Harnessing theories to support evidence uptake and change

Implementation of change in health care often has a focus on changing behaviour. [1] This can be challenging. Theories of change can help dissemination and implementation strategies by explaining how and why stakeholders might be influenced towards a desired outcome or describe the steps required for effective change.

We can organise theories of implementation in different ways. [1-3] One common way of thinking about different theories is whether they focus on the processes used or on what happened as a result of the implementation activity: [1]

  • Impact theories describe hypotheses and assumptions about how a specified intervention will facilitate change
  • Process theories guide how best to plan, organise and schedule implementation activities to effectively achieve change, and how activities will influence and be used by the target group.

Many of the generalised theories, models and frameworks (TMF) in implementation science draw on impact and process theories. [2] In this way these theories relating to change influence the activities associated with moving evidence to where it can be of benefit. Awareness of impact theories can be particularly useful in palliative care when you want to change behaviour of patients or health professionals.

Impact or determinant theories 

Wensing [1] identified a number of impact theories relevant to change in health care. Information is provided below on some of these theories is described below where the impact is focused on individuals, on the individual in a social context, or the organisational system. 

Theory

  • Cognitive theories - focus on the thinking and decision making process of an individual or how decisions are actually made.
  • Educational theories - focus on the motivation to learn.
  • Motivational theories - focus on attitudes, perceptions, and intentions of a person.

Theory

  • Social learning - focus on explaining individual behaviour within a certain context or setting
  • Communication theories - Focus on how effective communication can influence attitudes and behaviour
  • Social network theories - Focus on the penetration of a social network by targeting individuals at the periphery who are likely to have membership of more than one network.
  • Theories on teamwork - Focus on enhancing teamwork.
  • Theories on professionalisation - Focus on the individual professional through standards and accepted practices.
  • Theories on leadership - Targeting leadership and respected voices to influence the uptake of change.

Theory

  • Theory of effective organisations - focus on an organisation's characteristics such as communication and professionalism which influence the ability to implement change.
  • Theory of quality and safety management - focus on the use of audit and feedback to decision-makers to bring about change.
  • Theory of operations management - focus on health care delivery process design and function.
  • theory of complex systems - focus on the interconnections within a system to target random variation
  • Theory of organisational learning - focus on learning of individuals to bring about change in organisational routines.
  • Theory of organisation culture - a less defined focus but related to the belief that changes in culture can change performance.

Process theories 

Process theories identify the elements that can influence effective implementation of change without articulating the assumption behind why the activity will drive change.  Generally the theories of change are incorporated into a multi-step process to guide implementation at a practical level with an increased likelihood of success. [1]  An example is the Knowledge to Action framework. 

If you are interested in selecting a TMF to achieve behaviour change the supplement to Strifler's review of 159 TMFs is likely to be of interest. For each TMF the number of articles reporting on its use to assess level of behaviour change in individuals, organisations, community, or systems is indicated. [4] Application of TMFs to achieve individual-level change is common but less so for system-level change.

  1. Wensing M, Grol R, Grimshaw J, edtiors. Improving Patient Care: The Implementation of Change in Health Care [Internet]. 3rd ed. Wiley–Blackwell; 2020. [cited 2022 May 19].
  2. Damschroder LJ. Clarity out of chaos: Use of theory in implementation research. Psychiatry Res. 2020 Jan;283:112461. doi: 10.1016/j.psychres.2019.06.036.
  3. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015 Apr 21;10:53. doi: 10.1186/s13012-015-0242-0.
  4. Strifler L, Cardoso R, McGowan J, Cogo E, Nincic V, Khan PA et al. Scoping review identifies significant number of knowledge translation theories, models, and frameworkswith limited use. J Clin Epidemiol. 2018 Aug;100:92-102. doi: 10.1016/j.jclinepi.2018.04.008. Epub 2018 Apr 13.
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