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Implementation Research Theoretical Frameworks CyberSeminar Series . 4-Part Series: April 7 April 14 May 5 May 12. Objectives. Purpose/potential value and uses Process for selection and use Nature and underlying rationale of specific frameworks/approaches Evaluation. APRIL.

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implementation research theoretical frameworks cyberseminar series

Implementation Research Theoretical FrameworksCyberSeminar Series

4-Part Series:

April 7

April 14

May 5

May 12

CIPRS: Stetler/Damschroder, Theoretical Frameworks

objectives
Objectives
  • Purpose/potential value and uses
  • Process for selection and use
  • Nature and underlying rationale of specific frameworks/approaches
  • Evaluation

CIPRS: Stetler & Damschroder Theoretical Frameworks

april
APRIL
  • 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

slide4
MAY
  • May 5: A Mixed-model Approach-Cont.

Jeffrey Smith

Applying the CFIR

Laura Damschroder & Teresa Damush

  • May 12: Respond to Participant Interests/

Dialogue with Presenters

The “Theory” Team

CIPRS: Stetler & Damschroder Theoretical Frameworks

your active participation
Your Active Participation
  • 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:

cheryl.stetler@comcast.net

CIPRS: Stetler & Damschroder Theoretical Frameworks

foundations
Foundations
  • What are implementation “theories”?
  • How and why are they useful?

CIPRS: Stetler & Damschroder Theoretical Frameworks

foundations terminology
Foundations Terminology
  • Theory
  • Theoretical/conceptual framework
  • Model

CIPRS: Stetler & Damschroder Theoretical Frameworks

handout
Handout
  • 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

theory
Theory
  • 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 conceptual framework
Theoretical or Conceptual Framework
  • 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

model
Model
  • 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 illustration 1
No Commonality… Illustration1!
  • Conceptual models
    • Theories of change
    • Frameworks

CIPRS: Stetler & Damschroder Theoretical Frameworks

1.Ref: Graham& Tetroe, in press

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?
  • BUT: “Common Sense” alone hasn’t worked so far…
    • Trial & error approach
    • Reinventing the wheel
    • Cherry-picking interventions
    • Retrospectively trying to understand the black box

CIPRS: Stetler & Damschroder Theoretical Frameworks

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.

why theory queri dual objectives
Why “Theory”:QUERI Dual Objectives
  • 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 objectives
QUERI Dual Objectives
  • 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 planning
Using Theory for Implementation Planning

Select interventionsthat fit with plannedstrategies (based on theory)

Select theory of planned behaviorchange

Identify potential strategies for achieving change

Assess fit with initial theory

Evaluate effectivenessof intervention,strategies, tools

Launch interventionusing identified toolsand strategies

Identify interventiontools that fit bothstrategy and theory

CIPRS: Stetler & Damschroder Theoretical Frameworks

See references: Sales et al., 2006

using theory for implementation planning18
Using Theory for Implementation Planning

Select interventionsthat fit with plannedstrategies (based on theory)

Select theory of planned behaviorchange

Identify potential strategies for achieving change

Frameworks

Theories

Models

Assess fit with initial theory

Select theory of planned behaviorchange

Evaluate effectivenessof intervention,strategies, tools

Launch interventionusing identified toolsand strategies

Identify interventiontools that fit bothstrategy and theory

CIPRS: Stetler & Damschroder Theoretical Frameworks

See references: Sales et al., 2006

selecting a theory 1
Selecting 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 2
Selecting 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

CIPRS: Stetler & Damschroder Theoretical Frameworks

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.

theories re implementation
Theories re:Implementation
  • 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 theories
TYPES: Process Theories
  • 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
  • See references: Graham & Tetroe, in press
  • Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.
  • Grol, et al. 2007
  • 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.
  • 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 of research use
Ottawa Model ofResearch Use
  • Action-oriented
    • Prescribes 3 main steps
      • Assess
      • Monitor
      • Evaluate

CIPRS: Stetler & Damschroder Theoretical Frameworks

Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.

framework of dissemination in health services intervention research
Framework of Dissemination in Health Services Intervention Research

CIPRS: Stetler & Damschroder Theoretical Frameworks

Mendel et al, 2008

slide25

2001

CIPRS: Stetler & Damschroder Theoretical Frameworks

impact theories 1
Impact Theories - 1
  • Individual-level theories
    • Stage of change
    • Cognitive
    • Educational
    • Motivational

CIPRS: Stetler & Damschroder Theoretical Frameworks

Grol et al, 2007

individual level stage of change
Individual Level: Stage of Change
  • 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

CIPRS: Stetler & Damschroder Theoretical Frameworks

Grol et al, 2007

social cognitive theory
Social Cognitive Theory
  • 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.

Organizational Setting

CIPRS: Stetler & Damschroder Theoretical Frameworks

http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/

theory of planned behavior
Theory of Planned Behavior
  • Motivational theory

CIPRS: Stetler & Damschroder Theoretical Frameworks

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

impact theories 2
Impact Theories - 2
  • Social context theories
    • Social Marketing
    • Social learning
    • Communication
    • Social network & influence
    • Teamwork
    • Professional development
    • Leadership

CIPRS: Stetler & Damschroder Theoretical Frameworks

Grol et al, 2007.

social network theory
Social Network Theory
  • Tailor engagement strategy to social networks

CIPRS: Stetler & Damschroder Theoretical Frameworks

http://www.istheory.yorku.ca/socialnetworktheory.htm

impact theories 3
Impact Theories - 3
  • Organizational Context Theories
    • Innovative organizations
    • Quality management
    • Integrated care
    • Complexity
    • Organizational learning
    • Organizational culture
  • Political & Economic Context Theories
    • Reimbursement
    • Contracting

CIPRS: Stetler & Damschroder Theoretical Frameworks

Grol et al, 2007.

roger s theory of diffusion
Roger’s Theory of Diffusion

Characteristics of the intervention

Effective implementation

Organizational characteristics

Outcomes

Adoption decision

Environmental context

Application to infection prevention practices

Krein 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 conceptual model
Greenhalgh, et al’s Conceptual Model

CIPRS: Stetler & Damschroder Theoretical Frameworks

parihs framework

High

Evidence

High

Facilitation

Low

Context

High

PARiHS Framework

Positive influence

  • 3 major domains
    • Evidence
    • Context
    • Facilitation
  • Continuums of high and low values that interrelate to influence implementation

Negative influence

Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual. Health Care 1998;7(3):149-58.

CIPRS: Stetler & Damschroder Theoretical Frameworks

prism practical robust implementation and sustainability model
PRISM: Practical, Robust Implementation and Sustainability Model
  • 4 Domains:
    • Intervention Design
    • Recipients
    • External Environment
    • Implementation & Sustainability Infrastructure

CIPRS: Stetler & Damschroder Theoretical Frameworks

See references: Feldstein & Glasgow, 2008

implementation effectiveness model
Implementation Effectiveness Model
  • Quantitative measures of predictors of implementation effectiveness
    • Strength of relationships empirically estimated

CIPRS: Stetler & Damschroder Theoretical Frameworks

Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: An organizational analysis. J Appl Psychol. 2001;86(5):811-824.

cfir consolidated framework for implementation research
CFIRConsolidated Framework for Implementation Research
  • List of 39 constructs that influence implementation
  • No specific relationships defined
  • Reflects theory from multiple disciplines and findings from empirical research

CIPRS: Stetler & Damschroder Theoretical Frameworks

See references: Damschroder et al. Under Review.

dual queri objectives revisited
Dual QUERI Objectives: Revisited
  • Generalize knowledge about how to implement and sustain interventions
  • Replicate successful implementation

CIPRS: Stetler & Damschroder Theoretical Frameworks

selecting using a theoretical framework

Selecting & Using a Theoretical Framework

CIPRS: Stetler/Damschroder, Theoretical Frameworks

uses potential value 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

Uses/Potential Value [PDI*]

CIPRS: Stetler & Damschroder Theoretical Frameworks

specific selection and use queri centers
Specific Selection and Use: 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 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]

“Theoretical” Selection

CIPRS: Stetler & Damschroder Theoretical Frameworks

specific selection and use queri projects
Specific Selection and Use: 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 use
Project: Theory Selection and Use

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 cont d
Project: Theory Selection and Use cont’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 cont d47
Project: Theory Selection and Use cont’d
  • 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 usefulnessfor your issue
  • Assess “fit” of these various frameworks and make selection/s of one or more, as appropriate

CIPRS: Stetler & Damschroder Theoretical Frameworks

plan your implementation project in context of the selected framework
Plan your implementation project in context of the selected framework
  • 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 cont d
4. Plan…cont’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 examples
Application 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 understanding the black box
Challenges of Understanding the Black Box
  • 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 function
QUERI’s Dual Function

Transparent Selection, Use, Evaluation & Explicit Reporting of THEORETICAL FRAMEWORKS

  • Improve practice through scientifically-based implementation
  • Increase understanding of implementation science

CIPRS: Stetler & Damschroder Theoretical Frameworks

slide53
DISCUSSION/REACTION FORM

CIPRS: Stetler & Damschroder Theoretical Frameworks