The interplay of contextual elements in implementation: an ethnographic case study

Abstract

BackgroundContextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative.MethodsWe completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis.ResultsKey contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak.ConclusionInterrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.

The influence of contextual factors on healthcare quality improvement initiatives: a realist review

“…Some studies attempted to define context within a hierarchy of factors [47,54,58,71]. Others made a clear distinction between local contexts (as the implementation setting) and the broader contextual landscape [43]; for example, one study identified three distinct types of context-the setting of care context, the project-specific context and the wider general QI and implementation (QI&I) context [64].…”

“…Awareness of the potential impact of implementation contexts and local conditions featured widely in the literature in a range of forms. Context was described both in negative and positive terms: frequently contextual factors were portrayed as barriers and/or facilitators [46-48, 50, 69], and in one instance, context was viewed as a continuum of conditions from positive/favourable/ strong influences to negative/unfavourable/weak influences [58]. Interrelationships among contextual elements acted as barriers to uptake at some sites and as facilitators at other sites, and as such were a predictor of intervention uptake [58].…”

“…Context was described both in negative and positive terms: frequently contextual factors were portrayed as barriers and/or facilitators [46-48, 50, 69], and in one instance, context was viewed as a continuum of conditions from positive/favourable/ strong influences to negative/unfavourable/weak influences [58]. Interrelationships among contextual elements acted as barriers to uptake at some sites and as facilitators at other sites, and as such were a predictor of intervention uptake [58]. Some studies explored implementation in multiple settings, highlighting that conditions for readiness, underlying mechanisms and outcomes of the same intervention could be very different depending on the organisational context [43,52,53,56,60,66].…”

A Practical Guide to Using the Positive Deviance Method in Health Services Research

“…), which in turn informed the intervention we eventually developed to improve the organization and management of anticoagulation care (McCullough et al. ). The main results of this implementation study are forthcoming.…”

Bridging the second gap in translation: a case study of barriers and facilitators to implementing Patient-initiated Clinics into secondary care

“…When comparing Department A and C and their mixed progress, a case emerges for arguing that contextual readiness seems to be the strongest influencing factor. McCullough et al [24] suggest that a department needs 'at least one and possibly two contextual elements to be strong (such as leadership, teamwork or communication) for uptake to occur. If a site was relatively weak in all three of these, uptake would not occur, despite a strong belief in the evidence.…”