Identifying and selecting implementation theories, models and frameworks: a qualitative study to inform the development of a decision support tool.

BACKGROUND
Implementation theories, models and frameworks offer guidance when implementing and sustaining healthcare evidence-based interventions. However, selection can be challenging given the myriad of potential options. We propose to inform a decision support tool to facilitate the appropriate selection of an implementation theory, model or framework in practice. To inform tool development, this study aimed to explore barriers and facilitators to identifying and selecting implementation theories, models and frameworks in research and practice, as well as end-user preferences for features and functions of the proposed tool.


METHODS
We used an interpretive descriptive approach to conduct semi-structured interviews with implementation researchers and practitioners in Canada, the United States and Australia. Audio recordings were transcribed verbatim. Data were inductively coded by a single investigator with a subset of 20% coded independently by a second investigator and analyzed using thematic analysis.


RESULTS
Twenty-four individuals participated in the study. Categories of barriers/facilitators, to inform tool development, included characteristics of the individual or team conducting implementation and characteristics of the implementation theory, model or framework. Major barriers to selection included inconsistent terminology, poor fit with the implementation context and limited knowledge about and training in existing theories, models and frameworks. Major facilitators to selection included the importance of clear and concise language and evidence that the theory, model or framework was applied in a relevant health setting or context. Participants were enthusiastic about the development of a decision support tool that is user-friendly, accessible and practical. Preferences for tool features included key questions about the implementation intervention or project (e.g., purpose, stage of implementation, intended target for change) and a comprehensive list of relevant theories, models and frameworks to choose from along with a glossary of terms and the contexts in which they were applied.


CONCLUSIONS
An easy to use decision support tool that addresses key barriers to selecting an implementation theory, model or framework in practice may be beneficial to individuals who facilitate implementation practice activities. Findings on end-user preferences for tool features and functions will inform tool development and design through a user-centered approach.


Appendix 1. Consolidated criteria for reporting qualitative studies (COREQ)
A majority of participants were from Canada. Participants worked in a variety of healthcare environments and had a range of experience supporting implementation activities in healthcare environments. Participants had high self-rated knowledge and experience using certain implementation theories, models and frameworks that were familiar to them. 17. Interview guide See Appendix 2.
A semi-structured interview guide was prepared and revised as needed throughout data collection. The interview guide was reviewed by and pilot tested with 3 individuals who had experience with qualitative research and implementation science and practice, of which one was also a clinician.

Repeat interviews
Repeat interviews were not carried out. 19. Audio/visual recording Interviews were audio-recorded and transcribed verbatim. 20. Field notes Lisa Strifler took notes during and immediately following each interview and referred to these notes during data analysis and interpretation.

Duration
Interviews lasted 30 to 60 minutes.

Data saturation
Participants were recruited until no new themes were identified.

Transcripts returned
We did not return individual transcripts to participants for comment. However, the draft manuscript was shared with all participants for feedback on the research findings. Domain 3: analysis and findings 24. Number of data coders Data were inductively coded by a single investigator with a subset of 20% coded independently by a second investigator. 25. Description of the coding tree A description of the coding tree has not been provided but will be made available upon request.

Derivation of themes
Themes were derived from the data.

Software
NVivo 12 qualitative data analysis software (QSR International, Cambridge, MA) was used to organize and code the transcripts.

Participant checking
The final draft manuscript was shared with all participants for their feedback. 29. Quotations presented See Tables 2, 3 and 5. Direct quotes from participants were presented in tables to support the themes and study findings. Each quotation was identified using participant ID numbers.

Data and findings consistent
The data and findings are consistent.

Clarity of major themes
See Figure 1. Major themes underlying the perceived barriers and facilitators to selecting theories, models and/or frameworks included: (1) characteristics of the individual or team conducting implementation, including their attitudes, knowledge and training; (2) characteristics of the implementation theory, model or framework, including language, fit, ease of use and empirical evidence; (3) characteristics of the implementation project, including the purpose or outcome and level of complexity; and (4) characteristics of the environment, specifically availability of resources. The discussion places these findings in context with other literature showing a lack of use of theories, models and frameworks in practice. 32. Clarity of minor themes See Figure 1. Major themes were further categorised as minor themes, for example (1) characteristics of the individual or team conducting implementation was further categorized as (a) attitudes, (b) knowledge and (c) training. Understanding and conceptualization of theories, models and frameworks 3. Could you spend a few minutes describing your general understanding of KT/D&I theories, models and/or frameworks? For example, how you define or view them, and your familiarity with them? 4. What is your level of knowledge in terms of identifying, selecting and applying theories, models or frameworks to KT/D&I activities in practice? (1-Not at all knowledgeable, 2-Slightly knowledgeable, 3-Neutral, 4-Very knowledgeable, 5-Extremely knowledgeable) 5. What is your level of confidence in your ability to identify, select and apply KT/D&I theories, models or frameworks in practice? (1-Not at all confident, 2-Slightly confident, 3-Neutral, 4-Very confident, 5-Extremely confident) 6. What is your frequency of identifying, selecting and applying theories, models or frameworks to KT/D&I activities in practice? (1-Never, 2-Rarely, 3-Sometimes, 4-Frequently, 5-Always) Features and functions of tool 11. Some individuals in the field feel there is potential for a decision support tool to try to enhance appropriate selection and use of theories, models and frameworks. If you would now imagine that you are doing an implementation project and are looking to identify a KT/D&I theory, model or framework to inform the project, which features (or content items) would be useful for a decision support tool to have, in order to facilitate this task? Why?

Appendix 2. Telephone interview guide for implementation researchers and practitioners
12. In addition to features or content items, are there any aspects of the functionality of the tool that come to mind as being potentially useful? Why?
Additional comments and wrap-up 13. Before we wrap up, do you have any additional comments to add regarding the selection and use of KT/D&I theories, models or frameworks?
14. Thank you! If you think of anyone else who might be interested in participating in a similar interview, please feel free to share the study information sheet with them, which contains my contact information.