The Implementation in CONtext (ICON) framework: A meta-framework of context domains, attributes, and features in healthcare

Journal article

Squires, J.E., Graham, I.D., Santos, W.J., Hutchinson, A.M., Backman, C., Bergström, A., Brehaut, J., Brouwers, M., Burton, C., Candido, L.K., Cassidy, C., Chalmers, C., Chapman, A., Colquhoun, H., Curran, J., Demery Varin, M., Doering, P., Elliott Rose, A., Fairclough, L., Francis, J., Godfrey, C., Greenough, M., Grimshaw, J.M., Grinspun, D., Harvey, G., Hillmer, M., Ivers, N., Lavis, J., Li, S., Michie, S., Miller, W., Noseworthy, T., Rader, T., Robson, M., Rycroft-Malone, J., Stacey, D., Straus, S., Tricco, A.C., Wallin, L. and Watkins, V. 2023. The Implementation in CONtext (ICON) framework: A meta-framework of context domains, attributes, and features in healthcare. Health Research Policy and Systems. https://doi.org/10.1186/s12961-023-01028-z
AuthorsSquires, J.E., Graham, I.D., Santos, W.J., Hutchinson, A.M., Backman, C., Bergström, A., Brehaut, J., Brouwers, M., Burton, C., Candido, L.K., Cassidy, C., Chalmers, C., Chapman, A., Colquhoun, H., Curran, J., Demery Varin, M., Doering, P., Elliott Rose, A., Fairclough, L., Francis, J., Godfrey, C., Greenough, M., Grimshaw, J.M., Grinspun, D., Harvey, G., Hillmer, M., Ivers, N., Lavis, J., Li, S., Michie, S., Miller, W., Noseworthy, T., Rader, T., Robson, M., Rycroft-Malone, J., Stacey, D., Straus, S., Tricco, A.C., Wallin, L. and Watkins, V.
Abstract

Background
There is growing evidence that context mediates the effects of implementation interventions intended to increase healthcare professionals’ use of research evidence in clinical practice. However, conceptual clarity about what comprises context is elusive. The purpose of this study was to advance conceptual clarity on context by developing the Implementation in Context Framework, a meta-framework of the context domains, attributes and features that can facilitate or hinder healthcare professionals’ use of research evidence and the effectiveness of implementation interventions in clinical practice.

Methods
We conducted a meta-synthesis of data from three interrelated studies: (1) a concept analysis of published literature on context (n = 70 studies), (2) a secondary analysis of healthcare professional interviews (n = 145) examining context across 11 unique studies and (3) a descriptive qualitative study comprised of interviews with heath system stakeholders (n = 39) in four countries to elicit their tacit knowledge on the attributes and features of context. A rigorous protocol was followed for the meta-synthesis, resulting in development of the Implementation in Context Framework. Following this meta-synthesis, the framework was further refined through feedback from experts in context and implementation science.

Results
In the Implementation in Context Framework, context is conceptualized in three levels: micro (individual), meso (organizational), and macro (external). The three levels are composed of six contextual domains: (1) actors (micro), (2) organizational climate and structures (meso), (3) organizational social behaviour (meso), (4) organizational response to change (meso), (5) organizational processes (meso) and (6) external influences (macro). These six domains contain 22 core attributes of context and 108 features that illustrate these attributes.

Conclusions
The Implementation in Context Framework is the only meta-framework of context available to guide implementation efforts of healthcare professionals. It provides a comprehensive and critically needed understanding of the context domains, attributes and features relevant to healthcare professionals’ use of research evidence in clinical practice. The Implementation in Context Framework can inform implementation intervention design and delivery to better interpret the effects of implementation interventions, and pragmatically guide implementation efforts that enhance evidence uptake and sustainability by healthcare professionals.

KeywordsContext; Framework; Healthcare; Implementation; Knowledge translation
Year2023
JournalHealth Research Policy and Systems
PublisherBMC
Digital Object Identifier (DOI)https://doi.org/10.1186/s12961-023-01028-z
Official URLhttps://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-023-01028-z
Publication dates
Online07 Aug 2023
Publication process dates
Accepted05 Jul 2023
Deposited24 Jul 2023
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Masterson-Algar, P., Burton, C., Rycroft-Malone, J., Sackley, C.M. and Walker, M.F. 2014. Towards a programme theory for fidelity in the evaluation of complex interventions. Journal of Evaluation in Clinical Practice . 20 (4), pp. 445 - 452. https://doi.org/10.1111/jep.12174
Investigating the organisational impacts of quality improvement: a protocol for a realist evaluation of improvement approaches drawing on the Resource Based View of the Firm.
Burton, C., Rycroft Malone, J., Robert, G., Willson, A. and Hopkins, A. 2014. Investigating the organisational impacts of quality improvement: a protocol for a realist evaluation of improvement approaches drawing on the Resource Based View of the Firm. BMJ Open. 4:e005650. https://doi.org/10.1136/bmjopen-2014-005650
Resource based view of the firm as a theoretical lens on the organisational consequences of quality improvement.
Burton, C. and Rycroft-Malone, J. 2014. Resource based view of the firm as a theoretical lens on the organisational consequences of quality improvement. International Journal of Health Policy and Management. 3 (3), pp. 113 - 115. https://doi.org/10.15171/ijhpm.2014.74
The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'.
Burton, C., Payne, S., Turner, M., Bucknall, T., Rycroft-Malone, J., Tyrell, P., Horne, M., Ntambwe, L.I., Tyson, S., Mitchell, H., Williams, S. and Elghenzai, S. 2014. The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'. BMC Palliative Care. 13 (55). https://doi.org/10.1186/1472-684X-13-55
Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial.
Thomas, L.H., Watkins, C.L., Sutton, C.J., Forshaw, D., Leathley, M.J., French, B., Burton, C., Cheater, F., Roe, B., Britt, D., Booth, J., McColl, E., The ICONS Project Team and The ICONS Patient, Public and Carer Involvement Groups 2014. Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial. Trials. 15 (509). https://doi.org/10.1186/1745-6215-15-509
What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services
Burton, C.R., Horne, M., Woodward-Nutt, K., Bowen, A. and Tyrrell, P. 2014. What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services. Disability and Rehabilitation. 37 (21), pp. 1955-1960. https://doi.org/10.3109/09638288.2014.991454