The PARIHS Framework—A Framework for Guiding the ...

1 J Nurs Care QualVol. 19, No. 4, pp. 297-304 2004 Uppincott Williams & Wilkins, the Best Evidence to Change PracticeWe are living in an exciting era in wiiich we have a much more extensive body of nursing researchthan in the past decades upon which to base nursing practice. Aithough there remain many aspectsof patient care for which iittle research is available, our literature contains a wealth of knowledgeapplicable to practice. The purpose of this column in the Journal of Nursing Care Quality is to presentpractical information for direct-care nurses and quality improvement leaders about using the bestavailable evidence to change practice.

2 This column is coordinated by June H. Larrabee, PhD, RN, PARIHS Framework AFramework for Guiding theImplementation ofEvidence-based PracticeJo Rycrojt-Malone, PhD, MSc, BSc(Hons), RNFrom the Royal College of Nursing Institute, Oxford,United PARIHS Framework is the culmination of a projectteam's work. Kitson, Harvey, and McCormack con-ceived the Framework , first published in 1998. Since thattime, a larger project team, led by Jo Rycroft-Malone,has shaped its ongoing development and team: Alison Kitson, BSc(Hons), DPhil, RN,FRCN executive director of nursing, honorary profes-sorship.

3 Royal College of Nursing, London, UK; Gill Har-vey, BNursing, PhD, RHV, RGN, DN senior lecturer inhealthcare and public sector management. Centre forHealthcare Management, University of Manchester, UK;Kate Seers, BSc(Hons), PhD, RGN honorary professorand head of research, RCN Institute, Oxford, UK; Bren-dan McCormack, BSc(Hons)Nursing, DPHIL (Oxon),PGCEA, RGN, RMN professor of nursing research. Uni-versity of Ulster and Royal Hospitals Trust, Belfast, UK;and Angle Titchen, MSc, DPhll (Oxon), MCSP seniorresearch and development fellow, RCN Institute, Oxford, author.

4 Jo Rycroft-Malone, PhD, MSc,BSc(Hom), RN, Royal College of Nursing, Radcliffe Infir-mary, Woodstock Rd, Oxford OX2 6HE, United Kingdom(e-mail: a background of rising healthcosts, a management ethos of "doingthings right," and a drive for quality improve-ment, evidence-based healthcare has has emerged as one of the dominant themesof practice, management, and education inhealth services across the globe. Mountingpressure is being exerted to ensure that thedelivery of care is evidence based and clini-cally effective.)

5 Yet if you have been involvedin implementing change, getting research intopractice, or improving the quality of patientcare, you know what a complex, messy, anddemanding task it can be. If it was straightfor-ward, the production of "evidence," perhapsin the form of guidelines followed by an edu-cation or a teaching package, would lead to anexpectation that practitioners would automat-ically integrate it into their everyday we know that this is not the case, and of-ten practice lags behind what is known to becurrent best this context, research and practicedevelopment teams within the Royal College297298 JOURNAL OF NURSING CARE QUAUTY/OCTOBER-DECEMBER 2004of Nursing (RCN)

6 Institute in the UnitedKingdom have accumulated experience andknowledge about implementation and chang-ing practice from their involvement in a num-ber of different research, practice develop-ment, and quality improvement projects.'"''Analysis of work such as this indicates that anumber of key factors appear to play a role insuccessful implementation .^'' The PromotingAction on Research implementation in HealthServices ( PARIHS ) Framework represents theinterplay and interdependence of these fac-tors.

7 This multidimensional Framework wasdeveloped in an attempt to represent the com-plexity of the change processes involved inimplementing research-based PARIHS FRAMEWORKThe PARIHS Framework presents successfulresearch implementation as a function of therelationships among evidence, context, andfacilitation. The Framework considers theseelements to have a dynamic, simultaneous re-lationship. The 3 elements, evidence, context,and facilitation, are each positioned on a highto low^ continuum. The proposition is that forimplementation of evidence to be successful,there needs to be clarity about the nature ofthe evidence being used, the quality of con-text, and the type of facilitation needed to en-sure a successful change process.

8 Theoreticaland retrospective analysis of 4 studies that hadbeen undertaken by the RCN Institute^ ledto a proposal that the most successful imple-mentation seems to occur when evidence isscientifically robust and matches professionalconsensus and patient s preferences (high ev-idence), the context is receptive to changewith sympathetic cultures, strong leadership,and appropriate monitoring and feedback sys-tems (high context), and when there is appro-priate facilitation of change, with input fromskilled external and internal facilitators (highfacilitation).

9 The Framework was originally developedfrom collective experience and wisdom.^Since its conception and publication in 1998,the Framework has undergone research anddevelopment work. Most notably, this has in-cluded a concept analysis of each of the di-mensions: evidence, context, and facilitation,and a research study to assess its content va-lidity. This has enabled some theoretical rigorand conceptual clarity to be gained about theconstituent elements and as a result, a refine-ment of its content.

10 The following sectionsoutline the contents of the PARIHS frameworksubsequent to this research and many involved in the evidence-basedpractice (EBP) movements, evidence equalsresearch. However, in reality, a number ofdifferent sources of knowledge and informa-tion need to be combined and used in clini-cal decision making at the bedside with thepatient. It is proposed that evidence in EBPshould be considered to be "knowledge de-rived from a variety of sources that has beensubjected to testing and has found to becredible.