Table 1 Included determinant frameworks
Source | What is implemented and/or what is the desired outcome? | Development of the framework: how were the determinants identified in the framework? | Determinant categories (underlined categories are associated with contextual determinants and/or are labelled “context”) | Contextual determinants: categories and examples of sub-categories in the framework |
|---|---|---|---|---|
PARIHS: Kitson et al., 1998 [11], Rycroft-Malone, 2010 [12]; i-PARIHS: Harvey and Kitson, 2016 [38] | Effective practice | PARIHS was “developed inductively from the originators’ experience as change agents and researchers” ([12], p. 111), followed by conceptual work and empirical studies. I-PARIHS was developed based on research applying PARIHS and to account for critiques and evaluations of the framework by other researchers | PARIHS, 3 categories (1 relates to contextual influences): • Evidence • Facilitation • Context i-PARIHS, 4 categories (2 relate to contextual influences): • Innovation • Facilitation • Recipients • Context Categories are referred to as “elements” and sub-categories as “sub-elements” | PARIHS: • Context: culture (including values concerning innovation, power and authority, allocation of human, financial and equipment resources, rewards/recognition); leadership (including type of leadership, role clarity, teamwork, organizational structures, decision-making processes, approach to learning); evaluation (including feedback on individual, team and system performance) The category Evidence in PARIHS concerns characteristics of the evidence (including research and clinical experience), but also includes patient influences i-PARIHS: • Context (local level): culture; formal and informal leadership; evaluation of innovation and change; learning environment. Context (organizational level): senior leadership and management support; culture; structure and systems; absorptive capacity. Context (external health system level): policy drivers and priorities; regulatory frameworks; environmental (in) stability; inter-organizational networks and relationships • Recipients: collaboration and teamwork; local opinion leaders; existing networks; power and authority The category Innovation in i-PARIHS is similar to Evidence in PARIHS, but also incorporates innovation attributes (e.g. relative advantage and trialability) |
Cabana et al., 1999 [37] | Physicians’ adherence to clinical practice guidelines | Based on analysis of 76 articles that identify barriers to adherence to “clinical practice guidelines, practice parameters, clinical policies, or national consensus statements” ([37], p. 1458) | 10 categories (2 relate to contextual influences): • Lack of familiarity • Lack of awareness • Lack of agreement with specific guidelines • Lack of agreement with guidelines in general • Lack of outcome expectancy • Lack of self-efficacy • Lack of motivation/inertia of previous practice • Guideline factors • External barriers • Environmental factors Categories are referred to as “categories of barriers” | • External barriers: inability to reconcile patient preferences with guideline recommendations • Environmental factors: lack of time; lack of resources; organizational constraints (including insufficient staff or consultant support); lack of reimbursement; perceived increase in malpractice liability |
Mäkelä and Thorsen, 1999 [43] | Implementation of guidelines to achieve practice change | Based on “previous work in the area” and data from various projects within a project called Concerted Action of the Changing Professional Practice ([44], p. 24) | 3 categories (2 relate to contextual influences): • Professionals • Patients • Environment Categories are referred to as “barriers” and “facilitators” | • Patients: knowledge; skills; attitudes; other resources (including money and assistance) • Environment: Social factors (support for or discouragement of change by others, including colleagues, managers, opinion leaders, professional organizations and patients); organizational factors (including availability of guidelines at workplace and local infrastructures or rules and practicality within existing practice setting or routines); economic factors (including availability or lack of resources such as time and personnel) |
Grol and Wensing, 2004 [39] | Achieving evidence-based practice | Based on “a summary of some of the theories and models relating to implementing change in diabetes care” ([39], p. S57) | 3 categories (2 relate to contextual influences): • Individual professionals • Social context • Organizational and economic context Categories are referred to as “theories/models” and sub-categories as “factors” | • Social context: social learning (including incentives, feedback and reinforcement); social network and influence; patient influence; leadership • Organizational and economic context: innovativeness of organization (extent of specialization, decentralization, professionalization and functional differentiation); quality management (culture, leadership, organization of processes, customer focus); complexity (including interactions between parts of a complex system); organizational learning (capacity and arrangements for continuous learning in organization); economic (reimbursement arrangements, rewards, incentives) |
Fleuren et al., 2004 [40] | Implementation of innovations in health care organizations | Based on analysis of 57 articles followed by a Delphi process involving 44 implementation experts | 5 categories (4 relate to contextual influences): • Innovation • Socio-political context • Organization • Adopting person/user/health professional • Facilities needed to implement the innovation Categories are referred to as “determinants” | • Socio-political context: willingness of the patient to cooperate with the innovation; degree to which the patient is aware of the health benefits of the innovation; patient discomfort as a result of the innovation • Organization: organizational size; staff turnover; degree of staff capacity in the organization; nature of the collaboration between departments involved in the innovation • Adopting person/user/health professional: support from/of colleagues in implementing the innovation; support from/of other health professionals in implementing the innovation; support from/of their supervisors in the department/organization with respect to the implementation of the innovation; extent to which colleagues implement the innovation (modelling) • Facilities needed to implement the innovation: financial resources; reimbursement for health professionals/organizations; other resources; administrative support; time available; availability of staff; opinion leader |
Diffusion, dissemination and sustainability of innovations and delivery of health services | Based on analysis of 450 articles and books [23]; the model also consists of links between various determinants | 7 categories (5 relate to contextual influences): • Innovations • Adopters and adoption • Diffusion and dissemination • Inner context • Outer context • Implementation and routinization • Linkage between components in the model Categories are referred to as “key topic areas” | • Diffusion and dissemination: network structure; homophily; opinion leaders; champions; boundary spanners (individuals with external ties); formal dissemination programmes • Inner context: structural determinants of innovativeness (e.g. the organization’s size, maturity, differentiation, specialization, slack resources and decentralization); absorptive capacity for new knowledge; receptive context for change (including leadership, strategic vision, managerial relations): tension for change; innovation-system fit (innovation fit with existing values, norms, strategies, goals, skill mix, etc.); assessment of implications; support and advocacy; dedicated time and resources; capacity to evaluate the innovation • Outer context: informal inter-organizational networks; intentional spread strategies; wider environment; political directives • Implementation and routinization: organizational structure; leadership and management; human resource issues; funding; intra-organizational communication; extra-organizational networks; feedback; adaptation/reinvention • Linkage between components in the model: linkage at development stage (of the innovation); role of change agency; external change agents Greenhalgh et al. [49] feature slightly different terms and categorizations | |
Behaviour change | Based on analysis of 33 behaviour change theories (encompassing 128 constructs) | 14 categories of determinants (3 relate to contextual influences): • Knowledge • Skills • Beliefs about capabilities • Optimism • Beliefs about consequences • Reinforcement • Intentions • Goals • Memory, attention and decision process • Emotions • Behavioural regulation • Social/professional role and identity • Environmental context and resources • Social influences Categories are referred to as “domains” and sub-categories as “component constructs” | • Social/professional role and identity: professional identity; professional role; social identity; identity; professional boundaries; professional confidence; group identity; leadership; organizational commitment • Environmental context and resources: environmental stressors; resources/material resources; organizational culture/climate; salient events/critical incidents; person × environment interaction; barriers and facilitators • Social influences: social pressure; social norms; group conformity; social comparisons; group norms; social support; power; intergroup conflict; alienation; group identity; modelling | |
Wensing et al., 2005 [44] | Behaviour change | Based on analysis of the literature concerning theories on behaviour or organizational change in a variety of disciplines | 4 categories (3 relate to contextual influences): • Individuals • Professional group • Health care organization • Economic structures Categories are referred to as “factors” | • Professional group: team cognitions; team processes; leadership and key individuals; social network characteristics; professional development • Health care organization: specification; flexibility; continuous improvement; external communication; internal communication; leadership structure; specialization; technical knowledge; organizational size • Economic structures: positive incentives; provider and patient financial risk sharing; transaction costs; purchaser-provider contract relationships; competition intensity; priority on social agenda. |
Implementation of evidence-based interventions | Based on analysis of the diffusion and dissemination literature and the implementation literature in education and leadership | 3 categories (2 relate to contextual influences): • Competency drivers • Organization drivers • Leadership drivers Categories are referred to as “implementation drivers”, which constitute “the infrastructure for implementation because they are the processes required to implement, sustain and improve identified effective interventions” ([43], p. 15–16). The category Competency drivers refers to training of staff, thus being more akin to implementation strategies | • Organization drivers: decision-support data systems; facilitative administration; systems intervention (including creating feedback loops concerning the implementation); the importance of organizational culture, climate and infrastructure is also mentioned in the description of this category • Leadership: no sub-categories are listed | |
NICS, 2006 [45] | Change in clinical practice | The basis for the identified determinant categories is not explicitly stated, but most likely existing literature | 6 categories (4 relate to contextual influences): • The innovation itself • Individual professional • Patient • Social context • Organizational context • Economic and Political context Categories are referred to as “barriers” | • Patient: knowledge; skills; attitude; compliance • Social context: opinion of colleagues; culture of the network; collaboration; leadership • Organizational context: care processes; staff; capacities; resources; structures • Economic and political context: financial arrangements; regulations; policies |
Cochrane et al., 2007 [14] | Optimal care, in terms of implementation of guidelines, evidence and research into practice | Based on analysis of 256 articles to respond to two research questions: how are barriers assessed and what types of barriers are identified? | 7 categories (3 relate to contextual influences): • Cognitive/behavioural barriers • Attitudinal/rational-emotive barriers • Health care professional/physician barriers • Clinical practice guidelines/evidence barriers • Support/resource barriers • System/process barriers • Patient barriers Categories are referred to as “barriers” and sub-categories referred to as “categories” | • Support/resource barriers: time; support; human and material resources; financial resources • System/process barriers: organization and structure; teamwork structure and ethic; referral process • Patient barriers: patient characteristics; patient adherence The sub-categories are not fully explained in the framework or accompanying text (e.g. it is not obvious what is meant by “system” or “organizational” belonging to the “System/process barriers” category) |
Nutley et al., 2007 [25] | Use of research | Based on analysis of “a wide range of studies” in the “factors affecting” literature ([25], p. 66–67) | 4 categories (1 relate to contextual influences): • The nature of the research to be applied • The personal characteristics of both researchers and potential research users • The links between research and its users • The context for the use of research | No specific sub-categories are listed, but the following aspects are mentioned as important aspects of the context: lack of time; lack of professional autonomy to implement findings from research; local cultural resistance; lack of financial, administrative and personal support |
PRISM: Feldstein and Glasgow (2008) [41] | Adoption, implementation and sustainability of health care interventions and programs | Based on analysis of “models in common use in implementation and diffusion research”, authors’ implementation experience, and concepts from the areas such as quality improvement, chronic care and Diffusion of Innovations | 4 categories (all relate to contextual influences) • Program/intervention (organizational perspective and patient perspective) • Recipients (organizational characteristics and patient characteristics) • External environment • Implementation and sustainability infrastructure Categories are referred to as “domains” | Program/intervention: readiness; strength of the evidence base; coordination across departments and specialities; burden (complexity and cost); patient centeredness; patient choices; service and access; feedback of resultsRecipients: organizational health and culture; clinical leadership; management support and communication; systems and training; data and decision support; expectations of sustainability External environment: regulations; competition; reimbursement Implementation and sustainability infrastructure: dedicated team; bridge researchers; adaptable protocols and procedures; adopter training and support; plan for sustainability Both program/intervention and recipient categories consider staff at three levels: senior leaders, mid-level managers, and frontline workers |
CFIR: Damschroder et al., 2009 [15] | Influences on implementation (outcomes) | Based on analysis of the 19 theories, frameworks and models used in implementation science | 5 categories (3 relate to contextual influences): • Intervention characteristics • Characteristics of individuals • Process • Inner setting • Outer setting Categories are referred to as “domains” and sub-categories as “constructs” | • Process: planning; engaging (including opinion leaders and champions); executing; reflecting and evaluating (including feedback about the progress) • Inner setting: structural characteristics (including age maturity and size of the organization); networks and communications; culture; implementation climate (including absorptive capacity for change, tension for change, capability, relative priority, organizational incentives and rewards, learning climate); readiness for implementation (including leadership engagement, available resources, access to knowledge and information) • Outer setting: patient needs and resources; cosmopolitanism (networking with other external organizations); peer pressure (to implement an intervention); external policies and incentives |
Gurses et al., 2010 [46] | Compliance with evidence-based guidelines | Based on analysis of 13 theories, models and frameworks used in implementation science (11 found through literature review and 2 identified by brainstorming) | 4 categories (2 relate to contextual influences): • Clinician characteristics • Guideline characteristics • Implementation characteristics • System characteristics Categories are referred to as “categories” and sub-categories as “factors” | • Implementation characteristics: tension for change; mandate/preparation planning; leader and middle manager involvement and support; relative strength of supporters (including opinion leaders) and opponents; funding availability; monitoring and feedback mechanisms • System characteristics: task characteristics (including workload); tools and technologies (including available checklists as cognitive aids to facilitate work); physical environment (including layout, workspace and noise); organizational characteristics (including culture, teamwork, communication) |
SURE: WHO, 2011 [47] | Implementation of policy options | Based on “published lists of barriers for implementing change in health care” ([48], p. 6), although it is not clear which these lists are | 5 categories (4 relate to contextual influences): • Providers of care • Recipients of care • Other stakeholders • Health system constraints • Social and political constraints Categories are referred to as “barriers” | • Recipients of care: knowledge and skills; attitudes regarding programme acceptability, acceptability and credibility; motivation to change or adopt new behaviour • Other stakeholders: knowledge and skills; attitudes regarding programme acceptability, acceptability and credibility; motivation to change or adopt new behaviour • Health system constraints: accessibility of care; financial resources; human resources; educational system; clinical supervision; internal communication; external communication; allocation of authority; accountability; management or leadership; information systems; facilities; patient flow processes; procurement and distribution systems; incentives; bureaucracy; relationship with norms and standards • Social and political constraints: ideology; short-term thinking; contracts; legislation or regulations; donor policies; influential people; corruption; political stability |
TICD: Flottorp et al., 2013 [34] | Improvements in health care professional practice | Based on analysis of 12 “checklists” described in implementation science (theories, frameworks and models) | 7 categories of determinants (5 refer to contextual influences) • Guideline factors • Individual health professional factors • Patient factors • Professional interactions • Incentives and resources • Capacity for organizational change • Social, political and legal factors Categories are referred to as “domains of factors” | • Patient factors: patient needs; patient beliefs and knowledge; patient preferences; patient motivation; patient behaviour • Professional interaction: communication and influence; team processes; referral processes • Incentives and resources: availability of necessary resources; financial incentives and disincentives; nonfinancial incentives and disincentives; information system; quality assurance and patient safety systems; continuing education system; assistance for clinicians • Capacity for organizational change: mandate, authority, accountability; capable leadership; relative strength of supporters and opponents; regulations, rules, policies; priority of necessary change; monitoring and feedback; assistance for organizational changes • Social, political and legal factors: economic constraints on the health care budget; contracts; legislation; payer or funder policies; malpractice liability; influential people; corruption; political stability The category Guideline factors includes cultural appropriateness, i.e. congruity with customs and norms in the context of the implementation |