Editorial

Using Theory and Frameworks to Facilitate theImplementation of Evidence into Practice

As many authors in previous editorials and articles inWorldviews on Evidence-Based Practice have stated, the

implementation of evidence into practice is a multifacetedprocess. Using evidence in practice is not a one-off event;it is a complex process that requires more than a prac-titioner’s ability to critically appraise evidence and makerational decisions. The implementation of evidence-basedpractice depends on the achievement of significant andplanned change involving individuals, teams, and organi-zations. Despite a growing acknowledgment in the liter-ature that these complexities exist, translating this infor-mation into more effective implementation that impactson practice and outcomes remains a huge challenge. Weknow that often what is practiced lags behind what re-search evidence tells us we should be doing.

The lag between what we know and what we practice hasled to renewed calls within the implementation researchliterature to focus on the potential role of theory (e.g.,Bhattacharyya et al. 2006; Rycroft-Malone 2007). Thosethat are encouraging the use and development of theorysuggest that it is one way to understand what some call the“black box” of implementation; what happens between ev-idence and (in) action. The logic is that if we can betterunderstand more about what is going on, we will be ableto do things better in the future. The potential for theoryin implementation is in designing theory-based interven-tions, the identification of theoretically sensitive outcomes,and in theory-guided process evaluations (Rycroft-Malone& Bucknall 2010).

Historically, within evidence-based nursing there hasbeen a long-standing interest and tradition in the use ofmodels and framework. We can draw from a varied menuincluding the:

� Stetler model,� Ottawa model of research use,� Promoting Action on the Implementation of Health

Services (PARIHS) framework,� IOWA Model of Evidence-Based Practice,� Advancing Research and Clinical practice through

close Collaboration (ARCC) model,� Dobbins’ Dissemination and use of research evidence

for policy and practice framework,

Copyright ©2010 Sigma Theta Tau International1545-102X1/10

� Joanna Briggs Institute model,� Knowledge to Action framework.

But how would one choose from a menu like this, andwhat criteria would enable these choices to be made?

In reality, the implementation of evidence-based prac-tice is a complex and multifaceted process; therefore, itcould be argued that currently there is not a single the-oretical model or framework that wholly represents thiscomplexity and the processes involved. This is nicely illus-trated by Estabrooks and colleagues (2006) who located arange of models from organizational, social sciences, re-search utilization, and health promotion literatures, whichare relevant to implementation processes.

However, we suggest that the application of frameworksand models to implementation projects and research canmake a difference to (1) our understanding of the processesinvolved and (2) the outcomes that result. Therefore, weneed to be able to make decisions about the appropriate-ness of particular models and frameworks to the implemen-tation of evidence-based practice. There are some criteriathat we could apply, which are drawn from the literatureabout theory use and development, and knowledge trans-lation and evidence-based practice research more broadly.In answering the following questions, one could assessthe robustness and appropriateness of a particular modelor framework to use in a specific implementation project(Rycroft-Malone & Bucknall 2010).

Model or Framework?� A framework can provide anything from a skeletal set

of variables to something as extensive as a paradigm;as such they can be fairly abstract.

� A model is a more precise representation and is moreprescriptive.

Purpose?� Descriptive: the framework or model describes the

properties, characteristics, and qualities of a phe-nomenon.

� Explanatory: the framework or model specifies causalrelationships and mechanisms of a phenomenon, andin relation to other phenomena.

� Predictive: the framework or model predicts relation-ships between the dimensions or characteristics ofthe phenomenon through for example, hypothesesor propositions.

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Editorial

Development� Was the framework/model developed inductively or

deductively?� Was the framework/model developed from empirical

and/or collective insights?� Is there evidence to support or refute the frame-

work/model?

Theoretical UnderpinningsAre the theoretical underpinnings of the framework ormodel explicit, or are they implicit?

Conceptual Clarity� Does the framework or model have a well-described

and coherent language for enabling the identificationof key elements?

� Does the framework or model enable the identifica-tion of similarities and differences between theoriesas well as their strengths and weaknesses?

� Does the framework or model have the potential tostimulate new theoretical developments?

LevelsIs the framework or model applicable at an individual,team, unit, organization, and/or policy level?

SituationCould the framework or model be used in hypothetical(e.g., classroom, simulation) and/or real situations?

UsersWho are the relevant or intended users of theframework or model (i.e., Nurses/Medics/Allied Health/Multidisciplinary/Policy Makers)?

FunctionCan the framework or model be used for:

� assessment of facilitators and barriers,� intervention development,� outcome measurement and variable selection,� evaluation of processes?

Testable� Does the framework or model enable the generation

of testable hypotheses and/or propositions?� Is the framework or model supported by empirical

data?� Could the framework or model be used within dif-

ferent methodological approaches?

Usefulness� Could the framework or model facilitate a better un-

derstanding about the issue?� Could the framework or model help in the develop-

ment of an intervention?

� Could the framework or model facilitate the applica-tion and/or development of theory or new theoreticalinsights?

There is still much to learn about implementation andabout how best to apply models and frameworks to theseactivities. Some models and frameworks have undergonesubstantial use and development over time; others areyounger and will undergo testing and further refinementin the future. Whatever the choice of framework or model,the selection and application should come early in theprocess; it should be the foundation upon which imple-mentation projects and initiatives are built. The abovecriteria may provide some guidance (Rycroft-Malone &Bucknall 2010).

Whilst we are not suggesting that the application ofparticular frameworks and models to implementation ef-forts will guarantee success, they should go some way toimproving the chances.

Jo Rycroft-Malone Editorj.rycroft-malone@bangor.ac.uk

Tracey Bucknall Associate Editortracey.bucknall@deakin.edu.au

The Evidence-Based Practice Book SeriesOther books in the evidence-based practice series include

Bick D. & Graham I. (2010). Evaluating the impact of im-plementing evidence-based practice. Indianapolis, IN: Wiley-Blackwell & Sigma Theta Tau International.

Kent B. & McCormack B. (2010). Clinical context forevidence-based practice. Indianapolis, IN: Wiley Blackwell& Sigma Theta Tau International.

ReferencesBhattacharyya O., Reeves S., Garfinkel S. & Zwarenstein

M. (ICEBeRG Group). (2006). Designing theoretically-informed implementation interventions: Fine in theory,but evidence of effectiveness in practice is needed. Im-plementation Science, 1(5). Retrieved May 5, 2010, fromwww.implementationscience/com/content/1/1/5.

Estabrooks C.A., Thompson D.S., Lovely J.E. & HofmeyerA. (2006). A guide to knowledge translation theory. TheJournal of Continuing Education in the Health Professions,26, 25–36.

Rycroft-Malone J. (2007). Theory and knowledge trans-lation: Setting some co-ordinates? Nursing Research,56(4S), S78–S85.

Rycroft-Malone J. & Bucknall T. (Eds). (2010). Modelsand frameworks for implementing evidence-based prac-tice. Linking evidence to action. Indianapolis, IN: Wiley-Blackwell & Sigma Theta Tau International.

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