Article Text
PDF
Abstract
Background Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.
Methods We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers’ five main attributes of an innovation guided our synthesis of facilitation characteristics.
Results Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers’ innovation attributes: relative advantage, compatibility, complexity, trialability and observability.
Conclusions We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Change management
- Quality in healthcare
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Statistics from Altmetric.com
Strengths and limitations of this study
This study provides a comprehensive scoping review of a diverse literature of facilitator roles and characteristics of facilitation from various disciplines.
Arksey and O’Malley’s (2005) framework was used to guide the scoping review process.
Grey literature was not included, nor did we conduct a quality appraisal of included studies as this is not part of a scoping review undertaking, and this may introduce the potential for publication bias. However, the scoping review enabled us to synthesise the breadth of literature that characterises the quantity, nature and extent of research evidence on facilitation and the roles undertaken to facilitate the uptake of evidence.
Introduction
Scholars describe the potential for evidence-based decision making to have a positive impact on patient outcomes.1 Implementing evidence (ie, research findings) into practice is a complex, multifaceted process that requires a proactive effort to encourage use at the point of decision making.2–4 Multilevel factors influence this implementation5; some of these include individual (eg, education, attitude),6–8 organisational/contextual,9–14 system14 and innovation-specific factors.15 Several knowledge translation (KT) theories exist that can be used to guide the process of getting research evidence into practice.16 In their Promoting Action on Research Implementation in Health Services (PARiHS) framework, Kitson and colleagues17 highlighted the importance of facilitation that, along with strong evidence and a context supportive of change, can lead to successful research implementation. Facilitation is a technique where an individual makes things easier for others, by providing support to help them change their ways of thinking and working.17 In their refined integrated framework i-PARiHS, facilitation is an active element that integrates the other core constructs: innovation, recipients and context.18
In the healthcare literature, a small body of conceptual work on facilitation has considered it a promising approach to implementing evidence into practice.17–21 Facilitation has evolved from a concept in the education and counselling literature22 to an implementation intervention in the healthcare and KT literature3 4 20 and has recently been situated in the organisational learning theory literature.23 The literature on facilitation roles and characteristics is growing.19 Thompson and colleagues delineated the similarities and differences between five roles that aim to influence a practice or behaviour change: opinion leader, facilitator, champion, linking agent and change agent, noting much ambiguity remains among these roles.24 Harvey and colleagues explored the purpose, roles, skills and attributes of facilitators, suggesting that the concept of facilitation is only partially developed.20 Dogherty et al updated Harvey et al’s20 literature review and reported that, in addition to facilitation as role and process, project management and leadership were important components of facilitation.19
Two reviews have been conducted specifically on practice facilitation, also described as outreach facilitation, where facilitators assist primary care physicians with research implementation and quality improvement projects.25 26 These studies found that practice facilitators were effective in improving practice processes and patient care outcomes,25 and primary care physicians were almost three times more likely to adopt evidence-based guidelines with practice facilitation.26 Although some preliminary evidence supports practice facilitation as an effective intervention to implement evidence into practice, facilitation as a construct requires further development and testing for its effectiveness in improving outcomes.
Implementation methods—such as facilitation—can be viewed as practice innovations. Rogers defined an innovation as an idea or practice that is perceived as new by an individual.15 He described five main attributes of an innovation: (1) relative advantage—the perception that an innovation is better or more beneficial than existing practice; (2) high compatibility—the perception that the innovation is consistent with existing values, beliefs and needs; (3) low complexity—the perception that the innovation is easy to understand and use; (4) trialability—the opportunity to try the innovation before making a decision about its adoption; and (5) observability—the extent to which the effects of the innovation are observed and communicated to others.15 Innovations with all of these qualities tend to be adopted more rapidly than other innovations.15
By treating facilitation as an innovation and healthcare providers as potential adopters, we can better understand how the roles and characteristics of facilitation may contribute to successfully implementing research into practice. Our review complements and extends the review by Dogherty et al 27 which explored elements of facilitation based on an existing systematic review of the effectiveness of interventions to increase the use of practice guidelines in nursing. Our study adds to the evidence base on facilitation by describing the various roles and the characteristics of facilitation from the healthcare and management literature in the context of healthcare professionals that includes practice guidelines and other forms of research use, and the roles undertaken to facilitate the uptake of evidence. The research questions guiding this scoping review were:
What are the key facilitator roles identified in the literature?
What characteristics of facilitation contribute to research use by healthcare professionals?
Methods
We conducted a scoping review of the literature using Arksey and O’Malley’s framework to guide our review.28 Their scoping review framework has five stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarising and reporting the results; and an optional stage of a consultation exercise with stakeholders.28 We searched the following 10 electronic databases from the healthcare and management literature: ABI Inform (1970–2016), Business Source Complete (1886–2016), CINAHL (1982–2016), Cochrane Library (2003–2016), EBMR (1991–2016), Embase (1980–2016), Medline (in process and other non-indexed citations) (1950–2016), PsycINFO (1806–2016), Scopus (1960–2016) and Web of Science (1900–2016). We developed our search strategy with a research librarian who constructed expert searches tailored to each of the databases searched (box 1). Key terms and final search strategies were refined based on initial search results. For example, because our initial search revealed a large number of articles we decided not to search grey (unindexed) literature such as conference proceedings, dissertations, editorials and government reports. We manually searched reference lists of included papers to identify additional studies.
Example of search strategy: Medline
Search terms
(facilitator* or facilitative or facilitation).tw.
facilitat*.ti. or reminder systems/
(academic detail* or educational outreach worker* or opinion leader* or change agent* or champion* or linking agent* or promotor* or knowledge broker* or enabler* or enabling or boundary spanner* or coach*).tw.
or/1–3
evidence-based practice/ or evidence-based dentistry/ or evidence-based medicine/ or evidence-based emergency medicine/ or evidence-based nursing/
(ebp or ebm or ebn or cpg* or best practice*).tw.
(evidence adj2 practice*).tw.
(guideline* adj2 (implement* or adher*)).tw.
guideline adherence/ or quality assurance, health care/ or benchmarking/ or guidelines as topic/ or practice guidelines as topic/
(quality adj1 (improv* or manag*)).tw.
‘diffusion of innovation’/ or technology transfer/
(research adj2 (‘use’ or utili?* or adopt* or implement* or disseminat* or uptake or transfer* or translat* or support)).tw.
(knowledge adj2 (‘use’ or utili?* or adopt* or implement* or disseminat* or uptake or transfer* or translat* or support)).tw.
(evidence adj2 (‘use’ or utili?* or adopt* or implement* or disseminat* or uptake or transfer* or translat* or support)).tw.
(innovation adj2 adopt*).tw.
or/5–15
4 and 16
facilitat*.mp.
18 not 17
‘outcome and process assessment (health care)‘/ or ‘outcome assessment (health care)‘/ or treatment outcome/ or ‘process assessment (health care)"/
quality assurance, health care/ or benchmarking/
Quality Control/
‘Delivery of Health Care’/og [Organization & Administration]
og.fs.
or/20–24
19 and 16 and 25
17 or 26
(comment or editorial or letter or news or newspaper article).pt.
27 not 28
Selection criteria
We included conceptual papers and empirical studies both quantitative and qualitative that met the following criteria: (1) facilitator roles, characteristics, facilitation processes and/or interventions were described; (2) facilitation focused on healthcare providers; and (3) facilitation focused on research use in practice. We excluded: non-English literature;* study protocols; articles that focused solely on facilitation directed towards patients; articles focused solely on computerised/automated reminder systems or decision support systems.
Selection process
Three team members independently screened one-third of the references for inclusion. Because of the volume of search results, we first excluded references based on irrelevant titles and abstracts. Approximately 10% of articles were screened together for training and reliability. The team met periodically prior to and during screening to ensure consistency between reviewers.
Data charting
We developed a data dictionary detailing information to collect, for consistency between reviewers throughout charting. Each reviewer was assigned one-third of the included articles and extracted the following data elements: citation, purpose, theoretical framework, study design/method, sample and setting, description of facilitation role, characteristics, process and/or intervention. We did not appraise the quality of data extracted as the aim of the scoping review was to identify facilitator roles and characteristics of facilitation from the literature.
Data analysis and synthesis
We conducted a content analysis of extracted data to identify facilitator roles and characteristics of facilitation. Next, we conducted a thematic analysis using extracted data to further identify characteristics of facilitation. Because we conceptualised facilitation as an innovation, in the final analytical step, we used Rogers’ attributes of an innovation as a framework to first sort and then to synthesise within each category our identified characteristics of facilitation.15 We did not report literature review papers that included studies cited in our scoping review in our roles or attributes results tables to avoid duplication.
Stakeholder consultation
We consulted with stakeholders early in analysis to inform and validate findings.28 Our decision-maker partner (CC) arranged for two study team members to meet with seven regional managers from a large healthcare organisation for feedback on the identified facilitator roles. These managers provided feedback on understandability, meaningfulness, and usefulness and relevance to practice of the facilitator roles.
Results
Our searches found a combined total of 38 488 references (table 1). After removing duplicates and adding 18 articles from our manual search, we screened 26 593 articles and identified 791 as potentially relevant. Of these, 195 met our selection criteria and were included in our review (figure 1). We report characteristics of included studies (see online supplementary file 1), followed by facilitator roles (table 2) and characteristics (attributes) of facilitation (table 3).
Screening process.
Search results
Results: facilitator roles, n=150 articles
Results: characteristics (attributes) of facilitation, n=133 articles
Characteristics of included studies
Our sample included 130 primary research articles: quantitative (n=63), qualitative (n=39) and mixed methods (n=28) (used both qualitative and quantitative data collection methods). The remainder were descriptive papers (n=34), literature reviews (n=20) and theoretical/conceptual papers (n=11).
Over half of the research studies (n=85/130) included a mix of healthcare providers in their samples (eg, nurses and physicians); the remainder included a single healthcare provider group. Study setting was reported in 120 studies; the most frequent were hospitals (34%), primary care (23%) and other community-based facilities (18%). Less frequently cited were studies with more than one setting (13%), long-term care (8%), home care (2%) and symposiums (2%). For studies that also reported the country (n=120), most were conducted in the USA (29%), Canada (23%), UK (18%), Europe (10%) and Australia (9%). Some studies included more than one country (6%). A few studies were conducted in Africa (3%) and one in Singapore (1%) and Nicaragua (1%).
Nine definitions of facilitation were used (table 4). The definitions of facilitation from the PARiHS framework were the most frequently cited (n=19). A common thread in seven of the nine definitions is that facilitation is viewed as a process of providing support to enable change to occur.4 17 18 20 29–31 The other two definitions were notably different as they did not include process in their definitions. One article focused on relationships,32 the personal contact and support required, while the other article highlighted facilitation as a strategy for learning.33
Results: Definitions of facilitation
In 77/195 articles, a theory or conceptual framework(s) guided research or contextualised findings. Most frequently cited were the PARiHS framework17 (n=16), change theories (eg, Lewin’s theory of change)34 (n=10) and Rogers’ diffusion of innovation theory15 (n=10). Sixteen papers used more than one theory or framework.4 35–49 For example, papers citing the PARiHS framework had used it to: inform the decision to involve both external and internal facilitators41; conceptualise a nurse pain champion role40; guide design of a KT intervention for continuous improvement of patient care and evidence-based practice (EBP)38; and assist with the description of processes and outcomes of an EBP training programme.50 Examples of other frameworks used are Donabedian’s structure, process, outcome model37 51–54; Graham et al’s55 Knowledge to Action Framework41 48 56 57; and May et al’s58 Normalization Process Theory.59
Facilitator roles
We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Of note, overlap exists in the terms used to describe a clinical facilitator and a practice facilitator, and a practice facilitator and outreach facilitator. We describe conditions under which each role is considered most appropriate based on locality (facilitators located internal to the organisation, external, or combined external and internal) and formality (formal appointed role vs informal role). These nine facilitator roles expand (both in number and scope) those identified in previous reviews.19 20 24 For each role, we provide a definition, key features, training requirements, and key personal attributes and skills (table 2). As each facilitator role included change agent activities,24 we did not include change agent as a separate role.
Stakeholder feedback on the identified facilitator roles was positive and validated our findings. Stakeholders indicated that roles and characteristics were understandable and meaningful. They commented that understanding the key role and skills of each type of facilitator, and whether training was required, was useful in hiring processes.
A key goal and responsibility in all nine facilitator roles is to drive and motivate a practice change and to act as a resource for making the change. Overall, facilitator roles included attributes and skills such as credibility, trustworthiness, expertise, enthusiasm and good problem-solving and networking skills. Opinion leaders, coaches, champions, research facilitators and clinical/practice facilitators all work internally (locally) within the organisation. Two main features of opinion leaders as facilitators are: they are peer nominated42 60–68 and they are informal leaders who are influential because they are knowledgeable and experienced.42 63 69–71
Opinion leadership stems from medical literature71 and is based on diffusion of innovation15 and social influence theory.24 72 Opinion leaders have wide interpersonal communication networks60 61 and therefore have a key role in assisting others to recognise the need for improvement and communicating information about innovation within professional networks.42 Coaching has been used in the business/management literature as an approach to training,73 and more recently has been theoretically positioned in the context of EBP as a relational approach.74 A coach assists others with making a change particularly in guiding their learning during implementation using motivation, encouragement and positive reinforcement.75 76 A champion, whose role is also based on diffusion of innovation40 and social influence theory,24 is a local visionary who uses expert knowledge and vision to persuade others to adopt an innovation24 37 48 77–79; and help others to see the advantages of making a practice change and mentor them through the process.
Research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators were considered more formally appointed roles, and the majority of these facilitators were typically trained for their role. Research facilitators, described in the context of EBP, have expertise (research, clinical background) to support staff to strengthen their research skills, knowledge and participation in research in a clinical setting.39 80–83 A clinical/practice facilitator, also described in the context of EBP (eg, guideline implementation), provides ongoing education and support through the implementation process30 32 45 51 84–101 (though some were external). Facilitator roles considered external to the organisation included outreach facilitators, linking agents and knowledge brokers (the latter two being boundary spanner roles). An outreach facilitator assists healthcare providers (eg, those in primary care practices) through a formal implementation process (eg, using educational outreach visits/academic detailing/quality improvement).69 102–120 A clinical/practice facilitator or outreach facilitator role may be useful when staff are required to learn new skills for research implementation. The linking agent role is based on the concept of spanning the boundary between research and practice to bring about change.24 29 121–123 The knowledge broker role is based on the concepts of linkage and exchange (eg, establishing communication channels),43 116 124–126 knowledge management and capacity building (eg, builds relationships between two communities, typically policymakers and researchers).127 128 Recent studies focus on using external-internal facilitators based on the PARiHS framework—described as external facilitators (eg, research team members) supporting internal (local) facilitators to assist healthcare providers with implementing a practice change.49 56 57 129 130
Training requirements were a key distinguishing feature of the facilitator roles. External facilitators tended to be formally trained for their role but internal facilitators may or may not have received training. Only the opinion leader role was described as informal (with no training required).42 60–67 131 132 Of the 63 intervention studies, 24 identified training facilitators.32 37 46–48 68 69 102–107 118–120 129 133–139 Seventeen of these 24 studies described training components, with nine studies including length of training, ranging from 4 hours,107 40 hours,118 1–3 days68 102 137–139 to 6–7.5 months.32 106 Training components typically included course work (theoretical knowledge),37 47 102 119 120 or both course work and practical experience (skills training).32 48 106 107 118 137–139
In a recent article describing the i-PARiHS framework, Kitson and Harvey18 outline facilitator activities, and further identify three distinct facilitator roles: novice, experienced and expert facilitator. For example, the novice facilitator is skilled at clarifying tasks, and identifying key stakeholders; experienced facilitators support novices, assess system-wide activities and contextual issues, and develop skills in sustaining change; expert facilitators are positioned at a strategic level to provide project coordination and leadership for the initiative, and includes engaging stakeholders and political negotiation skills.18
Characteristics of facilitation
Within our sample of 195 articles, there were 133 articles from which we identified 15 characteristics of facilitation associated with research use by healthcare providers, and mapped these onto Rogers’ five attributes of innovation: (1) relative advantage (four characteristics), (2) compatibility (four characteristics), (3) complexity (four characteristics), (4) trialability (one characteristic) and (5) observability (two characteristics).15 Each of these attributes is described next and shown in table 3.
Relative advantage
Relative advantage is one of the strongest predictors of successful implementation and an innovation’s adoption rate, and was the most frequently cited attribute of facilitation in our review.15 The relative advantage or benefit of facilitation is that it involves a process for making change easier for others. We found four characteristics of facilitation considered advantageous to those involved in implementing research into practice: (1) encourages assessment of current practice; (2) presents ideas to others; (3) creates useful communication networks; and (4) provides support and resources to achieve goals. A facilitator can help healthcare professionals to identify gaps between knowledge and practice,4 32 36 101 127 140–142 and to acknowledge the need for improvement.4 56 77 143–145 Facilitators can assist others to understand the relative advantage of making a change,17 101 145 146 as well as the benefit of facilitation as an implementation innovation itself. A facilitator provides continuing support and identifies resources to help with the process, and monitors the change.4 30 41 48 49 56 57 78 86 92 94 95 111 133 141 142 147–156 For example, a facilitator builds organisational support for new practices151 157 and provides structure for learning.33
Compatibility
A key purpose of facilitation is to make change more compatible with existing practices. Several characteristics of facilitation promote compatibility of the change with existing practice including: mobilising existing knowledge and skills94; enhancing staff readiness to change and empowering staff3 35 66 76 95 121 141 158 159; supporting a culture for change20 27 40 44 45 62 66 75 99 128 134 144 145 148 153 160–165; and tailoring facilitation activities to local context (eg, social, cultural).49 50 56 61 75 103 142 150 166–171 For example, a facilitator understands the climate and practical realities of the organisation,27 99 128 160 164 and frames knowledge so that it is relevant to staff practice.158
Complexity
Facilitation supports the development of new knowledge and skills, requires facilitators to be trained or have experience with this role, may have multiple components, and is described as a bidirectional process that fosters relationship building. A complex intervention typically contains several interacting components.172 Most intervention studies in this review described a single intervention but interventions tended to be multifaceted, with several components or strategies typically delivered by a facilitator (eg, audit and feedback, consensus building).103 Eleven studies used multiple interventions (ie, more than one intervention arm),47 63 68 69 84 125 129 142 173–175 for example, reminders and a nurse facilitator,84 and opinion leader education and audit and feedback.63 However, facilitation as an innovation need not be complex. Facilitation is an enabling approach3 4 20 21 146 176 that can help reduce the (perceived or actual) complexity of a multifaceted intervention. Facilitation involves building trust and fostering mutual opportunities.4 30 74 Facilitators are experienced or are trained for their role to support others with implementation. The frequency and duration (dose) of facilitation varies; for example, some studies included daily facilitation for 3 months,90 monthly for 12 months,104 and on average 25 visits per site lasting 1 hour for 18 months.105
Trialability
The ability for potential adopters to test an intervention can enhance its adoption.15 We located examples of researchers who pilot tested a facilitation intervention (or its components) prior to full-scale evaluations.46 90 103 105 118 138 149 150 163 174 177–179 For example, in one study six nurses were trained for their facilitator role and gained experience conducting outreach visits in pilot general practices.105
Observability
Observability is seeing the results of an innovation, in our case being able to ascertain that individuals use research as a result of facilitation.15 Two characteristics of facilitation that reflected observability were facilitators encouraging others to role model the change33 45 86 99 126 180–182 and reinforcing the change (research use)75 108 109 183 184 and supporting sustainability.18 27 Some examples of role modelling included sharing examples of good practice68 and providing opportunities for formal shadowing.126 An example of reinforcing the change was a follow-up visit by a nurse facilitator to reinforce guideline implementation.109
Facilitation process
Although facilitation is identified in the literature as a process of enabling implementation of evidence into practice,19 20 few studies identified the actual process. Dogherty and colleagues outlined four stages of facilitation that include activities to facilitate research use in nursing: (1) planning for change, (2) leading and managing change, (3) monitoring progress and ongoing implementation, and (4) evaluating change.19 27 56 Elnitsky and colleagues141 described an internal facilitation process (within the organisation): learning the role of facilitator, assessing the culture, facilitating external programmes, negotiating and getting buy-in. They mapped this process to Dogherty and colleagues’ facilitation taxonomy (above) and subdomains of the PARiHS framework.155 Others have described facilitation as an interactive problem-solving process requiring supportive interpersonal relationships.4 Dogherty and colleagues185 described key factors to successful facilitation of EBP such as development of strategic partnerships, use of multiple strategies to effect change, and facilitator characteristics and approach (eg, leadership and team building skills). Barriers influencing the facilitation process were largely contextual constraints such as lack of engagement and resources and team functioning.
Discussion
Our review suggests that facilitation has become an important aspect of implementing research into practice, and has potential to be an effective innovation. Our literature synthesis advances previous reviews on facilitation by broadening our understanding of the roles of facilitators and the characteristics of facilitation.19 20 24 Our first research question addressed the key facilitator roles identified in the literature. We identified nine types of facilitator roles, the majority of which are formal appointed roles. Facilitators share a common goal of implementing an EBP change, and some roles share theoretical underpinnings—opinion leaders and champion roles are based on diffusion of innovation and social influence theory, and a linking agent and knowledge broker act as intermediaries/boundary spanners to bridge gaps. However, we have also highlighted some notable differences in these roles. Clearly, many facilitator roles are being used in healthcare systems. Our findings shed light on the variety, complexity and need for these roles. Policymakers can use these findings to design role statements and processes to impact outcomes for care providers and patients. Knowing the various types of facilitator roles can assist administrators and managers to implement a facilitator role that best supports change activities in their setting. For example, an outreach facilitator could be potentially useful in settings such as outpost nursing and home care. Boundary spanner facilitator roles may be most useful to bridge practitioners with internal and external stakeholders involved in planned change. The importance of external facilitators supporting internal facilitators in creating organisational facilitation capacity is highlighted in the literature.27 41 49 56 57 129 Building internal facilitation capacity may create sustainable infrastructures to support implementation activities designed for improving patient safety and quality of care delivery. Further research should be undertaken on external-internal facilitator roles as they may foster a more integrated approach to facilitating the use of research into practice.
Our second research question addressed the characteristics of facilitation that contribute to research use by healthcare professionals. Characteristics of facilitation are important because they identify those features that may potentially lead to greater success in implementing change. In the KT literature, the knowledge itself is typically considered the innovation. Studies have shown that facilitation itself should be operationalised as an innovation or tool used to influence implementation of other innovations (eg, guideline implementation via facilitation).32 46 51 63 69 75 103 105 107 109 136 Using Rogers’ framework enabled us to highlight characteristics of facilitation that may influence its adoption as an innovation.15 Relative advantage was the most frequently cited attribute of facilitation in our review. Rogers’ attributes of an innovation15 covered all of the results that we found and therefore it is confirmed to be a comprehensive model to describe characteristics of an innovation.
Further research could examine whether facilitation strategies with Rogers’ innovation attributes lead to successful implementation. For example, facilitation that is tailored to local context and offers ongoing support may be better received than a complex intervention. According to Greenhalgh et al, Rogers’ concept of reinvention (innovation adaptability) can be considered another innovation attribute that could lead to innovations being adopted more readily.15 186 Though we did not include the concept reinvention in our data analysis, three articles from our review described reinvention of the innovation as an important quality to enhance adoption.41 148 183 For example, Miller et al suggested designing a KT intervention with reinvention in mind, which involves knowing the attributes of the intervention that must be maintained for effectiveness183; this is important for adoption and sustainability of an innovation.41 Facilitators can assist with reinvention during implementation to individualise the innovation to better meet adopters’ needs.148 Reinvention as an attribute of an innovation could be explored in future reviews. Understanding these innovation attributes can lay the groundwork for well-designed and well-evaluated facilitation interventions to improve practice in healthcare delivery. However, we noted key gaps in the literature on the characteristics of facilitation. First, the process of facilitation remains unclear and largely implicit, which challenges descriptions of facilitation interventions for future study. Second, few studies were conducted in home care and long-term care settings, which is important to address as Canada and other countries are experiencing a shift in population demographics towards an ageing generation.
Two main limitations of our review, which may introduce the potential for publication bias, are that we did not include grey literature, nor did we conduct a quality appraisal of included studies as this is not part of a scoping study undertaking28 187 nor the purpose of our review. The scoping review enabled us to synthesise a breadth of literature that characterises the quantity, nature and extent of research evidence on facilitation187 and the roles undertaken to facilitate the uptake of evidence. Our search was further restricted to the English language. However, we tracked non-English language studies and could have included four of them. Our review was focused on research use specifically among healthcare professionals, which has a considerable body of literature that theorises, conceptualises and operationalises facilitation. While this diversity creates some inconsistencies in naming facilitator roles, it has a notable strength; the diversity of the disciplines that describe facilitator roles and characteristics of facilitation from various theoretical perspectives helps us to better understand facilitation.
High-quality rigorous studies are needed on facilitation to distinguish those characteristics or components that have greatest impact and effectiveness. While we did not assess rigour in this scoping review, others have noted a lack of rigorous studies evaluating facilitation.27 Our team is currently completing a systematic review to examine the effectiveness of facilitation as an implementation innovation in healthcare. Such work could also help to shed light on the process of facilitation, what facilitator role is best used and when, and what types of training are most effective for facilitators.
Conclusion
This scoping review highlights a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery. Implementing research into practice to improve patient care is complex and requires dedicated facilitators to support the change process. This scoping review advances the field of KT science by contributing to the evidence base needed to develop measures of facilitation and to design and test facilitation interventions for successful research use.
Acknowledgments
We gratefullyacknowledge stakeholders who reviewed the summary table of facilitator roles.We thank Ms. Tara MacGregor (research assistant) for her contribution in datascreening and extraction and Ms. Thane Chambers (Research Librarian, Faculty ofNursing, University of Alberta) for designing and conducting the searchstrategy. CAE holds a CIHR Canada Research Chair in Knowledge Translation (Tier1) (2005–2018). GGC holds a University of Alberta Centennial Professorship(2013–2020).
Acknowledgments
We gratefully acknowledge stakeholders who reviewed the summary table of facilitator roles. We thank Ms Tara MacGregor (research assistant) for her contribution in data screening and extraction and Ms Thane Chambers (Research Librarian, Faculty of Nursing, University of Alberta) for designing and conducting the search strategy. CAE holds a CIHR Canada Research Chair in Knowledge Translation (Tier 1) (2005–2018). GGC holds a University of Alberta Centennial Professorship (2013–2020).
References
- 1.↵
- 2.↵
- 3.↵
- 4.↵
- 5.↵
- 6.↵
- 7.↵
- 8.↵
- 9.↵
- 10.↵
- 11.↵
- 12.↵
- 13.↵
- 14.↵
- 15.↵
- 16.↵
- 17.↵
- 18.↵
- 19.↵
- 20.↵
- 21.↵
- 22.↵
- 23.↵
- 24.↵
- 25.↵
- 26.↵
- 27.↵
- 28.↵
- 29.↵
- 30.↵
- 31.↵
- 32.↵
- 33.↵
- 34.↵
- 35.↵
- 36.↵
- 37.↵
- 38.↵
- 39.↵
- 40.↵
- 41.↵
- 42.↵
- 43.↵
- 44.↵
- 45.↵
- 46.↵
- 47.↵
- 48.↵
- 49.↵
- 50.↵
- 51.↵
- 52.↵
- 53.↵
- 54.↵
- 55.↵
- 56.↵
- 57.↵
- 58.↵
- 59.↵
- 60.↵
- 61.↵
- 62.↵
- 63.↵
- 64.↵
- 65.↵
- 66.↵
- 67.↵
- 68.↵
- 69.↵
- 70.↵
- 71.↵
- 72.↵
- 73.↵
- 74.↵
- 75.↵
- 76.↵
- 77.↵
- 78.↵
- 79.↵
- 80.↵
- 81.↵
- 82.↵
- 83.↵
- 84.↵
- 85.↵
- 86.↵
- 87.↵
- 88.↵
- 89.↵
- 90.↵
- 91.↵
- 92.↵
- 93.↵
- 94.↵
- 95.↵
- 96.↵
- 97.↵
- 98.↵
- 99.↵
- 100.↵
- 101.↵
- 102.↵
- 103.↵
- 104.↵
- 105.↵
- 106.↵
- 107.↵
- 108.↵
- 109.↵
- 110.↵
- 111.↵
- 112.↵
- 113.↵
- 114.↵
- 115.↵
- 116.↵
- 117.↵
- 118.↵
- 119.↵
- 120.↵
- 121.↵
- 122.↵
- 123.↵
- 124.↵
- 125.↵
- 126.↵
- 127.↵
- 128.↵
- 129.↵
- 130.↵
- 131.↵
- 132.↵
- 133.↵
- 134.↵
- 135.↵
- 136.↵
- 137.↵
- 138.↵
- 139.↵
- 140.↵
- 141.↵
- 142.↵
- 143.↵
- 144.↵
- 145.↵
- 146.↵
- 147.↵
- 148.↵
- 149.↵
- 150.↵
- 151.↵
- 152.↵
- 153.↵
- 154.↵
- 155.↵
- 156.↵
- 157.↵
- 158.↵
- 159.↵
- 160.↵
- 161.↵
- 162.↵
- 163.↵
- 164.↵
- 165.↵
- 166.↵
- 167.↵
- 168.↵
- 169.↵
- 170.↵
- 171.↵
- 172.↵
- 173.↵
- 174.↵
- 175.↵
- 176.↵
- 177.↵
- 178.↵
- 179.↵
- 180.↵
- 181.↵
- 182.↵
- 183.↵
- 184.↵
- 185.↵
- 186.↵
- 187.↵
- 188.
- 189.
- 190.
- 191.
- 192.
- 193.
- 194.
- 195.
- 196.
- 197.
- 198.
- 199.
- 200.
- 201.
- 202.
- 203.
- 204.
- 205.
- 206.
- 207.
- 208.
- 209.
- 210.
- 211.
- 212.
Footnotes
↵* Non-English papers with English abstracts were kept if they met the abstract level inclusion criteria during the abstract screening. This was to determine the extent of the literature published in other languages. However, as we did not have the capacity to translate articles, these were not included in data extraction or analysis.
↵† There is overlap in the terms used to describe a clinical facilitator and a practice facilitator, and a practice facilitator and outreach facilitator.
Contributors CAE and LAC conceived of the study and secured funding for the study. LAC and FT screened search results for inclusion and extracted data from included articles. CAE conceived of the data analysis framework. LAC, GGC, FT and JPM participated in data analysis and synthesis. LAC and FT drafted the manuscript. All authors provided critical comments on the manuscript. CC (contributor) assisted with the stakeholder consultation.
Funding This work was supported by the Canadian Institutes of Health Research (CIHR) Knowledge Translation Synthesis Program, grant number: KRS 102076.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data is available.
Collaborators Caroline Clark: Associate Executive Director, Brain Care Centre, Edmonton, AB.