greater attention to the contexts necessary to optimize the effective implementation of performance management.

International attention has focussed on the variations between research evidence and practice in healthcare. This prompted the creation of formalized translational networks consisting of academic-service partnerships. The English Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) are one example of a translational network. Using longitudinal, archival case study data from one CLAHRC over a 3-year period (2008-11), this article explores the relationship between organizational form and the function(s) of a translational network. The article focuses on the research gaps on the effective structures and appropriate governance to support a translational network. Data analysis suggested that the policy of setting up translational networks is insufficient of itself to produce positive translational activity. The data indicate that to leverage the benefits of the whole network, attention must be paid to devising a structure which integrates research production and use and facilitates lateral cross-disciplinary and cross-organizational communication. Equally, appropriate governance arrangements are necessary, particularly in large, multi-stakeholder networks, where shared governance may be questionable. Inappropriate network structure and governance inhibits the potential of the translational network. Finally, the case provides insights into the movement of knowledge within and between network organizations. The data demonstrate that knowledge mobilization extends beyond knowledge translation; knowledge mobilization includes the negotiated utilization of knowledge - a balanced power form of collaboration. Whilst much translational effort is externally focused on the health system, our findings highlight the essential need for the internal negotiation and mobilization of knowledge within academia.

Debates about knowledge translation (KT) typically focus on the research–practice gap, which appears to be premised on the assumption that academics are a homogeneous collective, sharing a common view. We argue that a number of hidden barriers need to be addressed related to the understanding, interpretation, ability, and commitment to translate knowledge within academic communities. We explore this by presenting a qualitative case study in a health sciences faculty. Applying organizational and management theory, we discuss different types of boundaries and the resultant barriers generated, ranging from diversity in understanding and perceptions of KT to varying motivations and incentives to engage in translational activity. We illustrate how we are using the empirical findings to inform the development of a KT strategy that targets the identified barriers. Investing in this internal KT-focused activity is an important step to maximize the potential of future collaborations between producers and users of research in health care.

Background: Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.Methods: A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention.Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.Results: Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.Conclusions: This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.Trial registration: Current Controlled Trials ISRCTN11598502. Date 4/2/10.The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007–2013) under grant agreement no. 223646.

When applied to solving real-world problems in organisational settings, service improvement techniques are likely to evolve over time in response to the context of their implementation. However, the temporal dynamics of this evolution and its underlying microprocesses remain underresearched. To address this gap, we present a qualitative longitudinal case study of facilitation as a service improvement technique utilised by a UK-based collaborative knowledge mobilisation programme to improve the detection and management of Chronic Kidney Disease in primary care organisations. We argue that an uncritical and uncontrolled adaptation of facilitation may undermine its promise to positively affect organisational learning processes and mask the unsustainable nature of the resulting improvement outcomes captured by conventional performance measurement.

QUALITY PROBLEM: Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. INITIAL ASSESSMENT: Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses. CHOICE OF SOLUTION: An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. IMPLEMENTATION: A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. EVALUATION: Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. LESSONS LEARNED: An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.

Background Organisational context is frequently cited as an important consideration when implementing and evaluating quality improvement interventions in healthcare, but limited guidance is available on which aspects of context are most influential or modifiable. This paper examines how internal and external contextual factors mediate organisational-level performance improvement through applying the knowledge-based theory of absorptive capacity (AC). Methods Three healthcare case studies are presented. Each case is a UK National Health Service organisation that had been identified as having performance problems. Qualitative data were collected through semi-structured interviews with general and clinical managers within the organisation and members of external teams supporting or overseeing performance improvement (n=22). Interview data were analysed using an existing AC framework from the literature. Results The organisation with the highest AC showed the quickest and most comprehensive performance improvement. Internal characteristics including strategic priorities, processes for managing information, communication and orientation to learning and development impacted on the organisation's ability to engage successfully with external stakeholders and make use of available knowledge. This enabled the organisation to thrive despite the challenging external environment. Lower levels of AC appeared to delay or limit the improvement trajectory. Conclusions Developing a more detailed and nuanced understanding of how context influences improvement is an important step towards achieving more effective and sustainable quality improvement programmes in healthcare. AC, with its focus on knowledge and organisational learning, provides a useful way to explore the relationship between context and quality improvement and represents a potentially valuable area for future research and development.

Drawing on multiple qualitative case studies of evidence-based healthcare conducted in Sweden, Canada, Australia and the UK, we systematically explore the composition, circulation and role of codif...

When applied to solving real-world problems in the public sector, managerial techniques are likely to evolve over time in response to the context of their implementation. The temporal dynamics of this evolution and its underlying processes, however, remain under-researched. To address this gap, we present a qualitative longitudinal case study of a UK-based knowledge mobilization programme utilizing “facilitation” as a service improvement approach. We describe the processes underpinning the distortion of facilitation over time and argue that an uncritical and uncontrolled adaptation of managerial techniques may mask the unsustainable nature of the resulting improvement outcomes captured by conventional performance measurement.

Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

Background Chronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care. Methods A rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation. Results Our primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs. Conclusions Our rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0413-7) contains supplementary material, which is available to authorized users.

Background Multi-faceted approaches are generally recognised as the most effective way to support the implementation of evidence into practice. Audit and feedback often constitute one element of a multi-faceted implementation package, alongside other strategies, such as interactive education and facilitated support mechanisms. This paper describes a multi-faceted implementation strategy that used the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) as an online audit tool to support facilitators working to introduce evidence-based continence recommendations in nursing homes in four different European countries. Aims/objectives The paper describes the experience of using PACES with an international group of nursing home facilitators. In particular, the objectives of the paper are: to describe the process of introducing PACES to internal facilitators in eight nursing homes; to discuss the progress made during a 12-month period of collecting and analysing audit data using PACES; to summarise the collective experience of using PACES, including reflections on its strengths and limitations. Methods Descriptive data were collected during the 12-month period of working with PACES in the eight nursing home sites. These data included digital and written notes taken at an initial 3-day introductory programme, at monthly teleconferences held between the external and internal facilitators and at a final 2-day meeting. Qualitative analysis of the data was undertaken on an ongoing basis throughout the implementation period, which enabled formative evaluation of PACES. A final summative evaluation of the experience of using PACES was undertaken as part of the closing project meeting in June 2011. Results The nursing home facilitators took longer than anticipated to introduce PACES and it was only after 9‐10 months that they became confident and comfortable using the system. This was due to a combination of factors, including a lack of audit knowledge and skills, limited IT access and skills, language difficulties and problems with the PACES system itself. The initial plan of undertaking a full baseline audit followed by focused action cycles had to be revised to allow a more staged, smaller-scale approach to implementation and audit. This involved simplifying the audit process and removing steps such as the calculation of population size estimates. As a result, an accurate baseline measure, prior to introducing changes to continence care, was not achieved. However, by the end of the 12 months, the majority of facilitators had undertaken a full audit and reported value in the process. In particular, they benefited from comparing audit data across sites to share learning and best practice. Discussion/conclusion Working with PACES as part of a facilitated programme to support the implementation of evidence-based continence recommendations in nursing homes in four European countries has been a valuable learning experience, although not without its challenges. The findings highlight the importance of thorough training and support for first time users of PACES and the need to make the audit process as simple as possible in the initial stages.

Health care faces challenges that are only partially addressed by incremental innovations. This paper outlines the potential for action learning to be used to challenge existing paradigms and mindsets. It provides the background and introduction to the concept, and describes the main principles and approach. Limitations in the theoretical conceptualization and research evidence about action learning are explored. Meanwhile, action learning has been used as a learning tool for graduate entry-level health service managers, senior health-care leaders, and students on postgraduate courses. Evaluations of these programmes have unearthed the key characteristics and benefits of effective action learning. The conclusions are that effective action learning is enabled by skilled facilitation, has benefits in embedding double-loop learning and developing personal resilience, and may result in enhanced organizational ambidexterity. Further work is now required to build a stronger conceptual framework and to e...

Objective This study evaluated Leading 4 Change, a change leadership development program designed to support healthcare middle managers through a period of significant organisational change and enhance workplace resilience. Methods A mixed methods evaluation was conducted within the program’s framework of a quality improvement activity. Quantitative measures were participant responses (n=160) to online questionnaires, which were compared before and after the program, using an uncontrolled pre-post study design. Four questionnaires were used: Resilience @ Work, General Self-Efficacy, the 11-item Learning Organization Survey and organisational climate. Differences between the pre- and post-program periods were compared using linear mixed-effects models, incorporating repeated measures between ‘pre’ and ‘post’ periods. Qualitative data were obtained by interviewing four participants on three occasions during the program, and through text responses provided by participants during a presentation session after the program finished. Both interview data and textual data were subjected to thematic analysis. Results Integration of data from quantitative and qualitative analyses generated three main findings: (1) participants were satisfied and engaged with the program, which met their learning objectives; (2) the program led to increased workplace resilience, in particular the ability to manage stress and self-efficacy for individuals; and (3) organisational learning perceptions were unchanged. Conclusion Although conducted during a period of intense internal and external pressure, Leading 4 Change led to demonstrable effects. It effectively engaged middle managers across a health system. However, there was no evidence that the effect of the program extended beyond individual participants to their perceptions of their work environment as a learning organisation. What is known about the topic? Although much has been written about change management and change leadership within healthcare, the failure to manage the ‘people’ element and engage employees hampers the success of that change. However, how to engage employees and enhance their resilience and self-efficacy (self-belief to proactively manage) during change has been little explored. Further, the concept of a learning organisation has been developed in private, non-healthcare fields and there is little known about it in other areas, such as healthcare, particularly during change. What does this paper add? The paper describes the evaluation of a 16-week change leadership development program (Leading 4 Change) for middle managers of a public health system undergoing significant reform. It assesses how the program engaged employees, and how and to what extent their workplace resilience, self-efficacy and perceptions of their workplace as a learning organisation changed after the program. Based on the present study, individual development of staff does not necessarily translate directly to better staff perceptions of organisational outcomes. What are the implications for practitioners? Despite being clearly engaged with Leading 4 Change, quantitative and qualitative measures suggested mixed effects of the program on participants. Participants’ self-rated workplace resilience, ability to manage stress and self-efficacy increased after the program. However, there was no evidence that the effect of the program improved staff perceptions of their work as a learning organisation. For complex public sector healthcare organisations to become learning organisations, other organisational factors, in addition to staff development and training, require consideration.

Gill Harvey offers her advice on planning and running educational and safe school trips, including tips for schools that decide to work with a tour operator or other provider

Improved performance by public sector organizations is a political imperative in numerous countries. There are particular challenges in turnaround of poorly performing organizations. Theoretical explanations of the performance trajectories of public organizations, and especially the causes of failure, highlight the importance of knowledge processes, often from an organizational learning perspective. Absorptive capacity provides an alternative way of theorizing the relationships between organizational performance and knowledge processes, derived from the resource-based view of the firm and the broader concept of dynamic capabilities. The article reviews the conceptual, theoretical, and methodological implications of applying absorptive capacity to the performance of public organizations. It concludes that the approach has value and presents a number of propositions to be tested through empirical study, alongside some more general challenges for researchers who wish to study the concept further. Th...

English As a conclusion to this special edition, this article explores discussions at the final seminar in the series. Focusing on a case study topic (hospital discharge), participants were provided with six sources of evidence chosen to illustrate six very different approaches to generating valid knowledge. Participants then explored a series of questions about each (including reliability/validity, key limitations and contributions to new knowledge). Overall, none of the sources was felt to offer a definitive insight into the issue at stake. A key challenge, therefore, is to design deliberative processes to synthesise and integrate evidence of different types and from multiple sources.

BackgroundThe establishment of the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) was the culmination of a number of policy initiatives to bridge the gap between evidence and practice. CLAHRCs were created and funded to facilitate development of partnerships and connect the worlds of academia and practice in an effort to improve patient outcomes through the conduct and application of applied health research.ObjectivesOur starting point was to test the theory that bringing higher education institutions and health-care organisations closer together catalyses knowledge mobilisation. The overall purpose was to develop explanatory theory regarding implementation through CLAHRCs and answer the question ‘what works, for whom, why and in what circumstances?’. The study objectives focused on identifying and tracking implementation mechanisms and processes over time; determining what influences whether or not and how research is used in CLAHRCs; investigating the role played by boundary objects in the success or failure of implementation; and determining whether or not and how CLAHRCs develop and sustain interactions and communities of practice.MethodsThis study was a longitudinal realist evaluation using multiple qualitative case studies, incorporating stakeholder engagement and formative feedback. Three CLAHRCs were studied in depth over four rounds of data collection through a process of hypothesis generation, refining, testing and programme theory specification. Data collection included interviews, observation, documents, feedback sessions and an interpretive forum.FindingsKnowledge mobilisation in CLAHRCs was a function of a number of interconnected issues that provided more or less conducive conditions for collective action. The potential of CLAHRCs to close the metaphorical ‘know–do’ gap was dependent on historical regional relationships, their approach to engaging different communities, their architectures, what priorities were set and how, and providing additional resources for implementation, including investment in roles and activities to bridge and broker boundaries. Additionally, we observed a balance towards conducting research rather than implementing it. Key mechanisms of interpretations of collaborative action, opportunities for connectivity, facilitation, motivation, review and reflection, and unlocking barriers/releasing potential were important to the processes and outcomes of CLAHRCs. These mechanisms operated in different contexts including stakeholders’ positioning, or ‘where they were coming from’, governance arrangements, availability of resources, competing drivers, receptiveness to learning and evaluation, and alignment of structures, positions and resources. Preceding conditions influenced the course and journey of the CLAHRCs in a path-dependent way. We observed them evolving over time and their development led to the accumulation of different types of impacts, from those that were conceptual to, later in their life cycle, those that were more direct.ConclusionsMost studies of implementation focus on researching one-off projects, so a strength of this study was in researching a systems approach to knowledge mobilisation over time. Although CLAHRC-like approaches show promise, realising their full potential will require a longer and more sustained focus on relationship building, resource allocation and, in some cases, culture change. This reinforces the point that research implementation within a CLAHRC model is a long-term investment and one that is set within a life cycle of organisational collaboration.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background: Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by\ud bringing research users and producers closer together, a theory that is largely untested. This paper reports a\ud national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration\ud and implementation.\ud Methods: A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with\ud three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four\ud rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured\ud interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined\ud inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over\ud data collection rounds.\ud Results: The quality of existing relationships between higher education and local health service, and views about\ud whether implementation was a collaborative act, created a path dependency. Where implementation was\ud perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus\ud on knowledge production and transfer, rather than co-production. The collaborations’ architectures were\ud counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic\ud boundaries. More distributed leadership was associated with greater potential for engagement. The creation of\ud boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles\ud resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out\ud strongly as a context for motivation to engage, in that ‘what’s in it for me’ resulted in variable levels of engagement\ud along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on\ud attention to evaluation.\ud Conclusions: These collaborations did not emerge from a vacuum, and they needed time to learn and develop.\ud Their life cycle started with their position on collaboration, knowledge and implementation. More impactful\ud attempts at collective action in implementation might be determined by the deliberate alignment of a number of\ud features, including foundational relationships, vision, values, structures and processes and views about the nature of\ud the collaboration and implementation.

In this chapter we review how the PARIHS framework has been applied over the last 15 years to guide and evaluate the implementation of evidence-based practice in healthcare. We also consider how PARIHS compares to other implementation frameworks and models by drawing on some recently completed reviews within the implementation science literature. We then summarise the key theories that have been influential in informing and developing our understanding and practice of facilitation since the original development of the PARIHS framework. Building on this preceding discussion, we will explain why and how we have revised the PARIHS framework from its original conception to what we are now calling the integrated-PARIHS or i-PARIHS framework. This revised framework includes a re-conceptualisation of the constructs to be considered during implementation and is more explicitly underpinned by relevant theories of innovation, behavioural and organisational change and improvement. By bringing together our own and others’ experiential and empirical evidence of using PARIHS with the wider theoretical literature, our intention has been to produce a more integrated conceptual framework to guide implementation. The core elements of i-PARIHS will be described, namely: the innovation to be implemented; the intended recipients of the innovation; the internal and external context in which implementation takes place; and the facilitation approach that is required to operationalise the framework.

In the i-PARIHS framework, we argue that facilitation is the driving force for the successful implementation of evidence-based innovation in practice. Facilitation is also an enabler for the successful embedding, sustaining and spread of the innovation across, within and between individuals, teams and organisations. Facilitation achieves this by focusing on relationships, individual and group learning and managing the myriad of contextual factors that make each implementation journey unique.