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PROMOTING ACTION ON RESEARCH IMPLEMENTATION IN HEALTH
SERVICES (PARIHS) FRAMEWORK:
APPLICATION TO THE FRACTURE FIGHTERS PROGRAM
by
Vinita Anjali Bansod
A thesis submitted in conformity with the requirements for the degree of
Master of Science
Graduate Department of Health Policy, Management and Evaluation
APPENDIX F: Normative values: Multifactor Leadership Questionnaire (Form 5X) and
Organizational Readiness for Change (ORC) .............................................................. 153
1
CHAPTER 1: INTRODUCTION
Knowledge translation (KT) is defined as "the exchange, synthesis and ethically-sound
application of knowledge—within a complex system of interactions among researchers and
users—to accelerate the capture of the benefits of research for Canadians through improved
health, more effective services and products, and a strengthened health care system"(Canadian
Institutes of Health Research 2009). The discipline, also referred to as knowledge exchange,
knowledge to action, research utilization, knowledge utilization and knowledge transfer, has
increased in popularity since the mid-1980‘s and 1990‘s with the rise of evidence-based
medicine (Haynes 2004). Knowledge translation spans the entire research process from the
creation of knowledge to use by decision makers (Graham et al. 2006). In the past, a significant
proportion of health research dollars have been invested in clinical research, while relatively
little attention was given to ensuring these findings were incorporated into practice (Haynes and
Haines 1998). Therefore one of the central questions posed by health services researchers is how
to close the research-to-practice ―gap‖.
To date, multiple interventions and strategies have been developed in order to increase
the likelihood that clinicians will incorporate new research into their practice. The majority of
interventions have been shown to achieve moderate improvements in care (Oxman et al. 1995;
Bero et al. 1998; Grimshaw, Thomas et al. 2004), but with considerable variation in the observed
effects across interventions(Shojania and Grimshaw 2005). Although there is a widespread
agreement that evidence implementation requires strategies to meet the needs of the individual
stakeholder (or decision maker), there is an increasing acknowledgement of the importance of
organizational context. There may be differences in the context between studies that assessed
similar interventions, since few studies provide contextual data (Eccles et al. 2005). In addition,
2
leaders in the KT field have put out a call to increase the use and development of theoretically
grounded approaches to KT with hopes that this will shed light on the ―black box‖ of
implementation research (Rycroft-Malone 2007).
A promising framework to describe implementation success in health care organizations
has been developed by Kitson and colleagues (Kitson et al. 1998). The Promoting Action on
Research Implementation in Health Services (PARiHS) framework (Figure 1) states that
successful implementation is a function of three elements: 1) evidence 2) context and 3)
facilitation. Kitson and colleagues (1998) demonstrated that the most successful implementation
occurs when: 1) the evidence is scientifically robust and matches professional consensus
and
patient needs ("high" evidence); 2) the context is receptive to change with sympathetic cultures,
strong leadership, and appropriate monitoring and feedback systems ("high" context);
and 3)
there is appropriate facilitation of change with input from skilled external and internal facilitators
("high" facilitation)(Rycroft-Malone et al. 2002). F
AC
ILIT
AT
ION
CO
NT
EX
T
EV
IDE
NC
E
Implementation Success = f (Evidence, Context, Facilitation)
RESEARCH
CLINICAL
EXPERIENCE
PATIENT
EXPERIENCE
LEADERSHIP
CULTURE
EVALUATION
PURPOSE
ROLES
SKILLS &
ATTIBUTES
Figure 1: Promoting Action on Research Implementation in Health Services Framework
The aim of this thesis is to apply the PARiHS framework to a best-practice program for
post-fracture care in inpatient rehabilitation units. In 2003, a report by the Ontario Osteoporosis
3
Action Plan Committee (OAPC) of the Ministry of Health and Long-Term Care highlighted the
importance of addressing both a diagnostic and therapeutic care gap for patients with fragility
fractures (Ontario Action Plan Committee 2003). Osteoporosis guidelines have identified prior
fracture as a significant indicator of future fractures and osteoporosis, yet the majority of at-risk
individuals are under- investigated or treated (Elliot-Gibson et al. 2004; Giangregorio et al. 2006;
Bessette et al. 2008; Papaioannou et al. 2008). In response to the OAPC report, the Ontario
Ministry of Health and Long-Term Care announced a $15 million strategy to improve
osteoporosis care in Ontario (Smitherman 2005) with a priority to improve tertiary prevention of
fractures.
Fracture Fighters, in the inpatient rehabilitation setting was one of the programs funded
through the Ontario Osteoporosis Strategy to address this recommendation, since inpatient
rehabilitation protocols frequently did not make the link between fractures and osteoporosis and
therefore lacked osteoporosis assessment and management interventions (Ontario Osteoporosis
Strategy 2009). The program used a multi-component knowledge translation strategy based on
Pathman‘s Awareness-to-Adherence model of physician behaviour change (Pathman et al. 1996).
The primary strategy used trained front line clinicians (Clinical Coaches) to facilitate integration
of osteoporosis management into existing inpatient rehabilitation services provided to patients
post-fracture in order to prevent repeat fractures. Although a survey of participating
rehabilitation units at six month follow-up demonstrated improvements across all best-practice
categories, only about half of 36 participating sites provided education about osteoporosis,
supplements and referrals for osteoporosis follow-up (Jaglal et al. 2008).
In order to increase our understanding of how to design more effective knowledge
translation strategies for programs such as Fracture Fighters, we must first identify determinants
4
of change that include consideration of contextual or unit level factors. Identifying factors that
influence implementation is essential to allowing the design of more effective strategies that are
adapted to the factors that facilitate or impede actual change (Fleuren et al. 2004).
1.1 RESEARCH GOAL
The goal of this study is to apply the Promoting Action on Research Implementation in
Health Services (PARiHS) framework to the Fracture Fighters program to describe unit level
factors that may have influenced best-practice implementation.
1.2 PRIMARY OBJECTIVES
1. To propose a toolbox of measures to operationalize the PARiHS framework
2. To apply these measures to the Fracture Fighters program to describe:
a. leadership behaviours of inpatient rehabilitation managers
b. the organizational climate of participating rehabilitation units
c. the facilitation behaviours of Clinical Coaches
1.3 SECONDARY OBJECTIVE
3. To describe the relationship between leadership behaviours, organizational climate, and
facilitation traits among successful and unsuccessful units
1.4 OUTLINE OF THESIS CHAPTERS
This thesis is organized into the following five chapters:
Chapter 1: Introduction
5
This introductory chapter identifies the problem. The study goal and specific objectives
are listed.
Chapter 2: Literature Review
This chapter describes the persistent research-to-practice gap in osteoporosis
management and reviews a number of knowledge translation theories that could be applied to
explain research implementation in clinical practice. The chapter focuses on theories, models and
frameworks that are inclusive of contextual factors and describes why the Promoting Action on
Research Implementation in Health Services (PARiHS) framework was suited to examine
implementation issues of the Fracture Fighters inpatient rehabilitation best practice program.
Chapter 3: Manuscript 1 – Proposing A Toolbox of Measures for the Promoting Action on
Research Implementation in Health Services (PARiHS) Framework: Application to the
Fracture Fighters Program
This manuscript discusses the PARiHS elements of evidence, context and facilitation
with the goal of operationalizing the framework for evaluating the Fracture Fighters Program.
Each element and sub-element is discussed and appropriate measurement instruments are
selected to quantify each element and sub-element. A toolbox of measures is assembled into a
questionnaire to apply the PARiHS framework to Fracture Fighters.
Chapter 4: Manuscript 2 – Leadership, Organizational Climate and Facilitation: A Survey
of Inpatient Rehabilitation Units in Ontario
This chapter is also written in manuscript format. Based on the toolbox assembled in
Chapter 3, survey questionnaires were completed with unit managers and clinical coaches
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participating in the Fracture Fighters program to describe implementation success, leadership,
organizational climate and facilitation. Results suggest that there are potential differences in
leadership, organizational climate and facilitators between organizations who were successful in
implementing Fracture Fighters best-practices and those who were not.
Chapter 5: Discussion
This final chapter reports a synthesis of the results presented in Chapter 3 & 4 and the
implications for quantitative applications of the PARiHS framework. Specifically, implications
for use of the proposed PARiHS toolbox as a diagnostic and prescriptive tool for barrier
identification and tailoring during implementation planning and as a tool for evaluating
implementation of evidence in organizations are discussed. The discussion also includes
commentary on the limitations of this approach and suggestions for future research.
7
CHAPTER TWO: LITERATURE REVIEW
This chapter describes the persistent knowledge-to-practice gap in osteoporosis care for patients
post-fracture and reviews a number of knowledge translation theories that could be applied to
explain research implementation in clinical practice. The chapter focuses on theories, models and
frameworks that are inclusive of contextual factors and describes why the Promoting Action on
Research Implementation in Health Services (PARiHS) framework was suited to examine
implementation issues of the Fracture Fighters inpatient rehabilitation best practice program.
8
2.1 OSTEOPOROSIS & FRACTURES
Osteoporosis is a skeletal disease that affects one in four women and one in eight men
over the age of 50 in Canada (Hanley and Josse 1996). The disease is characterized by a
reduction in bone mass, and changes to bone structure, causing a decline in bone strength,
making individuals with the disease more susceptible to fractures (Cummings and Melton 2002 ).
Fragility or low trauma fractures, most commonly in the wrist, shoulder, pelvis, spine or hip can
occur in osteoporotic individuals as a result of minimum force such as a fall from standing height
that would be insufficient to fracture normal bone (Poole and Compston 2006). The
consequences of fractures are severe as hip fractures are associated with increased morbidity
(Lorrain et al. 2003) and mortality (Cree et al. 2003) and decreased quality of life (Adachi et al.
2003) and are costly to the health system. For example, the average acute care length of stay for
hip fracture is two weeks with 25% of community dwelling individuals discharged to long-term
care (Jaglal et al. 1996). The acute care cost of caring for a person with a hip fracture is
estimated to be between $10,000-$15,000 USD, with additional costs required for community
and institutional care post-discharge (Haentjens et al. 2005; Papaioannou et al. 2008). More
importantly, only a third to one half of individuals with hip fracture will regain their pre-fracture
level of physical function and 18 to 28% of patients with hip fractures will die within one year of
their fracture (Mossey et al. 1989; Marolttoli et al. 1992; Koval 1994; Cooper 1997; Magaziner
et al. 2000; Hannan et al. 2001).
Individuals who have already had one low trauma fracture are at the greatest risk of
sustaining a subsequent fracture (Klotzbuecher et al. 2000). For this reason, the Canadian
Osteoporosis Guidelines have highlighted the importance of appropriate osteoporosis
investigation (bone mineral density testing) and appropriate treatment of patients with low
9
trauma fractures (Brown and Josse 2002; Khan et al. 2007). Despite these recommendations the
majority of patients who experience these fractures are under-investigated and under-treated
identifying both a diagnostic and therapeutic gap (Elliot-Gibson et al. 2004; Giangregorio et al.
2006; Bessette et al. 2008; Papaioannou et al. 2008).
2.2 THE FRACTURE FIGHTERS PROGRAM
Recently the Ontario Ministry of Health and Long-Term Care (MOHLTC) announced a
five-year $15 million strategy to improve osteoporosis care in the province (Smitherman 2005).
The funding was in response to a report by the Osteoporosis Action Plan Committee (OAPC)
that highlighted the care gaps in prevention and management of osteoporosis in Ontario (Ontario
Action Plan Committee 2003). One recommendation included the need to improve the
management of tertiary prevention services for individuals with low trauma fractures.
Fracture Fighters was one of the programs funded through the Ontario Osteoporosis
Strategy to address this recommendation. The purpose of the program was to integrate
osteoporosis management into existing inpatient rehabilitation services provided to patients 40
years of age and older post-fracture in order to prevent repeat fractures. Inpatient rehabilitation
units were selected because they are positioned at an ideal point in the continuum of care to
intervene with patients with fractures, as the average length of stay is 25 days (Sutherland and
Walker 2008). In addition, an environmental scan of Ontario inpatient rehabilitation units
demonstrated that osteoporosis investigation and management strategies were not part of usual
treatment protocols (Jaglal et al. 2006). The Fracture Fighters best-practices were based on the
Canadian Osteoporosis Guidelines (Brown and Josse 2002), and current literature with
expectation the rehabilitation units would provide, at minimum, education and referral for
osteoporosis investigation. The full-list of osteoporosis best-practices are listed in Table 1.
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Table 1: Fracture Fighters Best-Practices for Inpatient Rehabilitation Units
Category Fracture Fighters Osteoporosis Best-Practices for Inpatient Rehabilitation
Education Osteoporosis and Fractures
Providing patients with fractures with osteoporosis education (verbal or
written);
Distributing a patient information booklet on osteoporosis and fractures*
Exercise
Demonstrating strength, posture, balance and weight-bearing exercise*;
Distributing an exercise tear-off sheet;
Talking to patients and their families about fractures and providing
education related to osteoporosis exercises
Diet & Supplements
Talking about the recommended intake from diet and supplements of
vitamin D and calcium*
Falls Risk
Providing education about home modifications
Assessment Completing a falls risk assessment;
Ordering Bone Mineral Density (BMD) testing as an inpatient if
available in facility+;
Ordering a BMD test as an outpatient+;
Referral Sending a recommendation to family physician to order BMD+;
Sending a letter to family physicians to follow-up for osteoporosis*;
Making a referral to the Community Care Access Centre (CCAC) for a
physical therapist to prescribe osteoporosis exercises; and
Making a referral to the CCAC occupational therapist for home safety
assessment
Management Initiating osteoporosis medications
*These were the minimal best-practice expectations; + one of three was expected
To integrate these best-practices into existing care the Fracture Fighters team developed a
multi-component knowledge translation strategy based on the Awareness-to-Adherence model of
clinician behaviour change (Pathman et al. 1996). The Awareness-to-Adherence model states
that clinicians must pass through sequential cognitive and behavioural steps as they comply with
a guideline. First, they must become aware of it, then intellectually agree to it, then decide to
follow it in their practice (adopt), and finally succeed in following it at appropriate times
(adherence). A variety of predisposing, enabling and reinforcing strategies have been suggested
based on the Awareness-to Adherence stage of the clinician, including distribution of educational
11
materials and academic detailing to increase awareness; opinion leaders and small group
sessions to promote agreement; clinical flowcharts or algorithms and audit and feedback to
facilitate adoption; and reminders to sustain adherence (Davis et al. 2003).
The Fracture Fighters primary strategy utilized trained front-line clinicians (Clinical
Coaches) to facilitate implementation. In order to increase their knowledge about osteoporosis
and their ability to implement the Fracture Fighters best practices two front-line clinicians (e.g.
nurse, physical therapist, occupational therapist) from each participating inpatient rehabilitation
unit were selected by their unit managers to be trained as Fracture Fighters Clinical Coaches.
Clinical Coaches attended one of seven one-day training workshops. The purpose of the
workshop was to provide clinicians with education about osteoporosis and best-practices. The
workshops were facilitated by two physical therapists and used evidence-based adult learning
methods such as interactive case discussions rather than didactic presentations. A short pre- post
osteoporosis knowledge questionnaire was administered and confirmed an increased knowledge
of osteoporosis and management practices post workshop. In addition, Clinical Coaches
received resources to raise awareness and facilitate the use of these practices (website, booklets,
posters, audit checklist) and strategies for implementation and integration of these practices into
standard fracture care. A number of additional resources were provided to Clinical Coaches after
the workshop specifically designed to aide them in program implementation including an
instructional video on how to discuss the Fracture Fighters program with their manager; two
PowerPoint presentations to facilitate small group teaching sessions within their unit; as well as
support and reminders from two Fracture Fighters implementation coordinators. A list of
Fracture Fighters resources are listed in Table 2. These materials were all developed by the
Fracture Fighters team based on osteoporosis best-practice guidelines and current research
evidence (www.fracturefighters.ca). Finally, throughout the implementation stage of the
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program, the Clinical Coaches were invited by the Fracture Fighters project team to participate in
an advisory committee, to share strategies and barriers with Clinical Coaches from other
inpatient rehabilitation sites and make program modifications. Clinical Coaches were asked to
facilitate a teaching session with their unit, update their manager on the Strategy, complete
Fracture Fighters audit checklists and provide on-going support to their unit.
Table 2: Fracture Fighters Resources
Type Format Target Title
Education Booklet Patient A Guide to Osteoporosis for
Patients with Fractures
Education Booklet Inpatient
Rehabilitation –
Health Care
Professionals
A Guide to Osteoporosis for
Health Care Professionals
Education Tear Off Pad Patient Exercise Program for Persons
with Osteoporosis
Audit Tool Tear off Pad Health Care
Professionals
Inpatient Rehabilitation Best-
Practice Checklist
Referral Letter Tear off Pad Health Care
Professionals
Letters to communicate
osteoporosis risk and follow-up
recommendations
Education Electronic Health Care
Professionals
Fracture Fighters Newsletter
Education Slide Deck Health Care
Professionals
Fracture Fighters information
on Osteoporosis and Fractures
Education Slide Deck Health Care
Professionals
Fracture Fighters information
on Osteoporosis and Fracture,
and Rehabilitation Topics
Education Electronic Health Care
Professionals
www.FractureFighters.ca
To evaluate the implementation of the program, telephone surveys (see Appendix A –
copy of survey) with unit Managers were conducted at baseline (prior to implementation) and
again at 6 months with Clinical Coaches to determine which best practices were successfully
implemented. Overall the results showed improvements from baseline across many best practice
13
categories (see Table 3), but many rehabilitation units were unsuccessful in providing education
about osteoporosis, supplements and referrals for osteoporosis follow-up.
Table 3: Percent of Inpatient Rehabilitation Units Implementing Selected Best-Practices (Jaglal
et al. 2008)
Osteoporosis Best Practice Baseline (% of sites) 6-months (% of sites) Osteoporosis education 23 77 Supplements (Vitamin D and Calcium) 17 50 Osteoporosis medication 22 47 BMD testing 9 25 Referral to GP for osteoporosis follow-up 0 42
A similar problem exists in many clinical realms – that is in some care settings, there is a
mismatch between the most effective management and the actual care provided even after
proven intervention strategies have been deployed (Grol and Grimshaw 2003). This is one of the
central foci of knowledge translation. Knowledge translation (KT) is defined as "the exchange,
synthesis and ethically-sound application of knowledge—within a complex system of
interactions among researchers and users—to accelerate the capture of the benefits of research
for Canadians through improved health, more effective services and products, and a strengthened
health care system" (Canadian Institutes of Health Research 2009). The following section will
review knowledge translation theories, models and frameworks to elucidate potential reasons
why some inpatient rehabilitation units were unsuccessful in implementing the Fracture Fighters
program.
2.3 KNOWLEDGE TRANSLATION MODELS, FRAMEWORKS AND THEORIES
Knowledge Translation is a concept that spans the entire research process, from the
creation of knowledge to use by decision-makers (e.g. clinicians) (Graham et al. 2006).
Although knowledge translation was only recently declared a fundamental part of the Canadian
14
Institutes of Health Research mandate (Canadian Institutes of Health Research 2000), the study
of the use of research evidence in the health system has evolved over the last 30 or 40 years
(Estabrooks et al. 2004).
Initial studies simply attempted to measure the use of research evidence among individual
professionals. Subsequently, researchers attempted to understand the factors that predicted,
facilitated or hindered the use of research evidence by individuals, which then led to studies on
the applicability of relevant theories to explain the phenomenon (Dobbins et al. 2002). In the last
decade, researchers have sought out different interventions to improve uptake, yet no one
strategy has emerged as most effective (Grimshaw, Eccles et al. 2004). This is the focus of
implementation research, the scientific study of methods to promote the uptake of research
findings and hence reduce inappropriate care (Eccles et al. 2005).
Many of the intervention strategies or products developed to date such as best-practice
guidelines were tailored based on improving innovation features or attributes (Estabrooks et al.
2004) and most, like the Fracture Fighters program were focused on individual level factors or
barriers to research use (e.g. lack of research skills, educational preparation) (Cummings et al.
2004; Fleuren et al. 2004; Estabrooks et al. 2007). A number of literature reviews of
implementation research have consistently shown that the majority of interventions can achieve
moderate improvements in care (Oxman et al. 1995; Bero et al. 1998; Grimshaw, Eccles et al.
2004), but with considerable variation in the observed effects across interventions (Grimshaw,
Thomas et al. 2004). Several potential explanations of this variation exists, first is that the
reviews combined studies comparing the effectiveness of intervention strategies across different
intervention targets (e.g. provider, patients) (Shojania and Grimshaw 2005). In addition, a
subsequent comparison of the impact of improvement strategies from two systematic reviews for
15
diabetes and hypertension respectively revealed that any given intervention strategy may work
for diabetes but not for hypertension, emphasizing that the effectiveness of a particular approach
to quality improvement depends at least partly on the clinical context and almost certainly on
other contextual factors that have received little study (Shojania and Grimshaw 2005). Therefore,
the effectiveness of implementation strategies may be dependent on the clinical features of the
target and relevant attitudes and beliefs of providers and patients but also the organizational or
social context (Shojania and Grimshaw 2005).
2.3.1 The Need to Consider Context
In their 2008 systematic review of guideline implementation with allied health
professionals, Hakkaennes & Dodd (2008) found that all except four included studies focused on
educational interventions, assuming that the reason that allied health professionals do not use
evidence is due to lack of knowledge. Although barriers that operate at the level of the
individual health care professional are important, there is increased recognition that there exists
multiple barriers to evidence-based practice which operate at levels beyond the control of
individual practitioners (Grimshaw, Eccles et al. 2004). Increasingly, investigators have begun
to acknowledge the importance of contextual factors in achieving successful implementation in
addition to the need to involve clinicians in the knowledge creation process (Logan and Graham
1998; Cummings et al. 2007). The environment or setting in which care is provided and
proposed changes are to be implemented is defined as the context (Rycroft-Malone et al. 2002).
Since few studies provide contextual data, there may be differences in the context between
studies that assessed homogenous interventions (Eccles et al. 2005). Specifically, Cummings
(2004) notes the how and why of organizational context are important unanswered questions
(Cummings et al. 2004). Ferlie and Shortell (2001) suggest that strategies focusing on the
16
individual alone are seldom effective on their own, because the individual approach fails to
recognize that medicine is largely practiced as part of a group or team embedded within a
complex system and organizational structure. They further suggest that there are four levels
(individual health professionals; groups/teams; organizations (hospital); larger health system) of
health care at which interventions to improve quality of care could be applied. Intervention plans
do not have to address all levels simultaneously, but should consider the effect on the other
levels.
In the case of Fracture Fighters, the inpatient rehabilitation unit is the context in which
the proposed changes were to be made. Several contextual factors have been suggested to affect
implementation of evidence in practice, these include but are not limited to: staff-mix, financial
disincentives, access to resources/equipment, academic affiliation of organization, organizational
culture/climate, evaluation, provision of education, learning environment/time to read/for
research activities, stress, organizational readiness for change, uncertainty, support, leadership
style, decision-making structure, staff turnover, autonomy (Funk et al. 1991; McCormack et al.
2002; Fleuren et al. 2004; Dijkstra et al. 2006; Meijers et al. 2006; Francke et al. 2008; Koh et al.
2008; Scott et al. 2008; Yano 2008; Bostrom et al. 2009). Therefore, it is plausible that failure to
implement Fracture Fighters best practices in some inpatient rehabilitation units was due to
contextual factors not accounted for during program planning and roll-out.
2.3.2 The Need for Theory
In addition to considering contextual factors, knowledge translation researchers have
begun to advocate for the use of theory to guide implementation research (Eccles et al. 2005;
Estabrooks et al. 2006; Grol et al. 2007). The lack of theoretical underpinning and interventions
17
attempting to explicitly and prospectively modify theoretical constructs has made it difficult to
interpret why interventions have positive or negative effects (Eccles et al. 2005).
Currently, no overarching knowledge translation theory exists (Estabrooks et al. 2006).
Indeed,
―new paradigms are needed that integrate salient psychological and organizational
theories into a uniform model and make them accessible to implementation researchers,
but in the absence of such paradigms, implementation researchers should capitalize on
the contribution of organizational theories already contributed by psychology, sociology,
management science and other disciplines in order to be explicit about the anticipated
mechanisms of action at the organizational level‖ (Yano 2008).
A short scan of the literature turned up over 70 theories, models and frameworks from a variety
of disciplines that have been applied or are suggested for knowledge translation research (See
Appendix B overview of KT theories, models and frameworks). Therefore, the inclusion of a
comprehensive review of all knowledge translation theories, models and frameworks would not
be feasible. Instead, five have been selected for inclusion in this discussion based on their focus
on the implementation stage of knowledge translation; relevance to the Canadian healthcare
context or frequent citation in the literature. These include: 1) Diffusion Theory and the Spread
of Ideas (Rogers 1995; Greenhalgh et al. 2004); 2) the Knowledge-to-Action Process (Graham et
al. 2006); 3) The Ottawa Model for Research Use (OMRU) (Logan and Graham 1998; Graham
and Logan 2004); 4) The Quality Enhancement Research Initiative (QUERI)(Stetler, Mittman et
al. 2008); and 5) The Promoting Action on Research Implementation in Health Services
(PARiHS) Framework (Kitson et al. 1998; Rycroft-Malone et al. 2002). Each of these will be
briefly described followed by selection of a KT model appropriate for the Fracture Fighters
program.
18
2.3.2.1 Diffusion Theory – Spread of Ideas (Rogers 1995; Greenhalgh et al. 2004)
The Diffusion of Innovations Theory was originally developed by Rogers (1995) and has
been one of the most oft cited theories in knowledge translation research (Estabrooks 2004).
Rogers (1995) defined innovation as any idea, practice or item that is perceived to be new by an
individual or other adopting unit; and diffusion as the process by which an innovation is
communicated through certain communication channels over time. In addition he described
Step 3: Measure and diagnose quality and performance gaps 3A. Measure existing practice patterns and outcomes across VA and identify variations from evidence-based
practices ("quality/performance gaps")
3B. Identify determinants of current practices
3C. Diagnose quality/performance gaps
3D. Identify barriers and facilitators to improvement
Step 4: Implement improvement programs 4A. Identify improvement/implementation strategies, programs and program components or tools
4B. Develop or adapt improvement/implementation strategies, programs and program components or tools
4C. Implement improvement/implementation strategies/programs to address quality gaps
Step 5/6: Evaluate improvement programs 5. Assess improvement program feasibility, implementation and impacts on patient, family and healthcare system
processes and outcomes
6. Assess improvement program impacts on health related quality of life (HRQOL)
2.3.2.5 Promoting Action on Research Implementation in Health Services (PARiHS) Framework
(Kitson et al. 1998; Rycroft-Malone et al. 2002)
The Promoting Action on Research Implementation in Health Services (PARiHS)
framework was originally proposed by Kitson et al (1998) as an alternative to existing linear or
unidimensional models of research to practice such as the coordinated implementation model.
The framework consisted of three elements: 1) evidence; 2) context and 3) facilitation and was
developed from the collective experience gained from research, practice development, and
24
quality improvement projects. Instead of a hierarchy or linearity of cause and effect each of the
dimensions are considered simultaneously (Kitson et al. 1998).
Through the application of the model to four case studies completed by the Royal College
of Nursing Institute, Kitson and colleagues (1998) demonstrated that most successful
implementation occurred when: 1) the evidence is scientifically robust and matches professional
consensus and patient needs ("high" evidence); 2) the context is receptive
to change with
sympathetic cultures, strong leadership, and appropriate monitoring and feedback systems
("high" context); and 3) there is appropriate facilitation for change with input
from skilled
external and internal facilitators ("high" facilitation) (Rycroft-Malone et al. 2002) (Figure 5)
Figure 5: Promoting Action on Research Implementation in Health Services (PARiHS)
Framework
25
Each element in the framework (evidence, context and facilitation) included a number of
sub-elements which were revisited in 2002 by the same authors (Harvey et al. 2002; McCormack
et al. 2002; Rycroft-Malone et al. 2002). They completed a content analysis by critically
reviewing the literature to further develop the sub-elements included within the framework. The
element of evidence has three sub-elements: research, clinical experience, patient experience;
context has three sub-elements of leadership, culture and evaluation; and high facilitation
included a match between the purpose and role of facilitation with the skills and attributes of the
facilitator. Each of the elements is ranked on a scale from low to high. A full outline of the
PARiHS elements is available in Appendix C (Rycroft-Malone et al. 2002).
Several empirical studies have provided support for the PARiHS framework by
demonstrating that successful implementation is a function of evidence, context and facilitation.
However, it is still unclear if the elements or sub-elements have equal weighting in getting
evidence into practice (Kitson et al. 2008). Two studies have demonstrated a dose-response
relationship in that higher levels of culture, leadership and evaluation (context) resulted in
greater research utilization (Cummings et al. 2007; Estabrooks et al. 2007) and two studies (Ellis
et al. 2005; Wallin et al. 2005) have utilized the PARiHS framework to guide qualitative
evaluations of evidence implementation. Ellis et al (2005) explored the relative and combined
importance of context and facilitation in successful implementation of clinical practice protocols
and concluded that good facilitation appeared to be more influential than context in overcoming
the barriers to evidence-based practice. Whereas, Wallin and colleagues (2005) demonstrated
that a facilitation intervention appeared to be no more effective than an improvement focused
organizational culture for implementing guidelines in neonatal care units in Australia.
26
2.3.2.6 Selection of the KT Model for Fracture Fighters Program
Common to these theories/models is attention to identifying, describing, and assessing
the practice environment and its influences, which may facilitate and/or impede the process of
research transfer and use. Other common features of the models are monitoring the progress of
the transfer effort, and evaluating usage of the evidence-based innovation and its impact on
outcomes of interest (Kontos and Poland 2009).
Grimshaw and colleagues (2004) suggest that it is unlikely that one theory will apply
equally well to every possible intervention, and thus it is more reasonable to try to find the best
fit between theories and particular interventions(Grimshaw, Eccles et al. 2004). Of the five
models described, the PARiHS framework was selected for application to the Fracture Fighters
program due to its emphasis on the importance of facilitation. Although many of these models do
mention the need for linkages, facilitation or opinion leaders, PARiHS included facilitation as
one of three core elements required for successful implementation, fitting with the primary type
of implementation strategy employed by Fracture Fighters, facilitation via the Clinical Coach
model. What distinguishes the PARiHS conceptual framework from the others is that as well as
mapping the interrelationships, PARiHS has the potential to be used as a practical and pragmatic
tool by practitioners and researchers at the local level during implementation planning (Kitson et
al. 2008). However, to do this there is a need to clarify the definition of each element and sub-
element and to identify appropriate questionnaires to measure each of the constructs.
The framework developers have prioritized the need to develop diagnostic and evaluative
tools based on PARiHS (Kitson, 2008). In this regard, in order to use PARiHS in practice,
instruments are needed to assess barriers and facilitators during implementation planning
(diagnose) as well as to determine the effectiveness of intervention strategies (evaluation). In
27
addition, concrete guidance on how to match tools to identified barriers (prescribe) is required
(Green et al. 2007).
2.4 SUMMARY
Unit or organizational level factors such as context are increasingly being recognized as
important considerations for evidence implementation. PARiHS may be a useful framework to
examine unit level factors that influence evidence implementation in practice. However, prior to
application, the PARiHS framework must be operationalized by identifying appropriate
measures of evidence, context and facilitation and respective sub-elements.
28
CHAPTER 3: Manuscript 1
TITLE: Proposing a Toolbox of Measures for the Promoting Action on Research
Implementation in Health Services (PARiHS) Framework: Application to Fracture
Fighters Program
3.1 ABSTRACT
Background: Interventions to increase uptake of research have led to moderate success, but no
overarching intervention strategy has emerged. This may be due to differences in the
environment in which these interventions are applied thus knowledge translation models and
frameworks have begun to incorporate contextual factors. The Promoting Action on Research
Implementation in Health Services (PARiHS) is one such framework but further work is needed
to operationally define the constructs of PARiHS to enable its widespread application.
Purpose: The purpose of this paper is to propose a toolbox of measures for the PARiHS
framework by describing its potential application to a best practice program called Fracture
Fighters.
Methods: Measures were selected after a review of statements suggested by the framework
developers and additional available measures of evidence, leadership, climate, evaluation and
facilitation. Where available, standardized measures were selected, based on content validity
with the PARiHS description of elements/sub-elements and evidence of psychometric validity
and reliability.
Results: The proposed toolbox consists of the following validated scales: the Multifactor
Leadership Questionnaire (Leadership); the Organizational Climate sub-scale of the
Organizational Readiness for Change measure (Climate); the Champion Behavior Measure and
29
the Opinion Leadership Scale (Facilitation). In addition, we suggested a simple measure of
evidence based on statements suggested by the framework developers and an assessment of
project-specific process indicators be included to provide information on the evidence and
evaluation sub-elements respectively.
Conclusion: The proposed toolbox will enable measurement of the PARiHS constructs of
evidence, context and facilitation and their respective sub-elements. Future research could apply
the proposed toolbox to provide further validation that high evidence, context and facilitation are
predictors of implementation success and provide refinements to the model by determining
which elements or sub-elements are the primary drivers of implementation success.
Word Count: 289
30
3.2 INTRODUCTION
Implementation research is the scientific study of methods to promote the uptake of
research findings and hence reduce inappropriate care (Eccles et al. 2005). In recent years it has
been given much attention by knowledge translation scholars and numerous interventions, such
as guideline dissemination, continuing medical education, reminders, educational outreach and
audit and feedback, have been developed and tested in order to increase the likelihood that
clinicians will incorporate new research into their current practice. However, several systematic
reviews of implementation strategies have concluded that there is no ―magic bullet‖ or one best
approach to increasing the use of evidence in practice (Oxman et al. 1995) and that multi-
component strategies are no more effective then single interventions (Grimshaw, Eccles et al.
2004). Although there is a widespread agreement that evidence implementation requires
strategies to meet the needs of the individual clinician, there is an increasing acknowledgement
of the importance of organizational context (Logan and Graham 1998; Cummings et al. 2007;
Wallin 2009).
Context is defined as the environment or setting in which the proposed change is to be
implemented (Rycroft-Malone et al. 2002). Some examples of contextual factors include:
academic affiliation of organization, functional differentiation/staff-mix, organizational
culture/climate, evaluation, access to resources/equipment, provision of education, learning
environment/time to read/for research activities, stress, organizational readiness for change,
A review of questionnaires to measure leadership indicated that the Multifactor
Leadership Questionnaire (MLQ Form 5X) is one of the most widely used instruments to
measure transactional and transformational behaviours in the organizational sciences (Tejeda et
al. 2001). The MLQ (Form 5X) contains 45 items in total, 36 which correspond to the nine
leadership factors. These nine leadership factors are derived from the Full-Range Leadership
Theory (Avolio and Bass 1991 ) and includes: 1) idealized influence attributed (perceived
socialized charisma); 2) Idealised influence behaviour (charismatic actions of the leader); 3)
41
Inspirational motivation (the ways leaders energize their followers); 4) Intellectual stimulation
(the way leaders challenge followers to think and problem solve); 5) Individualized consideration
(extent that advice is individualised to needs of the follower); 6) Contingent reward leadership
(constructive transactions); 7) Management-by-exception active (leaders goal is to ensure
standards are met); 8) Management-by-exception passive (leaders intervene only after mistakes
have already happened). The final factor is nontransactional laissez-faire leadership which
represents a leader who avoids decisions, relinquishes responsibility and does not use their
authority (Antonakis et al. 2003). Each of the 36 MLQ items are scored on a Likert scale from 1
to 5 (<1> not at all; <5> frequently if not always). Mean composite scores are computed for each
of the nine leadership factors. These individual leadership scores can subsequently be compared
to a normative score profile which is based on a US database of approximately 27,000 MLQ
respondents (See Appendix F for Percentiles of Individual Scores) (Avolio and Bass 2004). The
score profiles are reflective of a variety of industries (military, government, educational,
manufacturing, high technology, church, correctional, hospital, and volunteer organizations) and
a wide variety of rater groups (self-report, lower level rating, same level rating, higher level
rating) (Avolio and Bass 2004).
The MLQ (Form 5X) was developed and revised based on results from previous versions
of the MLQ and a confirmatory factor analysis (Antonakis et al. 2003). The developers of the
MLQ used a sample from their global database (United States n=27,000; Europe n=15,000;
Australia n =13,000; South Africa n =500) to complete a confirmatory factor analysis to test the
expanded nine factor model (MLQ Form 5X) whereas previous models included a six factor
model. In all instances there was clear support for the nine factor model regardless of rater
source or geographic variation (Bass and Avolio 1994). More importantly, the MLQ has been
validated in a health care setting, a group of Finnish nurses and nurse leaders (n=601) (Kanste et
42
al. 2007). Cronbach‘s alpha for the leadership subscales ranged from 0.78 to 0.94 in this group.
Inter-item correlations ranged from 0.30 to 0.70. Thus the MLQ would be suitable for evaluating
leadership in the clinical setting. Sample items are listed in Table 6.
Table 6: Leadership styles, behaviours and sample questionnaire items
Leadership
Style
Leadership Behaviour Sample MLQ Form 5X Question*
Transformational Charismatic (Idealized
Influence – attributed)
Instills pride in me for being associated with him/her
Charismatic (Idealized
Influence – behaviours)
Inspirational Motivation Talks optimistically about the future Intellectual Stimulation Suggests new ways of how to complete assignments Individualized Consideration
Appendix B – Knowledge Translation Theories, Models and Frameworks 129
Reference Title of KT Model,
Framework,
Theory
Key Concepts and Descriptions
Elder 1999 53. Health
Behaviour
Change Model
Stages of Change
Prochaska (1997) 54. Transtheoretical
Model
Health Behaviour Change. Progress through 6 stages
1) Precontemplation
2) Contemplation
3) Preparation
4) Action
5) Maintenance
6) termination
Pathman (1996) 55. Awareness-to-
Adherence
As applied to physician guidelines.
Behaviour and cognitive stages that physician must pass
through in order to adopt guidelines
1) Awareness
2) Agreement
3) Adoption
4) Adherence
Grol 2007 56. Social Learning
Theory
-changing performance take place through demonstration
and modeling and through reinforcement by others
e.g. Bandura Social Cognitive Theory
Grol 2007 57. Theories of
teamwork
-more effective teams are better able to make necessary
change to improve care because they share goals and are
able to share knowledge
Grol 2007 58. Theories of
professional
development
-professional loyalty, pride and consensus and
“reinvention” of change proposal by professional body are
important
Grol 2007 59. Theories of
leadership
Involvement and commitment of leaders and (top)
management in change process are important
Grol 2007 60. Theory of
innovative
organizations
Implementation should take into account the type of
organization; decentralized decision making (teams) about
innovation is important
Grol 2007 61. TQM (Total
Quality
Management)
or CQI
(continuous
quality
improvement)
-Improvement is a continuous cyclic process, shich plans
for change continually adapted on the basis of previous
experience; organization-wide measure are aimed at
improving culture, collaboration, customer focus, and
process
-pdsa cycles
Grol 2007 62. Theories of
integrated care
-change multidisciplinary care processes and collaboration
instead of individual decision making
Grol 2007 63. Reimbursement
theories
Attractive rewards and (financial) incentives can influence
the volume of specific activities
Appendix B – Knowledge Translation Theories, Models and Frameworks 130
Reference Title of KT Model,
Framework,
Theory
Key Concepts and Descriptions
64. Pay for
performance
Grol 2007 65. Theory of
contracting
-contractual agreements can guide professional and
organizational performance
Estabrooks 2006
guide to kt theory
66. Organizational
Innovation
Models
-tend to focus on explanation rather than
prescription and are circumscribed in the particular
aspect of innovation they address
Estabrooks 2006
guide to kt theory
67. Model of
Territorial
Rights and
Boundaries
Innovations are perceived as threats to existing
organizational practices and interests
Estabrooks 2006
guide to kt theory
68. Dual Core
Model of the
innovation
-innovations originate from cores that serve different
purposes
Estabrooks 2006
guide to kt theory
69. Ambidextrous
Model
-high structural complexity, low formalization and low
centralization initative innovation but the inverse conditions
facilitate implementation
-orgs with diverse and differentiated task structures initative
more innovations and those whith formalized and
centralized structures implement more innovations
Estabrooks 2006
guide to kt theory
70. Bandwagon
Model
-orgs are promoted to adopt and innovation through fear
that other organizations are benefitting
-adoption occurs regardless of how the innovation is
perceived by an organization
Estabrooks 2006
guide to kt theory
71. Desperation
Reaction Model
-innovations intended to address desparte situations diffuse
differently than other innovations.
Interactive Models
Jacobsen 2003 72. Understanding
the User
Context
Domains to consider when planning research-decision
maker:
User group
Issue
Research
Researcher-user relationship
Dissemination strategy
*Lists questions to ask for each domain
Majdzadeh (2008) 73. A knowledge translation cycle is described, with five
domains: knowledge creation, knowledge transfer, research
utilization, question transfer, and the context of
organization. Discussion: The knowledge translation cycle
offers a theoretical basis for identifying basic requirements
and linking mechanisms in the translation of knowledge for
research utilization.
74. Five stages: building a case for action, identifying
Appendix B – Knowledge Translation Theories, Models and Frameworks 131
Reference Title of KT Model,
Framework,
Theory
Key Concepts and Descriptions
contributory factors and points of intervention, defining
opportunities for action, evaluating potential interventions
and selecting a portfolio of specific policies, programmes
and actions. Each stage is cumulative and culminates in the
development of a plan to support the combination of
research evidence, theoretical perspectives and contextual
factors into a plan for translation into action
Kontos & Poland
(2009)
75. Critical
Realism and the
Arts Research
Utilization
Model
(CRARUM)
CRARUM has the potential to strengthen the science of
implementation research by addressing the complexities of
practice settings, and engaging potential adopters to
critically reflect on existing and proposed practices and
strategies for sustaining change
Stetler (2008) 76. QUERI Quality
Enhancement
Research
Initiative
1) Identify high-risk/high-volume diseases or problems.
2) Identify best practices.
3) Define existing practice patterns and outcomes across the
VA and current variation from best practices.
4) Identify and implement interventions to promote best
practices.
5) Document that best practices improve outcomes.
6) Document that outcomes are associated with improved
health-related quality of life.
Within Step 4, QUERI implementation efforts generally
follow a sequence of four phases to enable the refinement
and spread of effective and
sustainable implementation programs across multiple VA
medical centers and clinics. The phases include:
1) Single site pilot,
2) Small scale, multi-site implementation trial,
3) Large scale, multi-region implementation trial, and
4) System-wide rollout
Boissel (2004) 77. Eight-step
approach to
bridge the gap
between
research
information and
physician
prescription
-designed to optimize the indirect channel
1. identify and comprehensivly collect pertinent research
data
2. summarize individual study data – standardized format
3. assign level of evidence score for each study
4. rand related studies by assigned score
5. summarize – perform a meta-analysis
6. prepare coherent messages from summaried findings of
relevant studies
7.Relevant, efficient and neutral presentation
8. Transmit message “just in time” to physicians (e.g.
Appendix B – Knowledge Translation Theories, Models and Frameworks 132
Reference Title of KT Model,
Framework,
Theory
Key Concepts and Descriptions
online, e-bulletins)
Burrows (1995)
78. Review current practice motivation to change identify
relevant evidence and appraise implement in practice
Goode 1992 79. EB
multidisciplinar
y clinical
practice model.
Organisational commitment change agents planned
change process outcome (research based practice)
Provide an example of how model was used to improve
quality and decrease cost
Boissel, J.-P., E. Amsallem, M. Cucherat, et al. (2004). "Bridging the gap between therapeutic research results and physician prescribing decisions: Knowledge transfer, a prerequisite to knowledge translation." European Journal of Clinical Pharmacology 60(9): 609-616.
Bucknall, T. (2007). "A gaze through the lens of decision theory toward knowledge translation
science." Nursing Research 56(4S): S60-66. Burrows, D. E. and K. McLeish (1995). "A model for research-based practice." Journal of
Clinical Nursing 4(4): 243-247. Ceccato, N. E., L. E. Ferris, D. Manuel and J. Grimshaw (2007). "Adopting health behaviour
change theory throughout the clinical practice guideline process." Journal of Continuing Education in the Health Professions 27(4): 201-207.
Champagne, F. (2002). The ability to manage change in health care organizations.
Commision on the Future of Health Care in Canada. Dobbins, M., D. Ciliska, R. Cockerill, et al. (2002). "A framework for the dissemination and
utilization or research for health-care policy and practice." The Online Journal of Knowledge Synthesis for Nursing 9(7).
Dopson, S. (2007). "A view from organizational studies." Nursing Research 56(4S): S72-S77. Edgar, L., S. Lambert, R. Herbert, et al. (2006). "The joint venture model of knowledge
utilization: A tool for change in nursing." Canadian Journal of Nursing Leadership 19(2): 41-55.
Estabrooks, C. A., D. S. Thompson, J. E. Lovely and A. Hofmeyer (2006). "A guide to
knowledge translation theory." The Journal of Continuing Education in the Health Professions 26: 25-36.
Appendix B – Knowledge Translation Theories, Models and Frameworks 133
Graham, K. and J. Logan (2004). "Using the ottawa model of research use to implement a skin care program." Journal of Nursing Care & Quality 19(1): 18-24.
Greenhalgh, T., G. Robert, F. Macfarlane, et al. (2004). "Diffusion of innovations in service
organizations: Systematic review and recommendations." The Milbank quarterly 82(4): 581-629.
Goode, C. J. and F. Piedalue (1999). "Evidence-based clinical practice." Journal of Nursing
Administration 29(6): 15-21. Grol, R., M. Bosch, M. E. J. L. Hulscher, et al. (2007). "Planning and studying improvement in
patient care: The use of theoretical perspectives." Havelock, R. G. (1969). Planning for innovation through dissemination and utilization of
knowledge. Ann Arbor, Center for Research on Utilization of Scientific Knowledge. Horsley, J.-A., Y. Crane and J. D. Bingle (1978). "Research utilization as an organizational
process." Journal of Nursing Administration 8(7): 4-6. Jacobson, N., D. Butterill and P. Goering (2003). "Development of a framework for knowledge
translation: Understanding user context." Journal of Health Services and Policy Research 8(2): 94-99.
Kontos, P. and B. Poland (2009). "Mapping new theoretical and methodological terrain for
knowledge translation: Contributions from critical realism and the arts." Implementation Science 4(1): 1.
Landry, R. N., N. Amara and M. Lamari (2001). "Utilization of social science research
knowledge in canada." Research Policy 30(2): 333-349. Lavis, J. N., S. E. Ross, C. McLeod and A. Glidner (2003). "Measuring the impact of health
research." Journal of Health Services Research and Policy 8(3): 165-170. Lavis, J. N. (2004). "A political science perspective on evidence-based decision-making."
Using Knowledge and Evidence in Health Care: Multidisciplinary Perspectives on Evidence-Based Decision-Making in Health Care(Journal Article): 70-85.
Lavis, J. N., D. Robertson, J. M. Woodside, et al. (2003). "How can research organizations
more effectively transfer research knowledge to decision makers?" Milbank Quarterly 81(2): 221-248.
Logan, J. and I. D. Graham (1998). "Toward a comprehensive interdisciplinary model of
health care research use." Science Communication 20.
Appendix B – Knowledge Translation Theories, Models and Frameworks 134
Lomas, J. (2000). "Connecting research and practice." ISUMA: Canadian Journal of Policy Research 1(1): 140-144.
Majdzadeh, R., J. Sadighi, S. Nejat, et al. (2008). "Knowledge translation for research
utilization: Design of a knowledge translation model at tehran university of medical sciences." Journal of Continuing Education in the Health Professions 28(4): 270-277.
Pathman, D. E., T. R. Konrad, G. L. Freed, et al. (1996). "The awareness-to-adherence
model of the steps to clinical guideline compliance - the case of pediatric vaccine recommendations." Medical Care 34(9): 873-889.
Prochaska, J. O. and W. F. Velicer (1997). "Behavior change: The transtheoretical model of
health behavior change." American Journal of Health Promotion 12: 38-48. Rogers, E. M. (1995). Diffusion of innovations. New York, Free Press. Stetler, C. B. (2001). "Updating the stetler model of research utilization to facilitate evidence-
based practice." Nursing Outlook 49(6): 272-279. Stetler, C., B. Mittman and J. Francis (2008). "Overview of the va quality enhancement
research initiative (queri) and queri theme articles: Queri series." Implementation Science 3(1): 8.
Weiss, C. H. (1979). "The many meanings of research utilization." Public administration
review 39(Journal Article): 426-431.
Appendix C – Outline of PARiHS Elements 135
EVIDENCE
Research LOW ---------------------------------------------------------------------------------------------------------------HIGH
Poorly conceived, designed and/or
executed research
Well conceived, designed, executed research appropriate to
question
Seen as only type of evidence See as one part of decision
Not valued as evidence Lack of uncertainty acknowledged
Appendix D – Information Letters and Consent Forms 137
Clinical Coach Version Title of research project: Promoting Action on Research Implementation in Health Services
(PARIHS) Framework: Application to the Fracture Fighters Program Investigator: Ms. Vinita Bansod, MSc Student Department of Health Policy, Management and Evaluation, University of Toronto 155 College Street, Suite 425 Toronto, ON M5T 3M6 [email protected] or [email protected] Telephone: (416) 351-3732 x 2321 Fax: (416) 351-3746 Supervisor: Dr. Susan Jaglal Department of Physical Therapy, University of Toronto 160-500 University Avenue Toronto, ON M5G 1V7 [email protected] (416) 978-0315 Sponsor/Funding: The Fracture Fighters program is funded by the Ministry of Health and Long-Term Care Ontario Osteoporosis Strategy. The student investigator has received funding for Master studies from the Canadian Institutes of Health Research. Background & Purpose of Research: This study is being completed as part of a Master’s thesis in the Department of Health Policy, Management and Evaluation at the University of Toronto. Participants will include 36 inpatient rehabilitation clinicians who participated in the Fracture Fighters program as a Clinical Coach as well as their managers. The goal of this study is to apply the Promoting Action for Research Implementation in Health Services Framework to the Fracture Fighters program in order to describe factors that may have influenced the implementation of osteoporosis best practices for fracture patients. These factors include: the research and program content; organizational culture in participating inpatient rehabilitation units; management styles and the skills of clinical coach facilitators. This survey is the first of two sets of surveys included in the study. The second set of surveys will be completed with inpatient rehabilitation managers. Eligibility: To participate in this study you must be a Clinical Coach from one of thirty-six inpatient rehabilitation units participating in the Fracture Fighters program. Procedures (What is required of you?) If you are interested in participating, please sign the bottom of this (YELLOW) consent form and complete the BLUE survey provided in your package to the best of your ability. You are being provided a copy of the consent form to keep for your records. The survey should take between 20-30 minutes to complete. When you are finished with the survey, please mail it back in the envelope provided or fax to: (416) 351-3746 ATTENTION Vinita Bansod
Appendix D – Information Letters and Consent Forms 138
Voluntary Participation & Early Withdrawal: Your participation is entirely voluntary. You may choose to participate or withdraw at any time. You may also refuse to answer specific survey questions. Refusal to participate will not result in any penalty, loss of benefits (including legal) to which you are otherwise entitled. Risks/Benefits: There are no direct benefits to participating in the study. You will receive $50 for completing the survey. The results could also possibly help with planning future best-practice programs in a more effective way. The risks to participating are minor, your individual results will only be known to the student investigator and will never be reported in an individual manor. There is no risk that individual information will be shared with your department, hospital or colleagues. There are no costs to participating in this study. Privacy & Confidentiality All information you provide will be kept strictly confidential. Confidentiality can only be guaranteed to the extent permitted by law. No identifying information will be included in any reports or summaries of this research. Only the student researcher (Vinita Bansod) will have access to paper copies of the surveys and consent forms. Individual responses will not be shared with the Fracture Fighters implementation team, your hospital, unit manager or staff. All survey responses will be inputted into a computerized password protected database. No names or identifying information will be included in the database. Hard copies of the survey and consent forms will be locked in separate secure filing cabinets, only accessible to the student investigator. Hard copies will be destroyed at the completion of this thesis project (September 2009). Electronic copies will be retained for 5 years as per the requirements of research institutions. Publication of research findings: Publication of the results of the survey will only be reported in aggregate. Individual responses will not be reported and no respondent names will be included. Research participants may request a copy of the final thesis report. If you have questions about your rights as a research participant, please contact Jill Parsons, Health Sciences Ethics Review Officer, Ethics Review Office, University of Toronto, at telephone 416-946-5806 or by email: [email protected].” Signature:________________ Printed Name: _____________________ Date: ________________ Additional information: Please provide your mailing address so we may send you your $50 gift card.
Appendix D – Information Letters and Consent Forms 139
Manager Version Title of research project: Promoting Action on Research Implementation in Health Services
(PARIHS) Framework: Application to the Fracture Fighters Program Investigator: Ms. Vinita Bansod, MSc Student Department of Health Policy, Management and Evaluation, University of Toronto 155 College Street, Suite 425 Toronto, ON M5T 3M6 [email protected] or [email protected] (416) 351-3783 x 2321 Supervisor: Dr. Susan Jaglal Department of Physical Therapy, University of Toronto 160-500 University Avenue Toronto, ON M5G 1V7 [email protected] (416) 978-0315 Sponsor/Funding: The student investigator has received funding for Masters studies from the Canadian Institutes of Health Research. Background & Purpose of Research: This study is being completed as part of a Masters thesis in the Department of Health Policy, Management and Evaluation at the University of Toronto. Participants will include 36 inpatient rehabilitation clinicians who participated in the Fracture Fighters program as a Clinical Coach as well as their managers. The goal of this study is to apply the Promoting Action for Research Implementation in Health Services Framework to the Fracture Fighters program in order to describe factors that may have influenced the implementation of osteoporosis best practices for fracture patients. These factors include: the research and program content; organizational culture in participating inpatient rehabilitation units; management styles and the skills of clinical coach facilitators. This survey is the second of two sets of surveys included in the study. The first set of surveys was completed by clinical coaches of the Fracture Fighters program. Eligibility: To participate in this study you must be a manager of one of thirty-six inpatient rehabilitation units participating in the Fracture Fighters program. Procedures (What is required of you?) If you are interested in participating, please sign the bottom of this consent form and provide suggested dates and times to complete a telephone survey. If you agree, the student investigator will call you during your suggested time to complete a short 5-10 minute survey.
Appendix D – Information Letters and Consent Forms 140
Voluntary Participation & Early Withdrawal: Your participation is entirely voluntary. You may choose to participate or withdraw at any time. You may also refuse to answer specific survey questions. Refusal to participate will not result in any penalty, loss of benefits (including legal) to which you are otherwise entitled. Risks/Benefits: There are no direct benefits to participating in the study. You will receive a $50 gift card for completing the survey. In addition, the survey results could possibly help with planning future best-practice programs in a more effective way. The risks to participating are minor, your individual results will only be known to the student investigator and will never be reported in an individual manor. There is no risk that individual information will be shared with your department, hospital or colleagues. There are no costs to participating in this study. Privacy & Confidentiality All information you provide will be kept strictly confidential. Confidentiality can only be guaranteed to the extent permitted by law. No identifying information will be included in any reports or summaries of this research. Only the student researcher (Vinita Bansod) will have access to paper copies of the surveys and consent forms. Individual responses will not be shared with the Fracture Fighters implementation team, your hospital, unit manager or staff. All survey responses will be inputted into a computerized password protected database. No names or identifying information will be included in the database. Hard copies of the survey and consent forms will be locked in separate secure filing cabinets, only accessible to the student investigator. Hard copies will be destroyed at the completion of this thesis project (September 2009). Electronic copies will be retained for 5 years as per the requirements of research institutions. Publication of research findings: Publication of the results of the survey will only be reported in aggregate. Individual responses will not be reported and no respondent names will be included. Research participants may request a copy of the final thesis report. If you have questions about your rights as a research participant, please contact Jill Parsons, Health Sciences Ethics Review Officer, Ethics Review Office, University of Toronto, at telephone 416-946-5806 or by email: [email protected].” Signature:____________________ Printed Name:_______________ Date:_________________
Schedule for Phone Call (You may also request evenings and weekends) Preferred Dates/Times for Call: _____________________________________________________ Preferred Phone Number: _____________________________________________________ Please provide your mailing address so we may send you your $50 gift card:
Appendix E – Survey Instruments CLINICAL COACH QUESTIONNAIRE ID/NAME: ____141
SECTION A: EVIDENCE
This first set of questions will ask you to rate the evidence provided by the Fracture Fighters program. This includes evidence from research, clinical expertise and patient experiences. Please rate each statement on the following scale:
Research
1. I value the research evidence provided by Fracture Fighters 1 2 3 4 5
2. The Fracture Fighters research evidence fits with my understanding of fractures and osteoporosis management
1 2 3 4 5
3. The Fracture Fighters research evidence is useful in thinking about the issue of osteoporosis management for fracture patients
1 2 3 4 5
4. I am clear about what the key messages for the Fracture Fighters intervention are
1 2 3 4 5
5. There is consensus amongst my colleagues about the usefulness of Fracture Fighters research to the issue of osteoporosis management in fracture patients
1 2 3 4 5
Clinical Expertise
6. I have reflected on my own clinical experience in relation to fractures and osteoporosis
1 2 3 4 5
7. I have shared and critically reviewed my clinical experience in relation fractures and osteoporosis
1 2 3 4 5
8. I have shared and critically reviewed my clinical experience with knowledgeable colleagues outside of my (clinical) workplace
1 2 3 4 5
9. There is a consensus of (clinical) experience about the FF osteoporosis best-practices
1 2 3 4 5
10. Clinical experience will be used as one part of the evidence for implementing the program
1 2 3 4 5
11. The consensus of clinical experience fits with my understanding of fractures and osteoporosis
1 2 3 4 5
Patient Experiences
12. We routinely (and systematically) collect patients’ experiences about fractures and osteoporosis follow-up
1 2 3 4 5
13. Patients experiences will be used as one part of the evidence 1 2 3 4 5
14. I value patient experiences as evidence 1 2 3 4 5
15. The evidence of patients experiences fits my understanding of the issue(s) 1 2 3 4 5
16. Patient experiences are useful in thinking about the osteoporosis best-practices
1 2 3 4 5
17. There is a consensus amongst my colleagues about the usefulness of patient experiences to osteoporosis management in fracture patients
Appendix E – Survey Instruments CLINICAL COACH QUESTIONNAIRE ID/NAME: ____142
SECTION B: MULTI-FACTOR LEADERSHIP SCALE
Name of Manager:__________________________________________ The next questionnaire is to describe the leadership style of your inpatient rehabilitation manager (NAME) as you perceive it. Please do your best to answer all items. If an item is irrelevant, or if you are unsure or do not know the answer, let me know and we can leave the answer blank. Please answer this questionnaire anonymously.
Instructions: Judge how frequently each statement fits the person you are describing. Use the following rating scale:
THE PERSON I AM RATING. . .
1. Provides me with assistance in exchange for my efforts 0 1 2 3 4
2. Re-examines critical assumptions to question whether they are appropriate 0 1 2 3 4
3. Fails to interfere until problems become serious 0 1 2 3 4
4. Focuses attention on irregularities, mistakes, exceptions, and deviations from standards
0 1 2 3 4
5. Avoids getting involved when important issues arise 0 1 2 3 4
6. 0 1 2 3 4
7. 0 1 2 3 4
8. 0 1 2 3 4
9. 0 1 2 3 4
10. 0 1 2 3 4
11. 0 1 2 3 4
12. 0 1 2 3 4
13. 0 1 2 3 4
14. 0 1 2 3 4
15. 0 1 2 3 4
16. 0 1 2 3 4
17. 0 1 2 3 4
18.
0 1 2 3 4
Not at all Once in awhile Sometimes Fairly Often Frequently, if not always
<0> <1> <2> <3> <4>
Appendix E – Survey Instruments CLINICAL COACH QUESTIONNAIRE ID/NAME: ____143
19. 0 1 2 3 4
20. 0 1 2 3 4
21. 0 1 2 3 4
22. 0 1 2 3 4
23. 0 1 2 3 4
24. 0 1 2 3 4
25. 0 1 2 3 4
26. 0 1 2 3 4
27. 0 1 2 3 4
28. 0 1 2 3 4
29. 0 1 2 3 4
30. 0 1 2 3 4
31. 0 1 2 3 4
32. 0 1 2 3 4
33. 0 1 2 3 4
34. 0 1 2 3 4
35. 0 1 2 3 4
36. 0 1 2 3 4
37. 0 1 2 3 4
38. 0 1 2 3 4
39. 0 1 2 3 4
40. 0 1 2 3 4
41. 0 1 2 3 4
42. 0 1 2 3 4
43. 0 1 2 3 4
44. 0 1 2 3 4
45. 0 1 2 3 4
Not at all Once in awhile Sometimes Fairly Often Frequently, if not always
<0> <1> <2> <3> <4>
Appendix E – Survey Instruments CLINICAL COACH QUESTIONNAIRE ID/NAME: ____144
SECTION C: ORGANIZATIONAL CLIMATE The next set of questions will ask you about your view of the organizational climate of your inpatient rehabilitation unit. Please rate each statement on the following scale:
Mission
1. Some staff get confused about the main goals for this inpatient rehabilitation
unit. ® 1 2 3 4 5
2. Program staff understand how this inpatient rehabilitation unit fits as part of the treatment system in your community.
1 2 3 4 5
3. Your duties are clearly related to the goals of this inpatient rehabilitation unit. 1 2 3 4 5
4. This inpatient rehabilitation unit operates with clear goals and objectives. 1 2 3 4 5
5. Management here has a clear plan for this inpatient rehabilitation unit. 1 2 3 4 5
Cohesion
6. Staff in your inpatient rehabilitation unit all get along very well. 1 2 3 4 5
7. There is too much friction among staff members in my inpatient rehabilitation
unit. ® 1 2 3 4 5
8. The staff in my inpatient rehabilitation unit always work together as a team. 1 2 3 4 5
9. Staff in my inpatient rehabilitation unit are always quick to help one another when needed.
1 2 3 4 5
10. Mutual trust and cooperation among staff in my inpatient rehabilitation unit are strong.
1 2 3 4 5
11. Some staff in my inpatient rehabilitation unit do not do their fair share of
work. ® 1 2 3 4 5
Autonomy
12. Treatment planning decisions for clients here often have to be revised by a
supervisor. ® 1 2 3 4 5
13. Management here fully trusts your professional judgment. 1 2 3 4 5
14. Clinicians here are given broad authority in treating their own clients. 1 2 3 4 5
15. Clinicians here often try out different techniques to improve their effectiveness.
1 2 3 4 5
16. Staff members are given too many rules here. ® 1 2 3 4 5
Appendix E – Survey Instruments CLINICAL COACH QUESTIONNAIRE ID/NAME: ____146
SECTION D: EVALUATION
Please check which parts of the Fracture Fighters program your inpatient rehabilitation unit participated in. 1. Did your unit participate in the environmental scan ? □ YES □ NO
2. Are you a member of the Fracture Fighters advisory committee? □ YES □ NO
3. Do you provide your manager with regular updates about the Fracture Fighters program? □ YES □
NO
4. Did your unit participate in the audit checklist phase of the project? □ YES □ NO
5. Did you circulate the Fracture Fighters newsletter to your colleagues? □ YES □ NO
6. Is your unit participating in the Patient Survey phase of the project? □ YES □ NO
SECTION E: OPINION LEADERSHIP
For each of the following statements, please indicate the number that most closely matches your view of the opinions stated. The items are scaled from 1 to 7, with a higher number meaning stronger agreement B1. My opinion on osteoporosis best-practices seems not to count with other people ®
Strongly Disagree Strongly Agree
<1> <2> <3> <4> <5> <6> <7>
B2. When they choose how to treat fracture patients other people do not turn to me for advice ®
Strongly Disagree Strongly Agree
<1> <2> <3> <4> <5> <6> <7>
B3. Other people [rarely] come to me for advice about osteoporosis best practices ®
Strongly Disagree Strongly Agree
<1> <2> <3> <4> <5> <6> <7>
B4. People know how to treat fracture patients based on what I have told them
Strongly Disagree Strongly Agree
<1> <2> <3> <4> <5> <6> <7>
B5. I often persuade colleagues to treat fracture patients they way that I do
Strongly Disagree Strongly Agree
<1> <2> <3> <4> <5> <6> <7>
B6. I often influence my colleagues opinions about treating fracture patients
Strongly Disagree Strongly Agree
<1> <2> <3> <4> <5> <6> <7>
Appendix E – Survey Instruments CLINICAL COACH QUESTIONNAIRE ID/NAME: ____147
SECTION F: FRACTURE FIGHTERS BEST-PRACTICES
Please select the Osteoporosis best practices that your inpatient rehabilitation unit currently implements Education Gave out the Guide to Osteoporosis for Patients with Fracture (“Patient Information Booklet”) □ YES □ NO Exercise Demonstrated the exercise for osteoporosis (strength, balance, posture, weight-bearing) □ YES □ NO Nutrition Talked about the recommended intake from diet and supplements for vitamin D (800 IU) □ YES □ NO Post-Fracture Follow-up Arranged BMD test completed as inpatient □ YES □ NO Arranged BMD test to be completed as outpatient □ YES □ NO
Sent recommendation to family physician to order BMD □ YES □ NO Sent form letter to family physician for osteoporosis follow-up □ YES □ NO
SECTION H: Demographics and Practice Information
1) Age: __________
2) Gender □ male □female
3) What is your profession? □PT □OT □SLP □RN □RPN □ Other _________
Appendix E – Survey Instruments MANAGER QUESTIONNAIRE ID/MANAGER NAME: ____149
SECTION A: CHAMPION BEHAVIOUR SCALE
When answering the following set of questions, please think about the staff member who was trained for or acted as the Clinical Coach for the Fracture Fighters Program (Insert Name of Coach: __________________________) Please rate the following statements on this scale:
(Name of Coach) Demonstrates conviction in the Fracture Fighters Program
46. Expresses confidence in what the Fracture Fighters program can do 0 1 2 3 4
47. Points out reasons why the Fracture Fighters program will succeed 0 1 2 3 4
Not at All Frequently, if not always <0> <1> <2> <3> <4>
Appendix E – Survey Instruments MANAGER QUESTIONNAIRE ID/MANAGER NAME: ____150
SECTION B: SELF-RATED LEADERSHIP QUESTIONNAIRE This next section is to describe your leadership style as you perceive it. Please answer all items on this answer sheet. If an item is irrelevant, or if you are unsure or do not know the answer, leave the answer blank. Forty-five descriptive statements are listed on the following pages. Judge how frequently each statement fits you. The word “others” may mean your peers, clients, direct reports, supervisors, and/or all of these individuals.
Use the following rating scale:
1. I provide others with assistance in exchange for their efforts 0 1 2 3 4
2. I re-examine critical assumptions to question whether they are appropriate 0 1 2 3 4
3. I fail to interfere until problems become serious 0 1 2 3 4
4. I focus attention on irregularities, mistakes, exceptions, and deviations from standards
0 1 2 3 4
5. I avoid getting involved when important issues arise 0 1 2 3 4
6. 0 1 2 3 4
7. 0 1 2 3 4
8. 0 1 2 3 4
9. 0 1 2 3 4
10. 0 1 2 3 4
11. 0 1 2 3 4
12. 0 1 2 3 4
13. 0 1 2 3 4
14. 0 1 2 3 4
15. 0 1 2 3 4
16. 0 1 2 3 4
17. 0 1 2 3 4
18. 0 1 2 3 4
19. 0 1 2 3 4
Not at all Once in awhile Sometimes Fairly Often Frequently, if not always
<0> <1> <2> <3> <4>
Appendix E – Survey Instruments MANAGER QUESTIONNAIRE ID/MANAGER NAME: ____151
20. 0 1 2 3 4
21. 0 1 2 3 4
22. 0 1 2 3 4
23. 0 1 2 3 4
24. 0 1 2 3 4
25. 0 1 2 3 4
26. 0 1 2 3 4
27. 0 1 2 3 4
28. 0 1 2 3 4
29. 0 1 2 3 4
30. 0 1 2 3 4
31. 0 1 2 3 4
32. 0 1 2 3 4
33. 0 1 2 3 4
34. 0 1 2 3 4
35. 0 1 2 3 4
36. 0 1 2 3 4
37. 0 1 2 3 4
38. 0 1 2 3 4
39. 0 1 2 3 4
40. 0 1 2 3 4
41. 0 1 2 3 4
42. 0 1 2 3 4
43. 0 1 2 3 4
44. 0 1 2 3 4
45. 0 1 2 3 4
Not at all Once in awhile Sometimes Fairly Often Frequently, if not always
<0> <1> <2> <3> <4>
Appendix E – Survey Instruments MANAGER QUESTIONNAIRE ID/MANAGER NAME: ____152