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Table 4 Relational contributions

From: Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis

Relational focus

Key findings from individual articles

Sources

Relationships between facilitation and other (i-)PARIHS elements

Dyadic relationship between evidence and facilitation

The linkage between facilitation and evidence occurs as internal facilitators communicate the evidence to colleagues and this connection is described as ‘legitimizing the evidence’ and ‘informed advocacy.’

Diffin et al. (2018) [38]

Dyadic relationship between context and facilitation

Existing contextual factors help and hinder the facilitation process directly and indirectly. The strength of the influences of contextual factors on facilitation process fluctuates over the implementation intervals.

Diffin et al. (2018) [38];

Mekki et al. (2017) [40]

There is a complex interplay between facilitation and context, where macro and micro contextual factors contribute to tensions associated with facilitation. Tensions can have both positive and negative components.

Tierney et al. (2014) [39]

Dyadic relationship between recipients and facilitation

Recipients impact facilitation at two stages. Recipients’ learning skills (creative and analytical reasoning) and motivation influence the early stage of facilitation which concerns acquisition of new knowledge. Recipients’ application of new knowledge impacts the next stage of facilitation which is intended to put the agreed decisions into action.

Mekki et al. (2017) [40]

Temporal changes in i-PARIHS elements in response to facilitation

Facilitation changes barriers related to innovation, recipients, and context over time as the facilitation processes progress. Innovation, recipients, and context respond to facilitation at different time points and to different degrees.

Gustavson et al. (2021) [41]

Relationships between (i-)PARIHS elements (evidence, context, facilitation) and implementation outcomes

Relative importance of (i-)PARIHS elements/sub-elements

regarding necessity and sufficiency in impacting implementation outcomes

Evidence is necessary but not sufficient to influence evidence-based practice uptake

When there is a strong belief in evidence, strength in at least one contextual element (leadership, culture, or evaluation) is needed for uptake to occur; when there is limited belief in the evidence, strengths in the contextual elements unexpectedly reinforced the resistance to change.

McCullough et al. (2015) [42]

When the evidence is robust, uptake of the evidence is mainly determined by individual factors (practitioners’ and patients’ behaviors, attitudes, emotional responses), inter-professional functioning, and the organization’s existing systems and processes.

Rycroft-Malone et al. (2013) [35]

Leadership is necessary and sufficient to positively implementation outcomes

Leadership exerts the greatest influence on implementation processes in which favorable culture and evaluation influence facilitation only when the clinical leaders take an active role.

Mekki et al. (2017) [40]

Leadership and capacity (infrastructure, funding, clear goals), even in the absence of a strong knowledge translation culture, are sufficient to achieve tangible implementation outcomes.

Gagliardi et al. (2014) [20]

The impacts of facilitation and context on implementation outcomes depend on the phases of implementation

Phases of implementation include problem identification, intervention design, development of implementation strategy, and reinforcement. Leadership (not other context sub-elements) influences the phase problem identification. Facilitation sub-elements (role of facilitator, goal/purpose, character/style, and skills/attributes) influence all phases of implementation.

Ward et al. (2017) [43]

(i-)PARIHS elements/sub-elements interact in affecting implementation outcomes

Facilitation contributing to implementation outcomes is contingent on context

Facilitation with broad training goals in clinics with highly organized systems (such as mental health care) is negatively associated with evidence-based practice implementation.

Watts et al. [48]

Facilitation practices can yield positive impacts on research use in settings with low ratings for leadership and culture but where a proficient evaluation/feedback process is in place.

Lo et al. (2018) [45]

Facilitation practices influencing research use depends on different combined patterns of context sub-elements (e.g., leadership, culture, evaluation, structural resources, organizational slack)

Lo et al. (2021) [47]

Interactions among context sub-elements can produce synergy or compensation

The combination of strong context sub-elements (e.g., leadership, teamwork, and communication) magnify the effect of single elements, and a strong context sub-element may compensate for other weaker ones.

McCullough et al. (2015) [42]

Facilitation and context are complementary

Facilitation increases innovation uptake in settings with an initially unreceptive context. In settings with an initially strong, receptive context, innovation uptake is apparent despite the absence of facilitation interventions.

Slaughter and Estabrooks (2013) [44]

What types of facilitation work (or do not work), for whom, how, why, and in what circumstances, in improving implementation outcomes

Facilitation mechanisms grounded in organizational learning frameworks

Holistic facilitation based on action-oriented collaborative learning approaches fosters the development of a learning organization in which socio-culturally mediated knowledge spread occurred, which ultimately facilitated evidence implementation. Specifically, holistic facilitation promotes the re-creation of knowledge (where evidence is reshaped) as professionals exchange their perspectives and work collaboratively toward setting up goals; holistic facilitation prioritizes professionals’ needs and motivation, and contextual components that are related to evidence implementation.

Westergren (2012) [36]

Context–mechanism–outcome configurations grounded in realist approaches

Three interrelated mechanisms in which facilitation impacts implementation success has been identified: aligning the project with the needs and expectations of facilitators and the organization, prioritizing the project in the organization, and fostering collective engagement by staff and stakeholders. The three mechanisms together reinforce organizational learning and facilitators’ enactment of their roles over time, which led to positive outcomes. Whether a mechanism is triggered is contingent on context (e.g., outside regulatory environment, stability of the internal context, and relationships between internal facilitators and managers).

Rycroft-Malone et al. (2018) [46]

Theorizing the dynamism among PARIHS elements drawing on complex systems perspectives and broader theoretical models in implementation science

Complexity is an inherent characteristic of each PARIHS element and also emerges as a component of the dynamic (non-linear, non-static, and adaptive) relationships among these elements

The following general dynamism among complex interventions, context, facilitation/facilitative implementation process, and implementation outcomes has been identified:

• Complexity is an inherent characteristic of all the elements.

• Complexity also emerges as a component of the dynamic relationships among these elements.

• A complex intervention is formed by its interaction with the context at the macro, meso, and micro levels.

• Facilitation strategies respond to a full spectrum of contextual factors (from the inner to outer context), which will in turn reshape the intervention.

• Inner and outer context is never static, and the implementation of facilitation strategies and assimilation of the intervention generally alter the context.

• Changes in contextual factors should be evaluated as an outcome, as referred to as proximal contextual outcomes, besides distal intervention outcomes.

• Implementation process plays as a stand-alone component (described as socially mediated processes that are frequently qualified as facilitative).

• Elements respond to one another intentionally or organically, and their relationships evolve as the intervention is moved through the phases of preparation, introduction, activation, and integration toward adoption.

Pfadenhauer et al. (2017) [15];

Mills et al. (2019) [49];

Dryden-Palmer et al. (2020) [50]