This facilitation study set out to explore and describe the facilitation activity occurring within a natural experiment where groups were beginning an evidence implementation. We followed three cases adapting and planning for implementation of guidelines designed to impact changes in nursing practice. The findings were revealing both conceptually and practically in terms of facilitating EBP through guidelines. First, it should be noted that in following these cases and not being prescriptive about process, we discovered the range and types of facilitation that groups themselves deemed necessary or at least helpful. They all utilized a combination of external and local facilitation. In two of the cases, external facilitators provided support and assistance primarily to local facilitators who in turn assisted cases. The other case engaged more direct external facilitation support and exhibited more of the facilitation activities performed by case members themselves. It was beyond the scope of the study, but more support may have been required because of limited resources or the planned implementation having a larger scope (i.e., national versus local).
The practical elements emerging from the literature, described as 46 discrete activities, were in large part found as occurring in the three cases. There were only three activities that no one, facilitators nor case members, engaged in. Two of these activities fell under the larger grouping of 'evaluating change.' This may be because cases are in the beginning stages of implementation and have not yet reached the point of evaluation. The third activity was 'creating an open, supportive, and trusting environment conducive to change.' Evidence for this activity may not have emerged in the documented data due to the nature of case-audit as a data collection method because certain activities are not always observable on paper. Facilitators when asked, however, felt this was part of their role. Further enquiry is needed to determine whether these elements actually represent facilitation in the practical sense and to further explicate the role of facilitation in evaluation of evidence implementation.
The case documents revealed an additional five distinct activities related to facilitation. The newly identified elements offer further insight into the role and process. A fundamental issue in all study cases was that members involved in the projects performed certain activities of facilitation in conjunction with or in addition to local and external facilitators. This is central to the notion of facilitation being considered a process and not something to be expected only of an individual as the 'facilitator.'
The focus group interview augmented and built upon the findings of the case audit, reinforcing the elements of facilitation identified, and offering new insights into the role and process. Although facilitators were appointed to their roles and each operationalized facilitation individually, all could relate to the activities and process identified. Participants also noted a range of requisite skills and knowledge is required for effective facilitation and provided practical examples from their experiences.
In line with Harvey et al.'s  findings, facilitators performed a vast array of activities ranging from practical, task-oriented assistance to providing holistic and enabling support. The results should be interpreted with caution because the facilitation activity was considered performed even if engaged in by one facilitator in one case. However, the activities were generally performed by facilitators across cases. The activities engaged in by local and external facilitators across all cases could be considered key elements of the process (Table 3). When asked, facilitators themselves spontaneously identified many of these same elements as important. Although these findings have limited generalizability beyond these cases, they support the understanding of facilitation in the literature and add strength to descriptions of the concept.
There appeared to be some overlap between the local and external facilitator roles. For example, a large part of both roles involved overcoming others' resistance to change, providing resources/tools, and problem solving. However, the roles differed in that local facilitators took on the majority of the administrative and project-specific assistance, including data management, whereas external facilitators provided more general, ongoing support and reassurance. Interestingly, local facilitators recognized the external facilitators as 'expert' in relation to guideline adaptation and EBP processes and as such, the external facilitators were seen as bringing external credibility to the projects.
It is important to note that although cases performed certain facilitative activities, facilitators considered capacity-building to be an important element of their role. Facilitators were doing some but not all of the legwork while at the same time helping the cases to develop the skills and confidence to facilitate guideline adaptation. To a large extent, facilitators were helping the group develop the capacity to do it themselves as opposed to doing it for them. In this way, the role was not entirely prescriptive or rather largely nondirective but somewhere in the middle.
Administrative and project management emerged as important aspects of facilitation. It was noted in the case data that facilitators organized, scheduled, and often led meetings and were influential in ensuring the case remained on task. Other authors identify the potential overlap between facilitation and project management . This has been previously explained in a different sense whereby facilitators are described as project leads . The context in our study was different. In addition to a dedicated local facilitator, each case had an appointed project lead or co-leads selected for the position(s) due to their experience with guideline development and/or content area expertise. Participants in the focus group interview recognized that case members, particularly project leads, do not have the time to carry out the administrative tasks of organizing meetings and the follow up associated with keeping cases on track. Therefore, facilitators across cases took on these tasks.
We also found that facilitators used approaches which could be considered elements of other implementation interventions. For example, facilitators provided education to case members to increase their interpretation of the research evidence in order to adapt the knowledge to their environment and also assisted them with obtaining skills training in guideline adaptation and literature searching and appraisal. As well, facilitators supported and in some cases, organized and performed audit and feedback mechanisms to provide case members with information regarding their clinical practice performance. Facilitation process also involved components of a linking agent role namely, boundary-spanning and liaising between case members and other individuals at multiple levels, involved or uninvolved in the project, to obtain necessary resources. Similar to Stetler et al.'s  findings, facilitation could be deemed a mediating process or intervention because it involves organizing and enabling actualization of other change strategies.
These findings have important implications for those planning an evidence implementation. It is important to consider the different roles of all individuals involved. Recognition of the range of activities associated with facilitation and corresponding requisite knowledge and skills will be useful for selecting individuals to fulfill this type of role and in developing facilitator training programs. Despite there being some overlap between local and external facilitator roles, there are particular differences we have noted that should be considered in filling these roles and ensuring the appropriate people are involved in adaptation and implementation. Depending on the additional resources required, obtaining the assistance of an external facilitator with professional development and/or guideline implementation expertise may be useful in bringing external credibility to a project.
Our findings are consistent with the definition of facilitation put forth by Stetler et al. : 'a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship' . Across cases, both local and external facilitators engaged in activities related to problem solving and addressing specific issues and provided ongoing support and reassurance to case members.
As well, facilitators perceived effective communication and relationship building, particularly with project leads, to be key elements of the role. In a practice environment, the lead(s) might be the unit quality council or nurse manager who leads an implementation. The audit data also reflected the importance of communication. Both local and external facilitators fulfilled most of the activities under 'effective communication' according to the audit tool and provided regular communication and kept case members informed across all three cases. As described in the literature, enhancing relationships and fostering relationship building are components of facilitation [13, 14] along with themes of strong interpersonal and communication skills [3, 5, 6].
A key observation in this study is that facilitative activities tend to be shared across a number of individuals. This validates what was discovered in the literature review that facilitation is now being viewed as both an individual role as well as a process involving individuals and groups . Facilitators perceived facilitation as a team effort. This is important to consider in planning implementation work in relation to evaluating both the strengths and weaknesses of group members and ties into ensuring the correct individuals are involved. Participants identified that there is a need for a recognized individual, such as a facilitator, to coordinate the group. However, groups may bring their own assets and possess certain facilitative skills which could be capitalized on.
For example, Kitson et al.  proposed that facilitators play a key role in helping individuals understand what they need to change and how to make these changes to incorporate evidence into practice. Our results indicated that case members themselves were able to identify a need for practice change recognized as a priority by staff. This may be because case members had already identified an area for change prior to volunteering to participate in the guideline adaptation process. However, it begs the question of whether there are certain activities of facilitation that are more applicable if facilitated by case members themselves provided they have the internal capacity and resources. As cases were able to identify a problem area in their clinical practice, facilitators could spend more time focusing on assisting cases with 'how' to change practice as opposed to finding 'what' needs to be changed. Group members in all cases also identified leaders for their respective projects. This may be another area of facilitation more appropriate for group members to address themselves. Cases may be more cognizant of who amongst their colleagues would make a qualified leader as opposed to a facilitator being brought in to assist a group with a particular project.
Study findings should be interpreted in consideration of some limitations. First, facilitators were appointed or hired for the role, and this may have had an effect on their responses. It may have been beneficial to also seek the case members' perceptions on facilitation. Secondly, a potential source of bias was encountered in that one author (EJD) extracted data from the case manuals and categorized the evidence. Finally, we observed the facilitation taking place in three in-depth cases in the early stages of evidence implementation activity with a focus on adapting guidelines for use by nurses. Facilitation process may be applied differently in regards to changing the practice of different professional groups, particularly in regards to the dynamics of their practice (i.e., physicians may have somewhat more autonomy and independence in some areas of their practice whereas nurses largely work in teams). As well, although the cases focused on different guideline topics areas, all focused on one broader area of care (cancer) which may limit generalizability because there are distinct health delivery and system features in this area. Context is an important factor that relates to the facilitation approach taken; thus, the facilitation occurring in these cases may or may not be generalizable to other disciplines, points in the implementation process, or in other situations or settings.
Using multiple methods of data collection, we attempted to lessen bias through triangulation of different data sources. Data collected included group processes (i.e., meetings, communications as well as self reports, field notes) and a focus group interview with facilitators. To lessen the effect of potential bias in having one author interpret and categorize the evidence, the data manager checked the evidence supporting the categories and confirmed or challenged these interpretations. A detailed record of this discussion was kept. As well, facilitators' perceptions were sought as to whether the categories and activities in the audit fit or were misrepresented based on their own experiences. The context of the cases is described to inform potential transferability of the findings.