Table 3 Core concept articles

Strengths:

• PARIHS is described for the first time (but not yet named as such). It is an intuitively appealing framework that is succinct and yet allows for dynamic complexities of implementation.

• Framework anticipates interrelationship among the three main elements.

• PARIHS was an early well-articulated framework that went beyond focusing on evidence and acknowledged the non-linear nature of implementation.

Issues:

• Inconsistency in definitions and terms within the text of the article and terms presented in the table.

• The defined continuums lacked consistency and valence (e.g., 'low regard for individuals' on the 'low' end and 'patient centered' on the 'high' end) (p. 151).

• Sources considered 'high' research evidence are limited. Culture seems to include everything and lacks clarity. Does not differentiate external facilitation versus internal facilitation (e.g., through management or champions). Judges task-oriented facilitation as 'low' and 'holistic' facilitation as 'high.' Some concepts seem conflated (e.g., receptive context includes 'inclusive decision-making processes' which seems equally related to sub-element of leadership).

• Proposed as a diagnostic tool to help prepare the context and select the most appropriate intervention but supportive studies were limited and retrospective.

Strengths:

• Theory paper that proposes PARIHS as an inductively developed framework to help understand complex implementations.

Issues:

• Rationale for mapping findings from sample studies into PARIHS elements is unclear and loose. For example, in one case, physicians rejected evidence-based guidelines and the authors attribute this to inadequate facilitation without clear rationale for the attribution.

Strengths:

• Authors suggested that there is some evidence that facilitators may help change clinical and organizational practice, although current data limited their ability to make conclusions.

Issues:

• Regardless of their suggested changes to the framework per the literature, the authors point out that further research is still needed on this inherent part of the framework, i.e., regarding different models of facilitation.

• Definitional clarity in related sub-elements remains an issue; and some promising, potential sub-elements identified in the paper did not make it into their suggested refinements.

Strengths:

• Literature review included 'analysis of a broad range of health care literature.' (p. 579). Provided information on the level of maturity of the facilitation concept.

• Provided information for model refinement.

• Pointed out the need for more research on different models of facilitation; e.g., the need to better differentiate external and/or internal facilitation.

Issues:

• Missing details about how the analysis was conducted, beyond authors' brief description of Morse (1995) and Morse et al.'s (1996) approach.

Strengths:

• Provided some substantiation of contextual elements; especially for holistic view of implementation.

• Provided some conceptual backing.

• Evolved a sub-element in context from measurement to evaluation.

Issues:

• Concept of context lacks clarity because of the many ways it is characterized; e.g., 'what is clear from studies reviewed that have included a consideration of context is that there is inconsistency in the use of the term and that this has an impact on claims of its importance. Thus the implications of using context as a variable in research studies exploring research implementation are as yet largely unknown.' p. 101.

• Muddles whether Context is an overarching element or a sub-element on equal footing with Culture, Leadership, Evaluation that needs to be subsumed under some other broader category: i.e., 'the analysis of the characteristics and consequences of context suggests that other characteristics are equally important...and that these sub-elements need to be taken into account in any articulation of the concept of context.' p. 101.

Strengths:

• Draws on broader literature addressing context.

Issues:

• Key details of methodology missing, including parameters such as years covered by search and numbers of articles reviewed and included.

• Seemed to focus more on holistic organizational change versus task-oriented implementation.

Strengths:

• Model now refined per concept analyses.

• 'Its relative simplicity and intuitive appeal.'

Issues:

• Increased complexity of the framework; added sub-sub-elements; muddled the definitions in some cases, e.g., with language such as social construction acknowledged vs. perhaps consensus determined (This may reflect cultural/language/philosophical differences)

• Some clearly stated attributes of a facilitator were lost.

Strengths:

• Responsive to their concept analysis work to further the theoretical development of the framework.

• Recognizes that this is not a 'final' framework; noting that there will be continued evolution and 'it would be premature to suggest that this represents a final version' p. 178.

Issues:

• Did not delve into relationships among the core elements.

Strengths:

• PARIHS' expansive acknowledgement of what can and should constitute 'evidence' in implementing EBPs

Issues:

• Sub-element definitions lack clarity

• More understanding needed about how to integrate the multiple sources of evidence and how this melding can inform clinical decision-making

Strengths:

• Tackling the issue of the nature of evidence versus traditional approaches.

Issues:

• Lack of clarity demonstrated when authors talk about testing their framework for 'patient-centered evidence-based care' (p. 87-8)

Strengths:

• Asserted that PARIHS can embrace multiple theories.

• Further explored potential use of the model for a 'two-stage diagnostic and evaluative approach' focused on E and C whereby 'the intervention is shaped and moulded by the information gathered' in terms of the F element (p. 1-2).

Issues (Appendix):

• Lack of conceptual and definitional clarity of various items. Left the reader to figure out who the actor is; e.g., 'the research evidence is of sufficiently high quality' begs the question, who is deciding and according to whose standards? (p. 1 of Additional File 1)

• Phase 3's evolution lacked congruency with Phases 1 and 2, contributing to continued lack of consistency and definitional and conceptual clarity as one can't always see how a given phase builds to the next.

Strengths:

• Appendix provided clearest guidance to date to define and operationalize sub-elements.

Issues:

• Not clear what main thesis or objective was; article appeared written with multiple objectives.